Office of the Chief Coroner

Publications & Reports

The Office of the Chief Coroner’s Death Review of the Youth Suicides at the Pikangikum First Nation

2006 – 2008

Appendix 2: Audit Tool

Youth Suicides in Pikangikum 2006 – 2008

Reviewer’s Name:__________________________________

Date Completed (yyyy\mm\dd):________________________

A. Demographic Data

1. OCC File #___________________

2. Sex: M F (Circle)

3. Date of Death (yyyy\mm\dd):_________________

4. Place of Death: (Circle)

a. Indoors I) Home II) Kinship home III) Friend’s home

IV) Other______________________________

b. Outdoors(describe):_______________________________

5. Age at death: Years________Months________

6. Medical Cause of Death:__________________________________________

7. Manner of Death:________________________________________________

B. Risk Factor Identification

Individual Risk Factors

8. Mental health history: (circle) Y N

Depression Eating disorder Anxiety disorder

Psychotic disorder Other:________________________________

9. Previous hospitalization, short-stay, or visit to a health care practitioner or social worker in the month prior to death? Y N

When?____________Reason?_______________________________________

10. History of threatening self-harm: Y N

When?____________Nature of threat:_________________________________

______________________________________________________________________

11. History of deliberate self-harming injuries Y N UN

When?____________Nature of harm:__________________________________

_____________________________________________________________________

12. Previous suicide attempts? Y N UN

How many?__________When?____________Nature of attempt:____________

13. Substance Abuse: Y N UN

Alcohol Solvent Abuse Marijuana Others:___________

14. Substance Abuse at the time of death?

Alcohol Solvent Abuse Marijuana Others:______________

15. Current treatment with psychotropic medications? Y N UN

Type______________________________________________________

16. Was there a history of medical problems? Y N UN

List:________________________________________________________

17. Sexual orientation: (circle) hetero bisexual gay/lesbian

Familial Risk Factors

18. Family history of suicide completion: (circle)

parent sibling grandparent aunt/uncle cousin

other:______________

19. Family history of mental illness:

parent sibling grandparent aunt/uncle cousin

other:______________

type: ______________

20. Family history of substance abuse:

parent sibling grandparent aunt/uncle cousin

other:______________

21. Parental separation? Y N UN

22. Parental divorce? Y N UN

23. Domestic violence? Y N UN

Describe:____________________________________________________

24. Was decedent a victim of child abuse? Y N UN

Neglect Y N UN

Sexual abuse Y N UN

Physical abuse Y N UN

Describe:_____________________________________________________

25. Was there a history of ongoing parent-child conflict?

Describe:_____________________________________________________

Biological Risk Factors

26. Evidence of Foetal Alcohol Syndrome: Y N UN

Socio-Environmental Risk Factors

27. Was the decedent a victim of violence in their community?

Y N UN

Describe:_____________________________________________________

28. Was the decedent involved in criminal activity/convicted of a criminal offence? Y N UN

Describe:_____________________________________________________

29. History of serious aggression? (e.g. assaulted another person)

Y N UN

Bullying Y N

30. Upcoming court date? Y N

When?____________________

31. School attendance problems? Y N

32. School drop-out? Y N

Last date of attendance prior to death:_________________________

33. School achievement: (circle)

limited below expected age at age expected above age

34. Learning disability identified? Y N

Nature__________________________________________________

35. Poverty: Was the family reliant on government agencies for financial support? Y N UN

36. Did the family reside in overcrowded conditions? (e.g.>1 person/room)

Y N UN

37. Was the decedent homeless? Y N UN

Psychological Risk Factors

38. Had there been a recent death of a boyfriend, girlfriend, family member or friend in the month prior to death? Y N UN

Relationship:___________________________

39. Was the death of this boyfriend, girlfriend, family member or friend due to suicide? Y N NA

40. Had the decedent had a recent romantic break-up?

Y N UN

41. Did the decedent have an ongoing conflict within a romantic relationship?

Y N UN

C. Child Welfare Involvement

42. Was the file of the decedent or family open to CAS or had the file been open to CAS in the preceding 12 months? Y N

43. Had the file ever been open to CAS? Y N

44.Reasons the file was opened:

______________________________________________________________________________________________________________________

45. Was the youth’s mental health being monitored by the CAS?

Y N

Nature of concern being monitored:

_________________________________________________________________________________________________________________________________________________________________________________

46. Had efforts been made to accession mental health services for the deceased by the CAS? Y N

Describe:_________________________________________________________________________________________________________________________________________________________________________

Provide a summary of the death. Include a description of:

The circumstances of the death.

The 5 facts related to death.

The involvement of CAS at the time of death.

Any mental health services which had been provided in the months prior to death.

Any recommendations which arise from your review that may prevent deaths in similar circumstances in the future.

Narrative:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Bibliography