The boy who should have lived
Coroner will not order inquest into suicide of 12-year-old with mental-health issues
Two years after 12-year-old Chazz Petrella hanged himself from a tree in his backyard — following years of being bounced around between various schools, hospitals and mental health services — his parents have learned there will not be a coroner’s inquest into his death.
“If his care had been good, we wouldn’t be in this position in the first place,” said his mother, Janet Petrella-Ashby.
“For us, it’s extremely surprising that they’re not going to call an inquest, and that it took two years to decide. An inquest could have been called and completed by now.”
The family has received messages of support from many individuals, including politicians and the Provincial Advocate for Children and Youth, since sharing their story two years ago following the death of Chazz.
They had been anxiously waiting for a positive decision from the coroner’s office. The family says Ontario’s mental-health system failed them horribly, and they were hoping to learn how that happened and to ensure no other family has to have a similar experience.
The Petrellas say they continue to believe there is a lack of funding, training and co-ordination between the various agencies and argue their concerns could have been probed publicly and addressed through recommendations from an inquest jury.
“With so many aspects in his case, it’s difficult to imagine that they can’t find at least one aspect that could be improved upon in an inquest,” Petrella-Ashby said on the phone from the family home in Cobourg.
“I believe there’s a lot to be learned from Chazz’s case that an inquest could have opened the door to,” adds Chazz’s father, Frank Petrella.
The youngest of five children, Chazz’s behaviour changed dramatically as he moved through elementary school. He had fits of rage at the smallest problem, such as a lost Internet connection, and he would swear and throw things.
He would cut the cords to the home alarm system that rang every time a door or window was opened; he would sometimes go missing for days.
On one trip to the hospital in Oshawa, he tried to jump out of the car being driven by his sister on Highway 401. It took six police officers to subdue him, as adrenaline coursed through his small body.
Within the span of about two years, he bounced around between regular and sectioned classrooms, child and family services in Peterborough, a rural treatment centre and then back home.
In August 2014, Chazz tragically took his own life.
Today, his parents are asking the Chief Coroner of Ontario, Dr. Dirk Huyer, to reconsider the decision not to hold an inquest, which was initially made by the regional supervising coroner based in Kingston.
“After waiting patiently and in good faith for almost two years, why do my clients or the public not know the answers to the very obvious questions that arise from Chazz’s death?” says a letter sent to Huyer from the family’s lawyer, Julie Kirkpatrick.
“My clients again ask you to recognize that a public inquest into the complete circumstances surrounding Chazz’s death is the only mechanism that will achieve a reliable factual foundation for meaningful recommendations to be made by a jury of individuals who have not emerged from, worked within or become invested in the very system that failed Chazz and his family.”
A coroner’s office spokeswoman said an inquest is considered in every death investigation, and one is sometimes required by law, such as a death on a construction site or while in police custody. The office conducts about 15,000 death investigations per year.
“Further, inquests are conducted in the public interest and not in the private interest,” said spokeswoman Cheryl Mahyr, speaking generally. “If there is no perceived benefit to the public, then an inquest would not be held.”
In his letter outlining to the family and their lawyer why no inquest would be held, regional supervising coroner Dr. Paul Dungey suggested that aside from an inquest, there are other methods available at the coroner’s office to improve the system.
He highlighted that Chazz’s death was reviewed by the Pediatric Death Review Committee (PDRC), which probes the deaths of all children who had been receiving services from a children’s aid society within a year of their death. (The CAS was one of many agencies the Petrellas contacted for help.)
In Chazz’s case, the committee also asked an Ontario children’s mental health expert for a supplementary report.
“I want to acknowledge the complexity of this case and the difficulties this family had in navigating and accessing care for their son,” Dungey told Kirkpatrick in the letter. “I am not refuting your raised concern that the child and youth mental health care system and the ability to access it can be improved upon.” Dungey would not be commenting beyond the letter due to privacy considerations, said a coroner’s office spokeswoman.
He told Kirkpatrick in his letter that the committee and the expert made several recommendations, such as having the Ministry of Health enhance training for doctors and other emergency room staff in the assessment of suicide risk; improving the difficulty in understanding the available mental health services for children and youth; and “improved communication and collaboration” between child and youth agencies.
“It is my opinion that a jury presented with the circumstances of Chazz’s death would not make any additional, useful recommendations that would prevent deaths in similar circumstances,” Dungey wrote.
“The recommendations that have been made by the PDRC and the supplementary report are of a high standard; they are focused, reasonable and implementable and are consistent with those we would expect from an inquest jury examining Chazz’s death.”
But as noted by the family, the committee is mainly comprised of childwelfare consultants, children’s aid society officials and members of police services, and operates behind closed doors, unlike an inquest. Its reports are also not made public, but are shared with the family.
Kirkpatrick points out in her letter to Huyer that the family wants a jury of objective citizens at an inquest “to take a deep and careful look at what actually went so terribly wrong for Chazz.”
The family wants a full, public hearing of the case, and so took issue with Dungey’s statement in his letter that Chazz’s parents “have previously made the events surrounding his death and aspects of his interactions with the system of care public through contact with media providers.”
As Frank Petrella pointed out in an interview with the Star: “We didn’t seek out the media. The media sought us out. Not only did the media find the story troubling, but so did thousands of people who reached out and wanted to know how and why.”
They disagree with many of the committee’s findings, including that adequate psychiatric assessment services were made available to Chazz and that the suggested medications were “sensible.”
There was never a clear diagnosis, and the boy never got the comprehensive testing he should have received as soon as his behaviour began to spiral out of control, his family says.
Petrella-Ashby took Chazz to the hospital twice on the night before he died, because he had punched a wall and injured his hand. He received a cast on the first visit, but they had to return after Chazz gnawed through it.
Instead of Chazz being kept in the hospital, as his mother requested, he was given a sedative and sent home.
Dungey said in his letter to Kirkpatrick that she was correct in stating that Chazz, who stood at just over five feet and weighed 89 pounds, was given twice the daily adult dose of the sedative and that it is not recommended for people under 18. The family continues to question whether it led to his suicide.
Dungey also stated in the letter that his office requested that the hospital review the care Chazz received.
Ontario’s advocate for children and youth, Irwin Elman, said Chazz’s case is crying out for an inquest. He has also written to the chief coroner.
“I can’t see an inquest at this point in time that would be of more interest to the public than the heroic battle that families and children struggling with mental health issues take on each and every day,” he said. “There are so many families in this province touched by that battle.” With files from Laura Armstrong