Ministry of Community Safety and Correctional Services :: Part A: The Deaths of the Youths by Suicide

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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



Part A: The Deaths of the Youths by Suicide

A1. Introduction

The principal activity of this death review was to examine the deaths of the Pikangikum children individually, using a variety of different sources of information that were available to the coroner, which might not ordinarily be available to others examining the deaths. (Please refer to The Project Charter, Appendix 1.)

A2. Method of Review

Documents related to the children were examined by four reviewers from the Office of the Chief Coroner. The compiled documents, some obtained exercising the Coroner’s Authority to Seize, included:

  • The original investigating coroner’s report of the death, the Coroner’s Investigation Statement.
  • The Report of the Post Mortem Examination, as prepared by the pathologist.
  • The police reports of the death.
  • The health record of the deceased.
  • The Serious Occurrence Report of the Tikinagan Child and Family Services.
  • The Child Fatality Case Summary prepared by the Tikinagan Child and Family Services.
  • The Internal Review (if completed) prepared by the Tikinagan Child and Family Services.
  • The Paediatric Death Review Committee’s report of the death.
  • The educational records of the deceased.

The Office of the Chief Coroner was successful in obtaining all of the records with the exception of the educational records, which were not released to us by the Pikangikum Education Authority, despite repeated requests.

One of the limitations noted was that First Nations people living on reserve obtain their health care through a variety of different sources, both federal and provincial, and further, in different provinces on occasion. In each case, Health Canada did provide their existing records for the children, however, these records often did not contain medical treatments or interventions that occurred in provincial hospitals, or in drug treatment programs in other provinces.

The Office of the Chief Coroner assigned four reviewers to the cases. Each reviewer then completed an extensive audit tool surveying 48 different items.1 Each reviewer was required to review four of the deaths. These items broadly surveyed the following thematic areas:

  • Demographic data: age, sex, place of death, date of death, age at death, cause of death and manner of death.
  • Risk factor identification: mental health history, hospitalizations, history of threatening self-harm, previous suicide attempts, substance abuse, use of psychotropic medications, medical problems and sexual orientation.
  • Familial risk factors: family history of suicide completion, mental illness, substance abuse, separation, divorce, domestic violence, child abuse, ongoing parent-child conflict, history of residential schools in the parents of the children.
  • Biological risk factors: evidence of Foetal Alcohol Spectrum Disorder (FASD).
  • Socio-Environmental risk factors: reports that the decedent was a victim of violence, involved in criminal activity, assaults on other people, had an upcoming court date. Evidence of school attendance problems, learning disabilities, poverty, overcrowding, homelessness.
  • Psychological risk factors: recent death of boyfriend, girlfriend, family member or friend in the previous month. Was the death due to suicide, recent romantic break-up, or ongoing romantic conflict?
  • Child welfare involvement: was the file open to CAS at the time of death or within the previous 12 months and the reasons why? Was the child’s mental health monitored by a CAS? Were efforts made to procure mental health services for the deceased by the CAS?

Upon completion of the Audit Tool, the primary reviewer then completed a narrative summary of the death of the child.

On November 10, 2010, an expert panel was convened at the Office of the Chief Coroner for the purposes of reviewing all of the deaths. A summary report of the Audit Tool for the 16 deaths was compiled, and the document was reviewed to examine whether or not certain trends or observations contained within the compiled document might shed some light on causes, or potential direction for recommendations directed to the avoidance of death in the future. Following this, each one of the 16 deaths was reviewed individually, upon which issues arising from those deaths were identified, and recommendations developed.

The panel members are identified in Appendix 3.

A3. The Deaths

The following five deaths are provided to the reader as representative of the deaths which were reviewed by the panel. Each has a constellation of issues which reveal the difficult challenges the children faced. The themes and the tensions in their lives are recurrent and repetitive.

A repeated comment from the panel was that these children had demonstrated, time and time again in the face of overwhelming challenges and assaults on their physical, emotional, mental, and spiritual well-being, genuine resilience. Their tenacity and their ability to cope in their youthful troubled lives were viewed as strengths from which to build. Ultimately, they did succumb to an impulse in a suicidal act. The names in each case have been changed as have the dates for the purpose of confidentiality.

Case #1

Vanessa was 16 years 2 months of age when she was found hanging in the laundry room of the family home where she was suspended in a near sitting position by a shoelace. Vanessa had that evening, broken up with a boyfriend of six months. She left a note to him on her Internet webpage indicating that he would be sorry she was gone and he would miss her. Prior to committing suicide, she had telephoned a girlfriend and indicated that she was going to “do something” to herself. She was attending school at the time of her death, and was not a sniffer. She was however, an alcohol abuser who had been arrested on two occasions and placed in jail overnight.

