Shorter wait lists urged in report into Windsor student’s suicide
A coroner’s jury released sweeping recommendations following an inquest into the suicide death of Carleton University student Jason Simon of Windsor. The 37 recommendations, released this month, range from urging national and provincial strategies on suicide, to ensuring that patients receive needed therapy without spending a year or more on a waiting list.
About 80 people a year die by suicide in the Ottawa region, but only about a quarter of these cases have had interactions with health services.
Of the approximately 6,000 visits for psychiatric emergency services at The Ottawa Hospital every year, about half present with suicidal ideation or plans, the inquest heard.
Simon, a criminology student and army reservist who loved the outdoors, snowboarding and photography, was 20 years old when he hanged himself on Feb. 15, 2016. In the 28 days before his death, Simon sought help from a number of places, including a military hotline and walk-in clinic, health care providers at Carleton University and three hospitals, including the Kingston General Hospital, The Ottawa Hospital’s Civic campus and the Montfort Hospital. Simon’s parents, Margit and Attila Simon, both wearing T-shirts with photos of their son proudly wearing his reservist fatigues, sat through the inquest, which began Jan. 22.
They had no idea their son was struggling until about two weeks before his death. After getting a call from one of her son’s friends, Margit drove nine hours from the family’s home in Windsor to be by his side after he was admitted to hospital on Jan. 29, 2016, and begged the nurse to be allowed to see him.
“It was 28 days. It was downhill. And still we didn’t know because of the privacy laws. We were kept in the dark,” said Margit on Friday after the inquest wrapped up. The inquest focused on two areas: to consider new and innovative suicide prevention strategies, and to review a death in which a person used multiple psychiatric resources over a short period of a time, as Simon did.
The Simons said they learned things they hadn’t known before during the course of the inquest. “There was no case manager. He was falling through the cracks,” said Margit.
Some of the 37 recommendations targeted systemic change, such as urging hospitals and post secondary institutions in the region to adopt the Zero Suicide model, a systemic approach to suicide prevention developed in the U.S. that has been adopted by many hospitals, including some in Canada. The jurors also want the Ministry of Health and Long-Term Care to consider funding a pilot of a rapid-access outpatient mental health clinic. The Ottawa Hospital had pitched such a pilot in 2017, but the project was not funded. Hospitals should also be funded to create a short-stay observation unit adjacent to local emergency departments, the jurors recommended. The units would provide for suicide risk assessments and give every patient a “safety plan” that includes the patient’s natural support network, as well as a plan to remove the “means” of suicide. Margit Simon said after her son was hospitalized, she and her family scoured his room for anything that could be used as a ligature, but had no idea he had planned use the ceiling fan in his room and an electrical cord to take his life.
The recommendations touched on the importance of the safety plan, offering patients coping strategies, discussing warning signs and phone numbers for support. There was also mention of approaching patients about the advantages of involving family members in the safety plan. The inquest heard that Simon did not want his parents notified about his struggles. Central to the probe was Simon’s mental condition, which could swing from normal to suicidal and back again in the space of a few hours — and what could be done to treat it.
Simon was brought to the Civic emergency room on Jan. 29, 2016, after he called a hotline with an electrical cord around his neck, sparking a “mini standoff ” with police. But in the days that followed, psychiatric nurses noted that he was calm, co-operative and polite. Only days before his death, Simon was shopping for a car, going snowboarding and talking about going on a road trip. Psychiatrists told the jurors that Simon did not have a major mental illness such as schizophrenia. Rather, his behaviour suggested borderline personality disorder, a mental illness characterized by unstable emotions and risk-taking behaviour.
There is no pill or short-term therapy that could have acted as a quick fix to help Simon control his impulsivity and regulate his emotions, the inquest heard.
The “gold standard of treatment” for borderline personality disorder is dialectical behaviour therapy, known as DBT, which gives patients the skills to manage their emotions.
But DBT takes time and wait lists for the few publicly-funded DBT spaces can be long, the inquest heard. Some psychiatrists said they use elements of DBT, but not the full program. Because Simon was never formally diagnosed, he was not even on a waiting list, said his mother.
The recommendations strongly supported access to DBT, saying hospitals and community-based services should offer full DBT for all patients who qualify, and the wait list should not exceed 90 days. The recommendations contained everything Simon’s parents were hoping for, and more. But the next step will be to make sure it all happens, said Margit Simon. “The emails are going out and the phone calls. I’m not going to let it go.”