Jurors in Kamloops inquest make recommendations, hug family of ‘happy child’

'WE ASSUMED THAT… HE WAS UNDER THE BEST CARE AND THAT WASN'T THE CASE.'

KAMLOOPS – Jacob Setah was a fun-loving teenager from Yunesit’in who enjoyed time spent with his family members, all of whom hoped he would be in the safest place after hospitalizing him for his mental illness.

However on June 15, 2014 Setah, while in a state of psychosis, escaped Royal Inland Hospital’s psychiatric ward and fled to the top of the property’s three-storey parkade where he jumped from the top floor after RCMP attempted to apprehend him.

A four-day coroner’s inquest held at the Kamloops Law Courts concluded yesterday, April 14 after hearing from more than 30 witnesses who described the events preceding Setah’s death.

An inquest is not a criminal trial, but an opportunity to review the evidence before a five-person jury which will classify the death and make a list of recommendations to ensure a similar death does not occur.

The jury determined Setah’s death was a suicide and following their recommendations, entered the courtroom’s gallery to meet family members who travelled from Williams Lake for the duration of the hearing. Emotionally, each exchanged hugs, words of compassion and tears as they reflected on Setah and the inquest.

“My nephew was a very happy child. He laughed a lot. He loved to tease his sisters and he really enjoyed just being with family,” Valerie Setah said outside of court. “We assumed that when he was brought here he was under the best care and that wasn’t the case."

She adds the inquest has provided closure to family members and allowed them to come together and reflect.

Valerie, a practicing nurse, hopes the jury’s recommendations will be put in place and would like to see improvements to care continue in Williams Lake. She mentioned having care workers who speak Chilcotin would help with potential language barriers in the community.

Jurors made 15 recommendations to the First Nations Health Authority, Interior Health Authority, the Ministry of Children and Family Development and RCMP’s E-Division.

First Nations Health Authority:

• Work with the Yunesit’in government to provide resources for preventative measures or programs needed for early childhood and youth development to promote mental health.
• Dedicate financial assistance to families of youth that have been committed under the Mental Health Act and are forced to transfer to a dedicated psychiatric facility outside of their community to assist with travel so they can be there to provide support.
• Explore expansion of video conferencing health services (including mental health services) to all remote communities.

Interior Health Authority:

• Create an observation room for the Cariboo Memorial Hospital as quickly as possible where both adults and youth who have been committed under the Mental Health Act can stay for assessment.
• Establish that when youth are transferred out of their community to a designated psychiatric facility the receiving hospital should encourage and facilitate family involvement in their care when possible and appropriate.
• Enact a policy that states all psychiatric patients designated as ‘level one’ at Royal Inland Hospital should be seen daily by a psychiatrist.
• Expand the Car 40 program in Kamloops (partnership between RCMP and Interior Health) to operate at all times.
• Proceed with the planned mental health facility at Royal Inland Hospital as soon as possible.
• Give security personnel in mental health facilities specialized training to deal with their unique duties.
• Expand cultural sensitivity training for care providers when patient is presented to Royal Inland Hospital admitting emergency room.
• Ensure all public areas of Royal Inland Hospital are covered by security cameras.
• Add one more guard (total of two guards) in one-south psychiatric ward at Royal Inland Hospital.

Ministry of Children and Family Development: Adopt and implement the recommendations of the Williams Lake Collaborative Local Action Team to fund local agencies like Denisiqi Services to do the following:

• Establish specialized clinical assessments and planning for children and youth presenting to the emergency room in a mental health crisis.
• Create a crisis response team that is mobile, culturally inclusive and is resourced to provide intensive support to youth and their family for approximately five to seven days following the onset of a crisis.
• Create a designated youth crisis bed in Williams Lake where voluntary patients can go to support planning and prevent transfer to a designated psychiatric facility.

RCMP E-Division:

• Review the use of conducted energy weapons in the apprehension of patients under the Mental Health Act.
• Create a system to connect psychiatrists with RCMP members on critical incident scenes.

For previous coverage of the inquest, click here.