There had been seven children in the family. Tikinagan Children’s Aid society (CAS) became involved with the family in 1999 when a brother was apprehended for being intoxicated with solvents. This older brother, who was a solvent abuser, hanged himself in 2002 with an electrical cord. Vanessa’s parents had several issues which were epidemic in the community. They were alcoholics who would frequently binge drink. On one such occasion in March 2002, they left the home while intoxicated having made an arrangement for a family friend to pick up the children later in the day. This occurred several hours later. The friend picked up 10 year-old Vanessa, who was caring for her 4 month-old brother. They were brought to the home of the family friend, fed, and put to bed for the night at 22:30 hours, together in a single bed. The 4 month-old awoke at 03:00 hours, and Vanessa rocked him back to sleep. The following morning, he was found dead on a foam mattress beside the single bed. He died while sleeping in an unsafe sleep environment.

In June that year, both parents were jailed for domestic violence when Vanessa’s father struck her mother with a piece of wood. In the absence of the parents, the children were looked after by their grandparents. In the late summer that same year, her older brother, a known sniffer committed suicide as previously described. The following year, in 2003, Vanessa’s mother attempted suicide by overdosing on Tylenol and Motrin. By 2005, both parents were sober and abstaining. CAS reviewed the household and all of the children and the house were in good order.

Growing up in a household with both domestic violence and alcohol abuse, Vanessa began to abuse alcohol, and was a witness to significant assaults in the community. She also began socializing with a group of girls who were charged on occasions with swarming and beating other young girls. In addition, she herself was assaulted in the community.

At 14 years 2 months of age, she was attacked and assaulted by an intoxicated sniffer. At 14 years 7 months of age, she was assaulted by a male at school. At 15 years 3 months of age, she was physically assaulted by another girl.

In May 2006, while with a gang of girls, she participated in an assault on a girl who was pushed to the ground, kicked, and punched. Later that same month, she was charged when she threw a hockey stick at a peacekeeper’s vehicle. In July of 2006, again while with a gang of girls, she attacked another girl with a shovel. In addition to these acts of violence, she witnessed two assaults: in one, a male struck another in the head with a chair, and in another, a male struck another male in the head with a hammer.

Four months before her death, she was found publicly intoxicated and lodged in the police cells overnight. Three months later and one month before her death, she was again found to be publicly intoxicated and lodged in the police cells overnight.

In many ways, Vanessa’s family suffered with the same recurrent problems as other families:

  • Alcoholism in the parents.
  • Abandonment, neglect and lack of supervision of the children by the parents while under the influence of alcohol.
  • Domestic violence.
  • Suicide attempts in the parents.
  • The deaths of siblings: one at 4 months of age sleeping in an unsafe sleep environment, the other, by suicidal hanging while solvent sniffing.

Although she remained in school and was not a solvent abuser herself, she was both the victim of violent acts and a perpetrator as she became involved in female gang activity. Towards the end of her life, it was clear she was developing a pattern of alcohol abuse.

Case #2

Janice was 16 years 5 months of age when she died after being discovered hanging in the home she shared with her grandparents. Earlier in the day, she had been drinking alcohol with her friends and at the time of her death, she smelled of gasoline. It appeared that she had removed the ceiling tile exposing a rafter from which she attached a sheet. She was found by her brother. The cause of death was hanging, and the manner of death was suicide.

At her autopsy, she was noted to have a healed cigarette burn and a more recent one on her right forearm. These appeared to be self-inflicted.

Janice had endured a challenging life. She was one of 10 children, none of whom were actually raised by their biological parents. Her mother, at different times, did reside with her children, but this generally occurred only when the children were in Customary Care of the grandparents. The family first came to the attention of the CAS when Janice’s older brother stopped residing in the family home, and began living in a vacant residence inhabited by solvent sniffers. He ultimately was apprehended and brought into care of the CAS.

Janice was brought to the attention of the CAS by her mother, who was living with her common-law and not residing in the home where Janice lived with her grandparents. Her mother reported that Janice had become addicted to solvents, which she began using at 10 years of age. Her mother stated that she could not look after her. Janice was picked up by police and lodged in the police cells overnight at 10, 11, 12, and 13 years of age. When she was 13, she was apprehended six times for public intoxication due to solvent abuse from gasoline sniffing. She was taken into care and placed in several different foster homes in Sioux Lookout, Kenora, Poplar Hill, and Wabigoon until placed at the Selkirk Healing Centre in Manitoba from August 2003 until February 2004. Janice returned home under a Customary Care Service Agreement involving extended family members and community resources.

In May of 2004, at 12 years of age, Janice was found by her grandmother hanging in their home by a tee shirt and was cut down by an uncle. She was brought to the Pikangikum Nursing Station by her family. There she reported that this was in response to the death of her best friend by suicide two weeks before. She was also one of eight girls who had made a suicide pact. During the interview, she ran out of the Nursing Station, and was found by police two hours later. When brought to the Nursing Station, she was high on gas and was sent to jail for the night to detoxify and return to the clinic for a reassessment in the morning. This was reported to Tikinagan Child and Family Services. She was ultimately transferred to the Sioux Lookout Hospital, admitted with a diagnosis of suicide attempt, substance abuse (gasoline) and behaviour problem. She was referred to Nodin Child and Family Intervention Services, and ultimately, to a treatment centre in Saskatchewan.

