A Coroner’s inquest looking into the death of a Coquitlam teenager who died of a fentanyl overdose in a private substance abuse treatment facility last year has issued 21 recommendations aimed at reducing deaths from illicit drugs.
Brandon Jansen, 20, died in March while at a Powell River treatment centre, in one of the most high-profile cases of B.C.’s growing overdose crisis.
The BC Coroners Service inquest looked into what went wrong leading up to Jansen’s death.
The Coroner’s jury found that Jansen died of “a mixed opioid drug overdose” and deemed his death accidental.
The jury’s recommendations focused on providing better access to the opioid replacement therapy Suboxone and prescribing pharmaceutical grade heroin for chronic opioid users.
It also called for “improved standards and outcome measures for centres providing treatment for drug-dependent persons.”
WATCH: Brandon Jansen’s death
Here are the jury’s 21 recommendations:
To: The Minister of Health
1. Develop specific substance use treatment facility regulations under the Community Care and Assisted Living Act, including with respect to educational qualifications for persons working in such facilities.
2. Ensure free opioid maintenance drugs in the community for people leaving correction centres.
3. Review the need for increasing the number of supervised consumption sites rather than overdose prevention sites.
4. Explore options to create a shared database for the treatment of substance abuse to include medical, psychiatric, criminal and substance abuse treatment records.
5. Explore options for critical incident information sharing with respect to unexpected deaths in substance use facilities among licensees and Health Authorities with the goal of enhancing client safety and risk prevention.
6. Develop standards of practice for treating persons with opioid addictions.
7. Provide, develop and improve adolescent substance abuse treatment facilities.
To: The Minister of Health and CEOs of Regional Health Authorities
8. Consult with persons with lived experience with substance use dependency in policy and program development.
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To: The CEOs of Regional Health Authorities
9. Require all substance use treatment centres to educate clients with opioid use disorders about opioid maintenance treatments, the risks of relapse, ensure the understanding of tolerance levels, training for the use of naloxone, and provision of naloxone kits upon discharge.
10. Require all substance use treatment programs to report back to health authorities on client outcomes.
11. Provide opioid dependent users ready access to opioid replacement interventions.
12. Expand diacetylmorphine and hydromorphone treatment programs for chronic opioid users
To: The Minister of Public Safety and Solicitor General
13. Develop a standard of practice for inmate community release, including the requirement that inmates on opioid maintenance treatment are assigned to community physicians capable of treating them. Inmates also need the ability to apply for social assistance and housing prior to release.
To: The Minister of Education:
14. Conduct a review of approved drug education resources in line with current evidence based research. Implement into the education curriculum a substance abuse and addiction program, starting at the elementary level by giving the teachers the resources and tools needed.
15. Have Noloxone kits available in the school system with trained personal on site.
To: The Director of the BC Centre on Substance Use
16. Embark on comparative research of substance use treatment modalities with the goal of determining the features that lead to better client outcomes.
To: The Registrar of the College of Physicians and Surgeons of British Columbia
To: The Chair of the British Columbia Medical Association
To: The Board Chair of the College of Regi stered Nurses of British Columbia, and
To: The President of the British Columbia Nurse Practitioner Association
17. Ensure membership is aware that Suboxone is a first line treatment option for opioid use disorder, as well as the risks and benefits of Suboxone relative to methadone.
To: The CEO Sunshine Coast Health Centre
18. Review security procedures and training with all staff.
To: The CEO all Licensed Substance Use Treatment Centres
19. Review guidelines regarding cell phone / Electronic device polices.
20. Ensure all baggage is searched on entering the facility including clients and visitors.
21. Consider greater security measures for monitoring clients and visitors. e.g.- Fob System for door; – Video System
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