Skip to main content

The Globe and Mail

Coroner’s inquest recommends shift in B.C.’s approach to suicide

Lorraine Johnson, foreground, holds a photo of her son, Brian David Geisheimer, 30, as Deb Nolet, with a photo of her daughter, Sarah Louise Charles, talks to Kim Young outside the B.C. Coroner’s Service in Burnaby on Sept. 7, 2016.

John Lehmann/The Globe and Mail

A coroner's inquest into the deaths of three people who died by suicide shortly after leaving a Fraser Valley hospital, where they were admitted for mental-health reasons, has issued more than two dozen recommendations in hopes of preventing similar deaths.

The recommendations include implementing systematic and evidence-based suicide-prevention initiatives; a program to educate all health-care staff on privacy laws regarding the sharing of health-care information; and a policy that involves family in mental-health and addiction treatment.

Jonny Morris, a suicide-prevention expert who spoke on the final day of the eight-day inquest, said the recommendations have attempted to address the complexity of testimony from grieving parents, physicians, psychiatrists, social workers and police representatives.

Story continues below advertisement

"I think the recommendations, if acted upon, stand to make a difference moving forward," Mr. Morris said Monday.

Brian David Geisheimer, 30; Sebastien Pavit Abdi, 19; and Sarah Louise Charles, 41, died between December, 2014, and April, 2015, shortly after leaving Abbotsford Regional Hospital, where they were admitted for mental-health reasons. The BC Coroners Service grouped the deaths for their similarities; the inquest aimed to determine the facts of what happened and prevent similar deaths from occurring.

The inquest heard from parents who said they were denied involvement in their adult children's mental-health treatment and left feeling unsupported after their deaths; from physicians and paramedics who spoke of gaps and shortcomings in the mental-health-care system; and from Mr. Morris, who said a paradigm shift is needed to effectively prevent suicide.

The five-person jury adopted a recommendation suggested by both presiding coroner Donita Kuzma and Mr. Morris: for the provincial and federal health ministries to consider mandating the implementation of systematic and evidence-based suicide-prevention initiatives. An example of this would be to create a system of checks and balances so that patients are screened for suicide risk at multiple touchpoints during care.

The jury also recommended several health colleges, including the College of Physicians and Surgeons of B.C., to consider mandating the annual training and retraining of all staff on privacy laws related to the sharing of health-care information. It also recommended the Fraser Health Authority consider implementing a family involvement policy similar to one in place at Vancouver Coastal Health.

During the inquest, the jury heard that the Freedom of Information and Protection of Privacy Act was not written with health care in mind. Health-care workers worried about running afoul of the legislation can be reluctant to involve well-meaning family members in a patient's treatment plan – a consequence attributed to what Mr. Morris termed "privacy paralysis."

Other recommendations include: for Fraser Health to improve support for families and community-care providers after a death by suicide; for various colleges to consider mandating annual risk suicide assessment and management training for health-care and behavioural-health professionals; and for the Ministry of Health to consider adopting trauma-informed care principles.

Story continues below advertisement

Lorraine Johnson, mother of Mr. Geisheimer, said she was pleased the inquest was called, despite the difficulty in reliving the ordeal.

"My concern now is: Where do we go from here?" she said Monday, citing a previous inquest in which recommendations were not enacted.

Deborah Nolet, mother of Ms. Charles, called the recommendations relevant and comprehensive, and much of the physicians' testimony valuable and helpful.

"It is my fervent hope that the sharing of our desperate struggle for help, and that of Brian's and Sebastien's families, will begin to affect change in our approach to suicide, and the treatment of patients and families searching for help and understanding in the areas of substance abuse and mental health," Ms. Nolet wrote in an e-mail.

Nigel Fisher, program medical director of mental health and substance use at Fraser Health, said the health authority is reviewing the recommendations.

"The evidence showed how complex the patients are that present to our services and that a simple one-size-fits-all approach will not work," Dr. Fisher said in a statement.

Story continues below advertisement

"We will thoroughly review and respond to the recommendations brought forth by the jury."

British Columbia's Ministry of Health said the three deaths "highlight that there is work to be done to improve the way we provide care to patients across the province who may be at risk of suicide."

Health Minister Terry Lake has asked the ministry to review current guidelines regarding the sharing of health information, according to a statement provided by spokeswoman Kristy Anderson.

Susan Prins, a spokeswoman for the College of Physicians and Surgeons of B.C., said in an e-mail that the college "intends to review and consider all of the recommendations in detail."

Report an error Editorial code of conduct Licensing Options
As of December 20, 2017, we have temporarily removed commenting from our articles. We hope to have this resolved by the end of January 2018. Thank you for your patience. If you are looking to give feedback on our new site, please send it along to If you want to write a letter to the editor, please forward to