Janice was engaged in high risk behaviour. She was sniffing gasoline, staying out all night and not attending school. She was charged with assaulting another girl at 14 years of age. It was reported that she pushed the girl to the ground and kicked her in the face. She claimed to have no recall of the event. She was placed in care from May 2004 until May 2005. While in care, she was referred for treatment to the White Buffalo Treatment Centre in Prince Albert, Saskatchewan from May until August 2004, and in the Selkirk Healing Centre in St. Norbert Manitoba from August 2004 until March 2005. Janice returned to Pikangikum in March 2005 to live with her mother who was then residing with her grandparents.

In June 2005, a family services worker observed her mother intoxicated and unconscious on the floor of the home. As a result, Janice was placed at Mary Homes in Orleans, Ontario from July until September 2005. In October 2005, the Chief requested that Janice be removed from the community for beating up her grandmother. She was placed in care again from October 2005 until April 2006. She then returned to her grandparents’ home.

In February 2007, Janice, at 15 years of age, was assaulted by her boyfriend. She smelled of gasoline when brought to the Nursing Station. There was a concern that she was pregnant. That same year, she was involved in a very serious assault and charged. Apparently, she critically injured another girl by stabbing her with a knife. She was arrested and charged with aggravated assault and remanded to the Kenora District Jail. She was released on an undertaking to keep the peace. Janice was admitted to Portage Youth Centre in March of 2007. Janice returned home, and her case file was closed with the Tikinagan Child and Family Services in October 2007. It was assumed that she lost the suspected pregnancy, but the details are unknown. She had repeated pregnancy tests when followed by Tikinagan, and had tested positive for a sexually transmitted disease.

The following year, Janice was arrested for assaulting her boyfriend. Two weeks following that arrest and pending a court date, she hanged herself.

Janice does not appear to have been seen by a counsellor while in Pikangikum, or to have had a psychiatric diagnosis aside from solvent abuse. She was not engaged in any form of ongoing therapy, and abused alcohol and solvents until the day of her death.

Case #3

John was 12 years and 5 months of age when he hanged himself from a poplar tree outside his grandmother’s home. He was found suspended from a branch by a nylon cord, by two ten-year-old boys. Just prior to the event, he had visited his mother’s gravesite situated 100 feet away, outside his home.

His cause of death was hanging. His manner of death was suicide. His autopsy described him as a prepubescent male.

His mother had been a chronic alcoholic who had killed herself by hanging 11 months before. She was in her early thirties. Following her death, John had suffered visual and auditory hallucinations and expressed suicidal ideation.

John’s mother had abstained from alcohol during her pregnancy with him. He was born full term, but was thought to have suffered from congenital toxoplasmosis. He suffered global developmental delay, he was hearing impaired and speech delayed. He was not toilet-trained at 5 years of age, and his primary language was Ojibwa.

Both John’s parents were severe alcoholics. They drank regularly and frequently. There were four children in the family. He had a younger and an older brother, as well as an older sister. His file was open to the Tikinagan Child and Family Services due to caregiver capacity. John’s father was his only surviving parent and his father’s alcoholism worsened after the death of John’s mother. The family were initially referred to CAS when John’s father was found passed out from alcohol intoxication while caring for John’s older brother in another town. His older sister had repeatedly attempted suicide, and was a solvent abuser. His older brother had been referred out of town for therapy for solvent abuse. Service plans were developed with the CAS, in which “…the caregivers were to learn appropriate parenting skills to deal with a teenager, and, caregivers were to provide appropriate supervision for children.” It was common knowledge in the community that both parents were frequently intoxicated and there was poor attendance of the children at school.

In January of the year of his death, when John was 11 years of age, Nodin Child and Family Intervention Services referred John again to Tikinagan. They expressed concerns that he had been having hallucinations about his mother and the devil, and had been drinking with his father and his father’s girlfriend. A child protection investigation was undertaken and it verified concerns about lack of supervision and substance abuse on the part of the father. A few months later, his younger four-year-old brother was found wandering the streets alone at 08:30 in the morning.

John was a solvent abuser. He was arrested and lodged in the police cells overnight having been picked up for intoxication from gas fumes, shortly after his 12th birthday. At the time of his death, John had been residing at his grandmother’s home while Tikinagan staff was attempting to locate a residential treatment program for him for his solvent abuse and suicidal ideation. John was a heavy sniffer and had not been attending school in the months prior to his death.

The sole steadying influence for John was his paternal grandmother, who provided support and protected the children in the family. Prior to the death of his mother, the children had suffered years of neglect and emotional abandonment as a consequence of their parents’ alcoholism.

Case #4

Donald was 15 years and 10 months of age when he was found hanging in his parents’ home. He had suspended himself from a rafter to which he had affixed a bed sheet. His father found him in the morning. When asked why he thought his son had killed himself, his father responded that perhaps it was because he had told him to go to school the next day.

The cause of death was hanging. The manner of death was suicide. At autopsy, there was evidence of self-harming behaviour such as cigarette burns on his right forearm, as well as linear and oblique scars on both forearms (consistent with self-inflicted cutting).

