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GA Inquest on Youth Suicide: Lessons Learned

This report provides an overview of a coroner's inquest on a youth suicide, highlighting the chronology of events and the recommendations made by the jury. The recommendations address various stakeholders, including criminal lawyers, legal aid organizations, government ministries, and youth justice facilities.

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GA Inquest on Youth Suicide: Lessons Learned

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  1. GA Inqueston Youth Suicide: Lessons Learned Prepared by Justice M.T. Devlin Ontario Court of Justice HSJCC Conference, Toronto November 2015

  2. Chronology • May 8, 1991 - GA was born in Russia; he had an older sister EA, 7 years his senior • 2002 – Family of 4 immigrated to Canada (GA was 11 years old) • 2003 – Parents separated (GA was 12 years old)

  3. Chronology (cont’d) • GA initially lived with his mother, then his father, then returned to live with his mother • GA’s sister, EA, lived with his father

  4. Substance Abuse Issues • Parents noted that GA’s behaviour changed when he started high school, age 14 • GA reported: • Daily use of marijuana • Binge use of ecstasy • Psychologist identified the potential of a drug-induced psychosis

  5. Mental Health Issues • 2007 – 2008: GA’s behaviour began to deteriorate (GA was 15 – 16 yrs old): • Truancy, Missing Curfew • Breaking Rules; Disrespectful • Inappropriate sexual comments/pornography • Significant use of street drugs

  6. Criminal Charges • December 2006: GA (15) convicted of armed robbery/wear disguise • Sentenced to 77 days PSC + 18 mos. probation • July 2007 – GA (16) convicted of assault w. a weapon/carry concealed weapon • Sentenced to 40 days PSC + 12 mos. probation

  7. Final Charges • January 2008: GA (16)was charged with assault cause bodily harm regarding EA/FTC with his YCJA sentences x 2 • EA had visible injuries to her face • Blood was splattered in the vicinity of the assault • EA told the police she was “scared for her life”

  8. Initial Court Appearances • January 25, 2008: GA appeared in Court and pled guilty; s. 34 Assessment Ordered • March 25, 2008: Based on s. 34 Assessment, Crown indicated consideration of a NCR assessment • Duty Counsel recommended Special Duty Counsel (SDC) appointment for GA

  9. Follow-Up • April 2, 2008: SDC assigned to the case; adjournment to review s. 34 Assessment • April 4, 2008: • SDC converted to Amicus Curiae at the request of GA • GA refused to come into the courtroom • JPT conducted to explore options for further psychiatric assessment

  10. Section 34 Assessment • GA found to have significant mental health issues and severe substance abuse issues • Secure treatment facility recommended • GA’s mother reported she was too fearful of GA to have him return home • GA’s father stated GA could live with him except that EA (victim) lived with father

  11. Appearances before Second Judge • April 14, 2008: • GA appeared in Court before a new Judge • NCR Assessment was ordered for May 13, 2008 • GA was transferred to a new facility for NCR Assessment

  12. Follow-Up • May 13, 2008: • GA appeared in Court with AC • Further 30 days requested to complete NCR Assessment • GA adjourned to next day, May 14, 2008 to appear before original Judge

  13. Post-Court Events • GA was transported to DRPS holding cells where he remained until 19:30 • 19:30: GA was transported to youth facility – he appeared normal during transport • 21:00: GA requested his dinner and took it to his room • 21:50: GA was found in his room, hanging by his shoelaces

  14. Inquest • Coroner’s mandatory inquest held over 21 days • 35 witnesses were called • 49 exhibits were filed • Jury Verdict and Recommendations were released on October 24, 2011

  15. Overview of Recommendations • The Jury made 71 recommendations • The recommendations are addressed to 7 stakeholders: • Criminal Lawyers Association • Legal Aid Ontario • Ministry of the Attorney General • Ministry of Community & Youth Services • Ministry of Health/Long-Term Care • Ontario Court of Justice • Youth Justice Facilities

  16. Recommendations by Organization

  17. Issues Addressed by Recommendations

  18. OCJ Recommendations • Of the 71 recommendations, 8 were directed to the OCJ and other justice organizations • The 8 OCJ recommendations relate to: • Understanding the vulnerability of youths in custody • Processes such as JPT’s, Striking guilty pleas • Training and Education

  19. Overview of OCJ Recommendations • The recommendations to the OCJ can be categorized into 2 main categories: • Judicial Reminders – 4 • Education & Training - 4

  20. Reminders • Recommendation 11 (to MCYS, MAG, OCJ) • Reminder of the ”crucial role” of Probation Officers for all in-custody youth • Recommendation 59 (to MAG, OCJ) • Reminder that JPT’s require the attendance of the accused/and or counsel

  21. Reminders (cont’d) • Recommendation 60 (to MAG, OCJ) • Reminder that pleas may be struck and re-entered • Recommendation 61 (to MAC, OCJ, CLA) • CLA provide short-list of qualified amicus counsel

  22. Education & Training • Recommendation 24 (to MCYS, MAG, OCJ, CLA, LAO) • Formal training and education for all “Justice System Professionals” on youth and mental health issues

  23. Education & Training (cont’d) • Recommendations 25 and 28 (to MCYS, MAG, OCJ, CLA, LAO) • Create a Case Study of the GA case for ongoing training • Recommendation 64 (to MCYS, MAG, OCJ) • Annual training on the legal principles of amicus curiae

  24. Thank You • I am indebted to: • Our Co-Op Student, Taylor Comden, and • Our Judicial Secretary, Tammy Irvine

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