An inquest into the death of a 16-year-old patient who was found dead last December after running away from a Saanich youth psychiatric facility gets underway Monday.
Vancouver Island regional coroner Matt Brown will preside over the five-day inquest. It will see a jury hear evidence from witnesses and subsequently have the opportunity to make recommendations aimed at preventing similar deaths in the future.
Following the teen’s death on Dec. 19, 2010, the Vancouver Island Health Authority, which operates Ledger House, and Saanich police made internal changes to improve communication between the two organizations.
“We created communications protocols to make sure our staff in the communications centre and their staff who were calling us for assistance were really speaking the same language,” said Sgt. Dean Jantzen. “We formalized a risk-assessment protocol to make sure that any perceived risks are clearly shared.”
The inquest runs Dec. 12 to 16 at Western Communities Courthouse (1756 Island Hwy.).