WARNING: This story contains distressing details.
A coroner's jury has reached its verdict in the death of a 17-year-old Cree teen in a group home in Abbotsford, B.C., recommending more family-based services for children in care and faster action when those children go missing.
Traevon Chalifoux-Desjarlais was found in a bedroom closet in September 2020, four days after he was first reported missing by a group home staffer. Following a coroner's inquest, his death has been confirmed as a suicide.
Inquest testimony from the teen's mother, psychiatrist and guardianship social worker painted a picture of a vulnerable young man who faced overwhelming challenges in his short life, including an intellectual disability. He was taken into government care at birth and was moved a number of times, growing up between the homes of various relatives.
The verdict from the coroner's jury includes 18 recommendations for the Ministry of Children and Family Development, group home operator Rees Family Services, and Indigenous child welfare provider Xyolhemeylh, a delegated agency of the ministry.
The recommendations include making sure missing children are immediately reported to police, creating policies and funding structures that would favour family-based residential services over group homes operated by staff, and increasing the number of qualified Indigenous staff working directly with children and their families.
The jury also called for collaboration between the ministry and Indigenous communities to re-assess the living situations of children in care to make sure they're placed in safe and culturally appropriate homes, and contracting Indigenous elders to be available in those homes.
The nine-day inquest heard that Chalifoux-Desjarlais stopped taking his medication in the months before his death, which may have contributed to a rise in self-harming behaviour, including banging holes in his bedroom wall with his head and cutting up his mattress and sheets.
COVID-19 restrictions only made things worse by limiting the in-person contact he had with various care team personnel.
During the course of the inquest, a group home worker testified that he had searched Chalifoux-Desjarlais's room "multiple times" after reporting him missing on Sept. 14, 2020. When an Abbotsford police officer found the teen's body in the closet, three suicide notes were discovered on his bedside table and floor.
A coroner's inquest does not find blame or criminality but is meant to serve the public interest in revealing the facts and circumstances of a death. The jury's recommendations are intended to address improvements to policy and procedures.
If you or someone you know is struggling, here's where to get help:
If you're worried someone you know may be at risk of suicide, you should talk to them about it, says the Canadian Association for Suicide Prevention. Here are some warning signs:
Hopelessness and helplessness.