Timothy Henderson did not appear to be receiving needed care, says N.W.T. coroner

The N.W.T.'s chief coronerdid not blame the Northwest Territories mental health system for the death of Timothy Henderson in 2015, but she did say it appeared Hendersonwas not receiving neededmental health care.

According to CathyMenard's report released on Wednesday, 19-year old Timothy Henderson died by suicideat home in Yellowknife on April 21, 2015. Hendersonwas discovered by a family member shortly after retreating to the garage where the musician "often went to play music and relax."

• N.W.T.'s mental health care system failed our son, say grieving parents

• Timothy Henderson case review will not be public, says N.W.T. health minister

Efforts were made to resuscitate Hendersonat Yellowknife's Stanton Territorial Hospital before being transported to the University of Alberta Hospital in Edmonton. Henderson was kept alive there until April 26, 2015, when life support was removed and Hendersonwas declared dead.

Henderson's mother and father both previously laid partial blame at the feet of the N.W.T. health care system which they said failed Henderson terribly.

High risk, support lacking

In her report, Menard said Henderson was at a high risk of suicide because of the impulsive nature of previous suicide attempts, and "clouded judgment" given the teenager'spersistent substance abuse.

She stated that "an integrated treatment approach with thorough safety planning, careful psychiatric diagnosis and care, structured psychotherapy and addictions supports was required."

Instead of receiving that care and support,Henderson "did not appear to have sustained psychotherapeutic supports."

In February 2015, Henderson made multiple visits to the Edmonton University Hospitalfor mental health care, including a visit to self-report an attempted overdose on Ritalin. Henderson was studying music in the city.

The teenreturned to Yellowknife to live with familyin March. By April 8 Henderson had self-admitted toStanton Territorial Hospital's inpatient psychiatric unit for "suicidal ideation and poor coping skills."

According to the report, Henderson's medications were adjusted slightly before beingdischarged on April 17, 2015. Henderson'sdischarge plan included follow-up visits with a local counsellor andfamily doctor. Records do not indicate if those appointments were kept.

Henderson was offered residential addictions treatment, but declined. The teenager was scheduled for a follow-up psychiatric appointment five-weeks later, but died before then.

Recommendations

"Timothy Henderson...struggled with chronic suicidal ideation, social isolation, a lack of emotional coping skills and substance abuse disorders," Menard wrote.

In her comments and recommendations Menardsaidthat Henderson's isolation worsened after moving from Yellowknife to a large centre where familiaritywith ways to seek needed help may have been lacking.

To address this, Menard recommended the Department of Health andDepartment of Education better coordinate mental health support for individuals who need itif they are leaving the North for education opportunities elsewhere.

Menard also called on the Department of Health and Social Services to develop an "integrated" approach to treating mental health problems and substance addictions, particularly for youth as they transition out of pediatric care while dealing with depression and suicide attempts.

That approach would use multiple treatments, including: evidence-based psychotherapies, cognitive behavioural therapy, interpersonal psychotherapy and dialectic behaviour therapy. All of these techniques can be delivered by trained social workers, mental health nurses, psychologists or doctors, Menard said.

She also recommended the department work with communities to "develop explicit support for families" of those dealing with mental health issues.

"There has to be some supports because right now, in the current system, there doesn't appear to be any," Menard told the CBC.

"Any improvement or enhancement in this area would be greatly appreciated by families."

Menard said she hopes the territory's new Mental Health Act will address some of her concerns.

The act will come into effect this year.