Donald had a long history of solvent abuse, and on the evening before his death, his father had found him in the bushes behind the house and asked him to come inside. At the time, he smelled of gasoline.

The family were first referred to Tikinagan Child and Family Services in 2001 by the police due to:

  • Domestic disputes between the parents.
  • A suicide attempt by Donald’s mother.
  • Lack of supervision of the children.
  • The children not being in school.

In 2003, Donald required hospitalization due to burns received while sniffing gas. Apparently, his younger brother had poured gas on his leg and lit the gas on fire. While he was hospitalized, attempts were made to communicate with him, but he was non-communicative, and spoke Ojibwa almost exclusively. At 13 years of age, he had been out of school for two years, and it was suspected that he suffered with Foetal Alcohol Spectrum Disorder (FASD).

In 2004, the police remained concerned about sniffing in the children, and the parents were not engaged in parenting, as there was an ongoing domestic dispute. The CAS began to monitor the family once per month. In 2005, the father threatened to kill the mother with an axe, and the children were heavily involved in sniffing. Donald told his sister on one occasion that he would kill himself if his parents continued to drink. Donald was arrested for being intoxicated under the influence of solvents six times in 2003, ten times in 2004, and four times in 2005. In each instance, he was arrested and placed in jail overnight for safety reasons.

Donald and his brother were placed in care, but returned after two months as the grandmother opposed the placement. They returned in the early fall of 2005. While in care, Donald could not be tested due to lack of communication. He did not understand the reasons why he was in care.

Later that fall, Donald contacted his father when he wanted to use the snowmobile. He told his father that he would kill himself if his father did not return home promptly.

Ultimately, Donald was emotionally deprived and his parents, who were known to be heavy consumers of alcohol, were detached and uninvolved with him. His mental health needs were unknown and his substance abuse continued unabated until his death. He was a youth who was lost with no supports. His friends, when interviewed after his death, described him as quiet.

Case #5

Margaret was 18 years of age in 2008 when she was discovered suspended by a rope from a tree behind her home by her father. She resided there with her parents and several siblings. She had spent the day before solvent sniffing with her brother. He had noticed a rope in her pocket and had notified her father, who called the police. When the police arrived, Margaret fled and could not be located. The following morning, she was found by her father.

She had expressed feelings of depression and suicidal ideation many times in her young life. She was viewed as a high risk for suicide. Her companions, who were also sniffers, called her fat and ugly which she found very hurtful. In 2006, she informed a counsellor that she was hearing voices telling her to hang herself. She had made at least four suicide attempts in the past, including one month before her death and the very weekend before her death, when she was found hanging and cut down by a family member. She was not referred for any treatment on either occasion. She was under the influence of solvents each time.

In 2004, one of her brothers had committed suicide by hanging. His name was tattooed on her left forearm. In the year prior to her death, her younger brother had died and her good friend had committed suicide. She had recently lost a job that she had in town, and a suicide note dated the day of her death, stated that the reason she was committing suicide was because she wished to be dead as people hated her.

Four years before her death, she became involved with substance abuse and suicidal ideation. She was taken into care by Tikinagan Child and Family Services and placed in Winnipeg. A safety plan and good behaviour contract was signed by Margaret and her parents and it outlined expectations for her behaviour. These included keeping the peace, no mischief, violence or fighting and complying with her parents, police and Tikinagan.

In 2004, she was convicted of assault and sentenced to six months probation. In 2007, she was again convicted of assault, and served 66 days pre-sentence and was given another five days. Later that year, she was placed on four months probation for Failure to Comply with a Recognizance.

She herself was also the victim of violent assaults. In 2005, while intoxicated, she was struck in the head with a hockey stick, requiring suturing and a 3-day hospital admission. The following year, she was assaulted by two girls. She was sexually assaulted in 2006 and again in 2007 for which she received treatment. In 2006, she was alleged to having been beaten by her father, and in 2007 and 2008, by a sibling.

In 2006, she was transported via Medevac to Winnipeg and sent to a 16-Week Addiction Treatment Program due to her suicidal ideation and solvent abuse/addiction. In August of 2007, she was referred to Nodin Child and Family Intervention Services for mental health counselling. It is unknown if she was receiving any mental health supports at the time of her death.

Margaret’s life demonstrated a theme of feeling unloved and unwanted. She was a victim of both physical and sexual assault. The physical assault occurred both within and outside her family, and she herself became an aggressor. She abused solvents and despite being at extraordinarily high risk following an attempted hanging from which she was cut down by a family member, no medical intervention was sought. In addition, she had an undiagnosed mental illness, in which she suffered with auditory hallucinations. She had suffered many losses in her life including her brother, another infant brother, her friend, and her job at the time she ended her own life.

