An inquest into the death of a 16-year-old patient who committed suicide last December after running away from a Saanich youth psychiatric facility got underway Monday.
Vancouver Island regional coroner Matt Brown will preside over the five-day inquest at the Western Communities Courthouse.
It will see a jury hear evidence from witnesses. Jurors will subsequently have the opportunity to make recommendations aimed at preventing similar deaths in the future.
Following the teen’s death on Dec. 19, 2010, the Vancouver Island Health Authority, which operates Ledger House, and Saanich police made internal changes to improve communication between the two organizations.
“We created communications protocols to make sure our staff in the communications centre and their staff who were calling us for assistance were really speaking the same language,” said Sgt. Dean Jantzen.
“We formalized a risk-assessment protocol to make sure that any perceived risks are clearly shared.”
VIHA released a report on Friday outlining series of recommendations to prevent patient deaths.
Seven recommendations were made after an internal quality review found room for improvement, namely in how a patient is assessed as a suicide risk, how staff communicate internally and externally, and how release passes are distributed.
The inquest runs Dec. 12 to 16.