Ontario coroner calls inquest into suicide of Indigenous teen near group home

Family and community members of an Indigenous teen who died by suicide while in the care of the Ontario government and went undiscovered for seven months have succeeded in their effort to secure a public inquest into his death.

The Ontario government announced Thursday the west region supervising coroner would be examining the circumstances that led to the 2017 death of 16-year-old Devon Freeman, though it did not indicate when the inquiry would get underway.

The launch of an inquest marks a muted victory for Devon’s grandmother and his home First Nation in southern Ontario, who began calling for greater public scrutiny of his case in December.

Their official complaint to the coroner’s office said the teen was last seen alive in October 2017 near the Flamborough, Ont., group home where he had spent much of that year. Seven months later, in April 2018, his body was found in a wooded area roughly 35 metres from the home.

“One of the things that was told to me over and over when I was asking for an inquest was ‘Protocol was followed, everything was done the way it was supposed to be done,'” Shannon Crate, band representative for Devon’s home community of Georgina Island First Nation, said in an interview. “The protocols aren’t good enough. I just hope we can all learn from this so it never happens again.”

In a letter formally requesting the inquest, both the First Nation and Devon’s grandmother, Pamela Freeman, said communication breakdowns marred the case from beginning to end, with key players being kept in the dark about such crucial details as his mental health history and the length of time he was believed to be missing.

The letter outlined Devon’s long history of mental health struggles and suicidal ideation, dating back to his mother’s sudden death when he was six. The ensuing years were marked by escalating mental health challenges, increasingly erratic behaviour, and limited efforts to secure support and treatment, the letter said.

Pamela Freeman remained Devon’s primary caregiver for much of his life, but he officially became a Crown ward months before he died, it said. At that time, the letter said, he was living at the Lynwood Charlton Centre group home not far from Hamilton.

The letter said Devon tried to kill himself that spring, but was stopped by a friend. It said both group home staff and child protection officials learned of that attempt, but did not offer him meaningful supports at the time and did not share what they knew months later when Devon went missing for good.

The letter argued lack of information on his mental health history tainted the way Hamilton police responded to his disappearance in October 2017, repeatedly characterizing him as a runaway rather than a teen at risk of self-harm. The force did not immediately respond to a request for comment on the inquest and has previously declined to comment on the case.

A statement from the Ministry of the Solicitor General announcing the inquest offered few indications as to what the process would probe.

“The inquest will examine the events surrounding Mr. Freeman’s death,” it said. “The jury may make recommendations aimed at preventing further deaths.”

Devon’s case bares similarities to a dozen other files recently reviewed by the chief coroner’s office last year.

After a panel analyzed the deaths of 12 young people in the care of the province’s child welfare system, Dr. Dirk Huyer concluded poor communication between key players risked leaving kids without the care they need.

Two thirds of the children whose cases were reviewed were Indigenous, most died by suicide, and all contended with mental health struggles while living away from home.

Crate, the band representative, said Devon’s case fits the pattern, adding the inquest should shed light on the communication gaps and make recommendations to protect future Indigenous children from sharing Devon’s fate.

Crate said she’s experiencing mixed emotions about the pending inquest, saying the pain of rehashing the circumstances around Devon’s death will be worth the effort if it brings closure to the teen’s loved ones and helps keep children safe.

“What I’m hoping from this is we learn, and we heal, and we grow, and we do better,” she said.

This report by The Canadian Press was first published Feb. 13, 2020.

Michelle McQuigge, The Canadian Press