A coroner’s inquest into the death of a 17-year-old Cree boy at an Abbotsford group home has resulted in 18 recommendations aimed at preventing a similar tragedy in the future.
Traevon Desjarlais was found hanging in the closet of his room at the home on Sept. 18, 2020.
The facility was operated by Rees Family Services, under contract from the Fraser Valley Aboriginal Children and Family Services Society and funded by the provincial government.
The five-member coroner’s jury heard testimony from witnesses including Desjarlais’ mother, the group home foster parents, his social worker, his psychologist and the police who investigated when he was reported missing.
The recommendations focused heavily on shifting the model of care for Indigenous children back into their families and communities, improving Indigenous competency among staff in group homes and providing Indigenous youth with access to elders and their culture.
Speaking after the verdict was read, Desjarlais’ great-grandmother Theresa Campiou thanked the jury for their work, but said the recommendations should be viewed as “interim” solutions.
“There are many things missing from it, and the primary tool that is needed for our children in care is to have identity — having cultural practices, having cultural events doesn’t necessarily provide the identity,” she said.
“We’re realizing that the only way we can fix a broken system is to fix it for ourselves … and it isn’t for you people in the court, it isn’t for the lawyers, it isn’t for children’s services, it isn’t for your department’s to help create a system that is going to work for us — it is our responsibility to do that, it is our responsibility to ensure that our children are looked after in a manner that we understand.”
Several of the recommendations were aimed at the Ministry of Children and Family Development (MCFD).
The jury recommended the ministry speed up the development of legislation and policies favouring family-based services for youth and redirect funding away from contracted and staff-led residential facilities.
“The best outcome for Indigenous children in care is to have a sense of belonging to community and family,” the verdict stated.
It also called for the ministry to speed up a new IT system for all children in care, and to ensure that system is accessible to everyone providing services to a child.
Testimony at the inquest, it said, showed that not everyone involved in Desjarlais’ care, including a foster home worker, had up to date information on the teen — including that he was potentially suicidal.
To the MCFD and the Fraser Valley, Aboriginal Child and Family Services, the jury recommended ongoing reassessments in consultation with Indigenous communities and family care teams about children’s current and future placements to ensure they’re in a culturally appropriate and safe environment.
It also called for an increase in the complement of qualified Indigenous staff and cultural opportunities, noting testimony from multiple witnesses that there was a lack of Indigenous representation in Desjarlais’ care.
And it recommended the creation of a policy to ensure staff are aware missing children are reported immediately to police, that information is being shared in real-time with everyone on a child’s care team, and to report and document every point of contact with a child.
The jury also made several recommendations to Rees Family Services, noting that employees had indicated they had no knowledge or understanding of the impacts of colonization.
The jury called for a review of the organization’s staff in consultation with Indigenous communities to determine appropriate cultural competence, along with the creation of a policy and standards on cultural competence.
Rees should also develop a policy requiring staff to show a comprehensive understanding of Indigenous people’s histories, it recommended.
And it called for the organization to contract Indigenous elders to be available in youth group homes, finding
Over more than a week of testimony, the inquest heard how Desjarlais was taken from his mother as an infant and spent about 15 years living with relatives before he moved to the group home in 2019 when family members were no longer able to meet his special needs.
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The jury heard that the teen had anxiety and post-traumatic stress syndrome-type symptoms, but had stopped taking his medication.
It also heard that during the early months of the COVID-19 pandemic his mental health began to decline rapidly, and that he began to act erratically, including destroying his bed and smashing his head against his bedroom wall.
It also heard from a counsellor who said the teen had shared thoughts of self harm, but testified he didn’t think it was suicidal ideation.
The jury heard how he disappeared in September, 2020 and reported missing to Abbotsford police — only to be discovered dead in his closet four days later.
A group home foster parent told the inquest that he checked the room multiple times, but had apparently not looked in the closet.
If you or someone you know is in crisis and needs help, resources are available. In case of an emergency, please call 911.
The Canadian Association for Suicide Prevention, Depression Hurts and Kids Help Phone 1-800-668-6868 — all offer ways for getting help if you, or someone you know, is suffering from mental health issues.
For a directory of support services in your area, visit the Canadian Association for Suicide Prevention.
Learn more about how to help someone in crisis on the Government of Canada website.