A4. Emerging Themes from Review of the Individual Cases

The following trends were observed in the 16 deaths reviewed:

  1. The children were heavily involved in substance abuse, mostly solvent sniffing, but alcohol as well.
  2. The children appear to have become attached to a subculture of sniffers in the community to whom they became emotionally attached.
  3. Although they were placed in detoxification programs outside of Pikangikum, it does not appear that they were involved in active counselling or therapy for solvent abuse within the community, or upon their return to the community.
  4. Their rate of recidivism for solvent abuse was 100% following detoxification at outside programs.
  5. Their immediate family members were heavily involved in substance abuse, their parents in alcohol abuse, their siblings in solvent sniffing.
  6. The children had lost immediate family members to suicide, including siblings and parents.
  7. The children were subject to physical and emotional abandonment, neglect, and lack of supervision while their parents were under the influence of alcohol, which occurred commonly.
  8. The children resided in homes where domestic violence was common.
  9. The children were sometimes victims of physical and sexual abuse. At times, the perpetrators of the physical abuse were immediate family members.
  10. Some of the victimized children of physical abuse became abusers themselves.
  11. Many of the children had been arrested and charged with assault themselves.
  12. Most of the children had been arrested multiple times for solvent or alcohol intoxication and were then housed in jail for the night. Many had multiple episodes of incarceration.
  13. Many of the children had attempted suicide in the past.
  14. There was evidence in several of the children of self-inflicted injuries at autopsy.
  15. Grandparents had a significant stabilizing influence in their lives.
  16. Many had extensive involvement with CAS, and had been in the care of the CAS during their lives.
  17. Several had foster care placements for periods of time.
  18. Few of the children had any involvement with school at the time of their deaths. Their lives were occupied by sniffing at night, sleeping during the day and truancy from school.
  19. The children had ceased to be active in school at very early ages.
  20. Their levels of academic achievement ensured that they were ill prepared to face the rigours of adult life in contemporary society, either a First Nations’ society or otherwise.
  21. Some of the children had suffered with auditory and visual hallucinations and did not appear to have received a psychiatric assessment, diagnosis, or treatment for these symptoms.
  22. Episodes occurred in which the children were rescued from substantive parasuicidal events, such as being cut down while hanging. In some instances, no medical care at all was sought. At other times, the medical care needed could clearly not be obtained. An understanding of the gravity of the attempted hanging as a predictor of future successful suicide was under appreciated by community members.
  23. A recurrent theme was the negotiation between the family, the First Nation and Tikinagan Child and Family Services for where, and with whom, the child would reside. At times, it appeared that a child was returned to a family despite the presence of a fragile safety plan, at the insistence of the family or the First Nation. The preference of the child, the family, or the First Nation, however well-intentioned, was substituted for the professional judgement of the CAS. The outcome was ultimately the death of the child.
  24. In some cases, the police had apprehended children for public intoxication due to solvent abuse, but the CAS did not appear to have been notified or subsequently engaged with the family.

A5. The Cumulative Report and Identified Trends

There are some trends that emerged from this compilation of data that might readily lend itself to recommendations directed toward the avoidance of death in the future.

Demographic Data

  • Of the 16 deaths, eight (50%) occurred in each of both males and females.
  • A surprising finding was that fully ten of the 16 deaths appeared to have occurred in three clusters:
  1. Cluster #1: three deaths in five days in January 2006
  2. Cluster #2: four deaths in 27 days from May - June 2007
  3. Cluster #3: three deaths in 19 days in August 2007
  • The location of the death in seven instances was where the decedent was residing, in either their own homes, or those of their grandparents. The remainder occurred in the rural outdoors.
  • The age of the 16 children at death included:
  1. four at 12 years of age (25%)
  2. two at 13 years of age (12.5%)
  3. one at 15 years of age (6.25%)
  4. three at 16 years of age (18.75%)
  5. three at 17 years of age (18.75%)
  6. three at 18 years of age (18.75%)
  • All of the deaths were due to hanging (100%).

Individual Risk Factors

  • Nine (56.25%) of the children had suffered with some form of mental health history including depression, eating disorder, anxiety, psychotic disorder and/or undiagnosed disorders.
  • None (0%) of the sixteen had a previous hospitalization, short-stay, or visit to a healthcare practitioner or social worker in the month prior to death.
  • Nine (56.25%) had a history of threatening self-harm.
  • Six (37.5%) had suffered self-harming injuries, including cutting, burning themselves with cigarettes or self inflicted abrasions.
  • Eight (50%) had previous suicide attempts.
  • 14 (87.5%) were known to abuse substances, and the history of 2 was unknown. These 14 were solvent abusers.
  • 11 (68.75%) were abusing substances at the time of their deaths, including solvents in 10 cases, alcohol in 1 case, and both in 2 cases.
  • None (0%) of the children were taking psychotropic medication.
  • Six (37.5%) of the children had recorded medical problems.
  • Sexual orientation was implied by inference from relationships, but was thought to include 12 heterosexuals, and four whose orientation was unknown. This data is soft at best.

