A coroner's report into the death of 17-year-old Alex Malamalatabua – who jumped from a construction crane while he was a psychiatric patient at B.C. Children's Hospital last summer – has raised troubling new questions about his care prior to the suicide.
The coroner's office found Alex had toxic levels of the antidepressant Zoloft in his system when he died. The investigation concluded that, during his hospital stay, the teenager repeatedly "cheeked his meds" – hid them in his mouth rather than swallowing them.
What the report doesn't explain, however, is how a young patient who is known to be a chronic high risk of suicide could go six weeks essentially untreated and then, in his condition, walk out of the hospital late at night unescorted, with a pass.
"This type of finding is nothing short of devastating," Mary Ellen Turpel-Lafond, the Representative for Children and Youth, said in an interview. She has previously raised concerns about the inability of the Ministry of Children and Family Development to find Alex a suitable placement outside of the hospital. She has been waiting for the coroner's report before launching a full inquiry.
Despite the pain of sharing details of Alex's death publicly, his mother, Jacquie Malamalatabua, has supported a review by the independent watchdog in the hope that other families may benefit from better care and support.
Alex had been admitted to the hospital's child and adolescent psychiatric emergency unit in March of 2015. It was supposed to be a short-term stay to stabilize him and doctors felt he needed to be discharged, but Alex was still there in July, waiting for the ministry to find a community placement where he would receive supportive care.
Now there is the additional question about the quality of care the youth received while he was in treatment.
"Given the concentration that was found in Alex's blood compared to the dosage he was prescribed, it is estimated that he saved his medication for approximately six weeks prior to his death," coroner Adele Lambert wrote. "It is unknown where the medication had been hidden as Alex's room at the hospital was regularly searched."
The coroner's only recommendation was that the representative's office should review the government's services to Alex. Ms. Turpel-Lafond believes the best place to start is to read the findings of an internal review conducted by the hospital's governing body, the Provincial Health Services Authority. However, PHSA officials refused to provide the review even on a confidential basis to the representative.
Premier Christy Clark tried to break the impasse in November, urged the hospital authority to find a way to share its findings. But the Ministry of Health now says it cannot help, so Ms. Turpel-Lafond is launching her investigation without the benefit of reading the review.
"It is exactly the type of case in which collaboration is key," Ms. Turpel-Lafond said. The hospital has shared its recommendations and has assisted with staff interviews, but she said that is inadequate and has not assured her that the issues of hospital safety or working with the ministry on finding placements for children leaving the hospital have been addressed.
In a written statement, the hospital's head of privacy, Sandra MacKay, said the agency is doing what it can to help the independent watchdog with her inquiries, but the review cannot be released in any way. "These reviews are conducted under Section 51 of the BC Evidence Act to promote full, open and candid discussions amongst health-care professionals."
Health Minister Terry Lake refused to answer questions about the coroner's findings or the hospital's insistence on withholding its report from the representative. A statement from the ministry reiterated the need to maintain privacy under the Evidence Act.
However, for parents who are faced with the difficult decision, as Ms. Malamalatabua did, to entrust a child to hospital care, Mr. Lake surely must be able to say if he is certain that the hospital has made changes to ensure what happened with Alex cannot happen again.
"Someone has to be accountable back to the mom," Ms. Turpel-Lafond said. "This is a family that goes into a health-care system with a vulnerable youngster and has a tragic experience, and they deserve a certain level of accountability."