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VIHA releases report after review of teen suicide and disappearance from Ledger House

Dec 09 2011

The Vancouver Island Health Authority has released its review following the suicide of a 16-year-old girl who went missing from a youth psychiatric facility in Saanich a year ago this month.

The report contains seven recommendations, including a new pass protocol for staff supervising patients when they leave or come back from a residential mental health facility.

Hayden Blair Kozeletski disappeared from Ledger House at the Queen Alexandra Centre for Children's Health on Dec. 19, shortly after returning to the facility from a weekend outing.

She was later found dead a short distance from the hospital.

The teen’s death sparked a series of reviews, including one by Representative for Children and Youth Mary Ellen Turpel-Lafond and one by Saanich police — who at the time, classified a report of the missing girl as “routine” and put it in a holding queue to be dispatched when an officer became available.

It was 45 minutes before Ledger House called police to report Hayden missing. Police had not yet responded another 90 minutes later when her body was found by her father in a beach area near the hospital grounds.

Next week, coroner Matthew Brown will preside over an inquest into the teen’s death. A jury will hear evidence at the Western Communities Courthouse Dec. 12 to 16 to determine the facts of the case and make recommendations on ways to prevent future deaths.

VIHA’s report, released Friday, lists actions taken in response to its own internal review and subsequent seven recommendations. The new pass protocol outlines the process for patients leaving the facility, from determining patient readiness for a pass to when patients return from a pass.

“It also includes clear directions for when a patient on a pass presents to an emergency department or urgent care centre,” the report says. “Specifically, it directs staff and physicians to contact the mental health facility where the pass was granted for help in care planning and, if required, to transfer the patient back to the mental health facility.”

While up Island on a weekend pass from Ledger House on the weekend of Dec. 18, Hayden had been taken to a hospital emergency ward because of concerns about her mental health.

VIHA reports it has made two further changes in protocol at Ledger House to enhance shift-to-shift communication.

• The registered nurse located in the special care unit of Ledger House will now be in charge of the Ledger program after hours. This change ensures the person in charge will have a strong knowledge of policies, procedures, and protocols.

• The patient pass protocol has been updated. Now, a mental-health-status assessment will be filed for all patients prior to leaving on a pass, as well as when they return from a pass; a suicide-risk assessment will also be completed when necessary.

As well, parents are now expected to remain on the unit to give a pass report to staff before leaving, the report says. “To ensure these assessments and communications are occurring, regular audits are performed and education is provided to staff as required.”

In an earlier internal review by Saanich police, the department concluded it should have responded with more urgency when Hayden was first reported missing from Ledger House late on a Sunday afternoon.

The police review, which was released to the Times Colonist earlier this year under B.C.’s Freedom of Information Act, said Hayden was missing for 45 minutes before Ledger House called police. The precise time of her death is unknown, and it would be “purely speculative” to say whether a quicker police response might have saved her life, the review said.

The department continues to classify missing persons cases as routine, but now requires that supervisors or officers are notified immediately to ensure that such calls do not sit in a holding queue.


-with files from Lindsay Kines