Familial Risk Factors

  • Nine (56.25%) of the children had endured a family history of suicide, including parents (two), sibling (six) and aunt/uncle in three.
  • Five (31.25%) had a family history of mental illness.
  • 13 (81.25%) had a family history of substance abuse including parents (nine), siblings (eight), grandparents (four) and cousins (two). Some had more than one.
  • Parental separation had occurred in three (18.25%), but none were divorced.
  • Domestic violence occurred in seven (43.75%), was absent in two, and in seven instances was unknown.
  • In nine (56.25%) cases, there was evidence of child abuse, in two cases there was not, and in five cases it was unknown. The forms of abuse did overlap, however, there were nine cases of neglect, two of sexual abuse and one of physical abuse. Forms of abuse with respect to neglect included supervision, nourishment, and hygiene.
  • In seven (43.75%) cases, there was a history of ongoing parent-child conflict. These conflicts concerned gas sniffing behaviour in the children and general behaviour management.

Biological Risk Factors

  • One child had evidence of Foetal Alcohol Spectrum Disorder.

Socio-Environmental Risk Factors

  • Nine (56.25%) of the deceased had been victims of violence in the community.
  • Nine (56.25%) had been involved in criminal activity themselves, including such items as break and enter, theft and assault.
  • Six (37.5%) had a history of serious aggression toward another person and four were involved in episodes of bullying.
  • Two (12.5%) had upcoming court dates.
  • Nine (56.25%) had school attendance problems and had dropped out. Only one did not, and the Office of the Chief Coroner was unable to determine the school status of the other six.2
  • One child had an identified learning disability.3
  • Seven (43.75%) of the children resided in overcrowded conditions; one residence had 16 people living in it, two residences had eight people living in it, two had a minimum of six residents and one had five people living in it.
  • None (0%) of the children were homeless.

Psychological Risk Factors

  • Three (18.57%) had suffered the death of a friend in the month prior to the their death.
  • In all three (18.75%) cases, the death of the friend was from suicide.
  • In three (18.75%) cases, the decedent had suffered a recent romantic break-up.
  • Four (25%) of the decedents had an ongoing conflict in a romantic relationship.

Child Welfare Involvement

  • In nine (56.25%) cases, the file was open or had been open to the CAS in the previous 12 months.
  • In 11 (68.75%) cases, the file had been open to the CAS in the past.
  • The reasons that files had been opened included inability to manage behaviour, parent-child conflict, lack of supervision, neglect, home conditions, sibling gas sniffing, suicide attempt in mother, alcohol abuse, children not in school, parental substance abuse, child abuse, questions about caregiver capacity, death of a sibling and solvent abuse.
  • In four (25%) cases, the youth’s mental health was being monitored by the CAS.
  • In five (31.25%) cases the CAS had attempted to obtain mental health services for the youth.

A6. Discussion

The most compelling trend arising from the review was the identification of the youth suicide occurring in clusters. There were three clusters of death: one in January 2006, another in May/June 2007 and a third in August 2007. A cluster, as related to suicide, is a grouping of suicides occurring within a specified period of time. This concept has been further defined by Davidson, who restricts the use of the term to “…three or more suicides occurring within a defined space and time.”4 Contagion is a process whereby one suicide facilitates another.5 O’Carroll has estimated that 5% of teenage suicides in the United States are due to clusters. Referencing a period of one month within Pikangikum, there were three such clusters.

Youth exposed to suicide will be affected by that exposure in different ways. There is evidence that a suicidal event will profoundly affect those with a previous history of suicidal ideation; depression, substance abuse, personality disorders, recent losses and legal problems are further known risk factors for suicide.6 Virtually all of the youth involved in the deaths at Pikangikum had several of these risk factors. The report of a youth conference conducted in Pikangikum on March 25-27, 2008 stated the following:

“Following the suicide of a 16 year old student in Nov. 2007, a debriefing was held with three groups of students (N=50). Of these students, 41 said they were unable to resolve the loss of a loved one, friend, or relative; 26 think of suicide and have tried it.”7

The trend for suicides to occur in clusters underscores the need for a postvention program where survivors are assisted in coping and individuals at risk for suicidal behaviour are identified and referred for counselling. Postvention is a strategy directed to the prevention of a cluster when a community has been exposed to a suicide.8

Another trend was the surprisingly young age of the children who took their lives. Six of the children were under the age of 15 for the years 2006-2008. When one reviews the entire population of Ontario for the same period of time, there were 24 total deaths by suicide of children in a population of approximately 13,000,000.

Suicide in youth of this age is extremely rare. Despite this, Pikangikum youth contributed to 25% of all suicide deaths in the province for children less than 15 years of age during this time period. This suggests that primary prevention programs need to be tailored to the “young” youth, those from 10-14 years of age.

All of the children killed themselves by hanging. It may be that hanging was the most accessible method. Typically, suicides are completed in a variety of ways including: lethal intoxication, either drugs or carbon monoxide, descent from a height, blunt force trauma due to walking/jumping in front of a train or subway, self-inflicted gunshot wounds, self-inflicted sharp force injuries as with a knife, and hanging. All of the 16 deaths at Pikangikum were by hanging. This represents a copycat or imitation phenomena.

