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Inquest calls for 23 recommendations aimed at preventing teen suicides

Five-day inquest examined how to better prevent the events that led to Hayden Kozeletski’s death on Dec. 19, 2010.

Twenty-three recommendations are being urged following a juried inquest into the the death of a 16-year-old patient who killed herself after walking away from a Saanich psychiatric facility.

A five-day inquest, which wrapped last Friday, examined how to better prevent the events that led to Hayden Kozeletski’s death on Dec. 19, 2010. The inquest ended with a request for more stringent protocols for the Vancouver Island Health Authority, which operates Ledger House.

Among the recommendations are:

• a crisis nurse be made available 24-7 in all hospitals;

• Ledger House patients who are issued a day pass must undergo a debrief upon returning to the facility, alongside their parents/guardians;

• when a patient runs away from Ledger House, the last staff member who worked with them is responsible for calling Saanich police and relaying all pertinent information.

Additionally, the jury recommended that the Ministry of Health fund two beds for suicidal youth patients at Comox's St. Joseph's Hospital.

The Ministry of Education is also asked to provide suicide awareness training to middle and high school councillors.

There are also recommendations with regards to how patients are assessed to be deemed at-risk of suicide, and how that information is shared among relevant healthcare professionals.

To read the entire list of recommendations, download the findings at bit.ly/uUFQVy.

kslavin@saanichnews.com