None of the 16 children had a visit to a physician, nurse, mental health worker, hospital, or clinic in the month before their deaths. Three possible explanations exist that may explain this result. The first is that they simply did not seek care, choosing to quietly endure their personal turmoil. The second is that they could not access care. However, the presence of a nursing station within the community operating 24/7 would not support this reasoning. The third is that despite good evidence that they were fragile, given that:

  • Nine (56.25%) had a history of threatening self-harm,
  • Six (37.5%) had suffered self-harming injuries, including cutting, burning themselves with cigarettes or self inflicted abrasions,
  • Eight (50%) had previous suicide attempts,

it appears that family, friends, and companions did not compel them to seek care. In one of the cases, the decedent had attempted suicide in the week before her death and had been cut down by a family member from an attempted hanging. She clearly presented a serious risk. However, she was not brought to a qualified professional for care. Pikangikum is a community in which suicide is a known occurrence. It may be that the community has been desensitized to parasuicidal behaviour, due to its frequency. It may be that there has never been instructional education made available to its constituents to assist them in recognizing very serious symptomatology that necessitates the observer to compel the child/youth to obtain medical care. An opportunity for education in a primary prevention program clearly exists.

Nine (56.25%) of the children had suffered with some form of mental health history including depression, yet none of the children were taking psychotropic medication. There is a strong correlation between psychiatric illnesses and suicide. It is believed that 90% of suicide victims are suffering with a psychiatric illness at the time of their deaths.9 However, for younger victims, the same does not necessarily hold true.

“…in the controlled psychologic autopsy studies of suicides ages 15 and younger, Brent and colleagues found that 40% did not have any detectable psychopathology. In comparison, 90% of youth suicides aged up to 19 years had a psychiatric disorder. These findings deserve attention. In adolescent suicides, those who have no evidence of psychopathology have had disciplinary or legal problems, and particularly, greater prevalence of a loaded gun in the home.

Furthermore, Brent noted that youngsters aged 15 years and younger who had no diagnosable disorder might have had subsyndromal difficulties, excessive stress, and available means. Foley and colleagues noted that suicidal youth aged 16 and younger who had no diagnosable disorders had subthreshold, most commonly disruptive disorders; disabling relationship difficulties; or psychiatric symptoms with no associated impairment.”10

In a few of the cases examined during the Pikangikum review, the children were suffering auditory and visual hallucinations. In one case, the hallucinations were telling the youth to kill herself by hanging. These symptoms were reported to others, but acute intervention through immediate psychiatric referral was not contemplated, and the children, who may have been suffering with treatable psychosis, did not receive either a medication that may have helped, or an urgent/emergent psychiatric consultation.

In the evolution of suicide prevention plans, targeted strategies based on this information might suggest that children and youth expressing suicidal ideation or exhibiting parasuicidal behaviour such as attempted hanging, should be brought promptly to a healthcare facility for a formal evaluation by a psychiatrist. The potential benefits of medication should be realized. However, for those less than 15 years of age, there may be an absence of psychopathology and the same generalizations about the benefits of medications may not be true. Importantly however, is that none of the cohort of children examined in the review was being treated with medications.

A concerning finding was that of the children who took their lives, 14 (87.5%) were known to abuse substances. These 14 were solvent abusers. In addition, 11 (68.75%) were abusing substances at the time of their deaths, including solvents in 10 cases, alcohol in 1 case, and both in 2 cases.

Solvent abuse is an extremely compelling social and public health issue in Pikangikum. A recently completed self-reporting survey of school age girls in grades 3 and 4 (7, 8, and 9 years of age) revealed the following:

  • 27% reported that they had sniffed
  • Of the sniffers, 19% reported that they had sniffed a lot since school had started
  • The five most common reasons for sniffing:
  1. So my friends will like me
  2. To have fun
  3. I was bored
  4. To stay warm
  5. To stop the pain and sadness inside of me

“Sniffing” is nasal inhalation; “huffing” is breathing fumes from a solvent soaked rag stuffed into the mouth; and “bagging” is breathing fumes from substances placed in a plastic bag held tightly around the mouth.11

Sniffing is a common problem worldwide and it is a group activity. The typical user is an adolescent male, with low self-esteem and a family background of alcoholism and physical aggression.12 Approximately 3-5% of adolescents in Canada have tried inhalants.13 Children who are intoxicated using volatile substances such as gasoline, resemble alcohol intoxication characterized by stimulation, loss of inhibition and depression at higher doses. Chronic solvent abuse may cause paranoid psychosis, permanent epileptic foci, and cognitive impairment. Some may develop one or more of the following symptoms:

  • Schizophreniform illnesses with visual hallucinations.
  • Temporal lobe epilepsy manifested as recurrent explosive behaviour.
  • A decrease in intelligence quotient.14

Some of the children reviewed exhibited the described behaviours, namely visual hallucinations and repeated episodes of explosive violent behaviour, which they subsequently had difficulty recalling.

Treatment is very challenging. Pikangikum has offered a land-based detoxification program. The program is offered over 12 days, involving four workers and about eight children per rotation aged eight to 18. The treatment involves the assignment of activities in shifts, and includes chores such as: drawing, writing, traditional outdoor activity, trap line, cutting wood, crafts, a sharing circle, playing hockey, broom ball, and volleyball.

The program Director, Lachie Macfadden estimated that 95-100% of the participants sniff when they return home, and it may be closer to 100%. Upon discharge from the program, the children go directly back to the environment from which they came. Following the program, the participants have difficulty re-integrating and it was reported that parents do not provide guidance. Residential treatment programs outside of the community frequently accessed include:

  • Whiskyjack Treatment Centre, Norway House, Manitoba
  • Ka-Na-Chi-Hih Specialized Solvent Abuse Treatment Centre, Thunder Bay, Ontario
  • Nimkee NupiGawagan Healing Centre, Muncey, Ontario
  • White Buffalo Youth Inhalant Treatment Centre, Saskatoon

Given the correlation between substance abuse and suicide, the high prevalence of solvent abuse in the community, and the prevalence of solvent abuse in the children examined in this death review, where 14 (87.5%) were known abusers, effective treatment strategies must be evolved.

In March 1999, during a joint health policy forum, Phil Fontaine, then National Chief of Assembly of First Nations identified issues contributing to the malaise of First Nations; “…three national components that must be taken into account; poverty, the effects of poverty and actions to eradicate poverty.”15

Review of familial risk factors revealed some compelling findings around exposure to suicide, family history of substance abuse, the presence of domestic violence and child abuse.

Nine (56.25%) of the children had endured a family history of suicide, including parents (two), sibling (six), and aunt/uncle (three). According to Hazell, the relationship between exposure to suicide and suicidal behaviour is that, “…direct exposure to suicide and subsequent suicidal behaviour is that exposure encourages imitative behaviour.”16 One child who hanged himself was seen visiting his mother’s grave site, approximately 100 feet from where he took his own life, immediately before he was found. She too, had died by hanging the previous year.

Also, 13 (81.25%) had a family history of substance abuse, including chronic alcoholism, and was a common finding amongst the parents of the deceased.

Domestic violence occurred in seven (43.75%) of the families of the children and in nine (56.25%) of the cases, there was evidence of child abuse.

Effective community strategies which provide in-community counselling regarding alcohol abuse for parents, as well as education for children and families around domestic violence should become a component of a comprehensive community-based suicide prevention strategy.

With respect to socio-environmental risk factors, our data around school attendance was incomplete as it was not provided by the Pikangikum Education Authority. However, the files themselves were revealing in that they suggested a pattern of behaviour in which the children were heavily involved in solvent abuse, slept during the day and went out at night. Interviews with educators suggested that children drop out of school beginning at approximately ten years of age. They become involved in solvent abuse and are otherwise disengaged with programming in the community in terms of recreation.

A7. Concluding Remarks

Our limited information is that 56.25%, or nine of the 16 children, had school attendance problems and had dropped out. Only one of the children who died was known to be in school, and was not a solvent abuser. The Office of the Chief Coroner was unable to determine the school status of the other six children.

Anecdotal interviews with a former principal suggested that he was aware of only one child in seven years that had taken her life by suicide, and was actively going to school at the time.

Programs directed by the First Nation to improve school attendance and to keep children and youth engaged in education would appear to have the most potential for benefits in preventing youth solvent abuse and suicide.

1 See Appendix 2: Youth Suicides in Pikangikum 2006 – 2008, Audit Tool.

2 The school records had been the subject of an Authority for Seizure. The Pikangikum Education Authority declined to provide these.

3 Again, this information is likely inaccurate as access to school records was not obtained.

4 Davidson L., Suicide clusters in youth. In: Pfeffer CR, ed. Suicide among youth; perspectives on risk and prevention. Washington DC: American Psychiatric Press, 1989:83-99.

5 Hazell, P., Adolescent suicide clusters: Evidence, mechanisms and prevention, Australian and New Zealand Journal of Psychiatry 1993; 27:653-665.

6 Ibid., p. 657.

7 Macfadden, Lachie, Pikangikum Youth Conference 2008, April 6th, p. 2.

8 Hazell, P. Adolescent suicide clusters: Evidence, mechanisms and prevention, Australian and New Zealand Journal of Psychiatry 1993; 27:p.660.

9 Links, P, Ending the Darkness of Suicide [editorial] Can J Psychiatry 2006;51;(3):129-130.

10 Dervic, K, et al, Completed Suicide in Childhood, Psychiatr Clin North Am (2008), p.282.

11 McGarvey, E et al, Adolescent inhalant abuser: environments of use. Am J Drug Alcohol Abuse 1999;25:731-41

12 Howard, M, et al, Inhalant use among urban American Indian Youth. Addiction 1999;94:83-95.

13 Dinwiddie, SH, Abuse of inhalants; a review. Addiction 1994;89:925-39.

14 Ibid, p. 397.

15 Weir, E, Public Health; Inhalation use and addiction in Canada, CMAJ, Feb. 6, 2001; 164(3).

16 Hazell, P., Adolescent suicide clusters: Evidence, mechanisms and prevention, Australian and New Zealand Journal of Psychiatry 1993;27:p. 658.