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

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Part C: Health in Pikangikum

C1. Introduction

The healthcare system in First Nations communities in the Sioux Lookout Zone, including Pikangikum, are provided by multiple providers, both federal and provincial, often delivering these services in silos. Lack of integration is a key factor limiting positive outcomes.

“The federal system of health care delivery for status First Nation people resembles a collage of public health programs with limited accountability, fragmented delivery, and jurisdictional ambiguity.” ¹

A review of the healthcare system was conducted as a component of the trip to the Pikangikum First Nation, through a series of interviews with the Local Health Integration Network, the Sioux Lookout Health Authority, Nodin Child and Family Intervention Services, the Pikangikum Health Authority, the nursing station, and healthcare providers providing primary, secondary and tertiary care out of the community.

C2. The North West Local Health Integration Network (LHIN)

The North West LHIN is responsible for a total population of 232,135 of which, 19% of this population is Aboriginal. The Aboriginal population is vulnerable. It “…has a high burden of illness, is often located in very remote communities and faces linguistic and cultural barriers to accessing health services.”² The North West LHIN has a higher mortality rate at 676 per 100,000 versus the remainder of the province at 559 per 100,000. Of note, life expectancy is shorter by about two years for both men and women. The North West LHIN experiences the following challenges related to healthcare:

There are 24 nursing stations in the North West LHIN. One is located in Pikangikum.

The Integrated Health Services Plan is a plan setting out the priorities of the Ministry of Health and Long-Term Care. One of those priorities is to enhance mental health and addiction services. In setting its strategic directions, the LHIN identified a critical success factor as “integration and redesign of the health system.”⁴ To this end, the North West LHIN conducted an Aboriginal Health Programs and Services Inventory.⁵

C3. The Sioux Lookout First Nation Health Authority (SLFNHA)

The Sioux Lookout First Nation Health Authority is executing the Anishnawbe Health Plan, a process which hopes to bring the healthcare system in the Sioux Lookout Zone under First Nations governance and management.⁶

Their mission is to:

Continuity of care has been a significant issue for First Nations communities. There were traditionally different physician groups, all providing service in different manners and with different fee schedules. For example, the Sioux Lookout Zone Family Physicians’ Association provided service to the First Nations for approximately 5 days per month, and would care for these clients when they came off reserve and needed admission to the Meno-Ya-Win Health Centre. Another group, AMDOCS from Manitoba, would provide in-community service for up to 25 days per month for members of the Independent First Nations Alliance (IFNA) including Pikangikum, but would not provide care to their clients when they were transferred off-reserve to the Health Centre. A third group, the Hugh Allen Group Physicians, were community-based in the town of Sioux Lookout and would provide care for the inhabitants of the town, and were increasingly being asked to care for transfer patients from reserves by other physician groups such as AMDOCS. The orphan patient dilemma that has plagued healthcare facilities throughout Ontario has played out in the north as well.

SLFNHA is providing, or in the process of providing, the following services to the Sioux Lookout zone:

• Health Services

The health services envision a unified regional primary care system under First Nation governance and management. A goal is to provide increased access and availability of healthcare services in the communities. Most recently, the SLFNA has been successful in assisting with the negotiations for the provision of 24-hour emergency and inpatient care at the Meno-Ya-Win Hospital.

New initiatives which are planned include the creation of a unified electronic medical record, the development of the Public Health System with the First Nations communities, and developing a model of care for dental services.

• Tuberculosis Control and Surveillance Program
• Canada Prenatal Nutrition Program
• Developmental Services Program

The Developmental Services Program works with adults and youths living with developmental disabilities, mental health issues and/or challenging behaviours. In this program, SLFNA partners with Community Living Sioux Lookout and Surrey Place Centre, a multidisciplinary clinical team comprised of a psychiatrist, a psychiatric nurse, psychologists, behaviour therapists, speech and language pathologists and an occupational therapist. This is funded through the Ministry of Community and Social Services. This program worked with 59 clients in 14 First Nations communities in 2008-2009. Pikangikum was not one of the communities utilizing this resource.

• Telemedicine Program

SLFNHA has partnered with KO Telemedicine partners to support the adoption and use of telemedicine to connect with their clients in communities.

• First Nation and Inuit Health Information System

Collects and retains data on immunization in 29 First Nations communities.

• Nodin Child and Family Intervention Services
• Client Service Programs

Provides non-medical healthcare services for First Nations clients travelling to Sioux Lookout for appointments. This includes ground transportation, courier and shuttle service, hotel and private accommodations, client/advocacy support and activity coordination.

An interview with Mr. James Morris, Executive Director, SLFNA, communicated that a further initiative of the SLFNA was the construction of a new hostel next to the new hospital which will have 100 beds and serve as an accommodation and reception centre for northern patients. In February 2009, SLFNHA organized a 3-day meeting with representatives from 33 First Nations communities to discuss the prescription drug abuse problem which strategized local and regional solutions.

The SLFNHA provided community-oriented and specific service to Pikangikum. The Family Healing Program funded through the Aboriginal Healing and Wellness Strategy had three intakes in Pikangikum in 2010. In each intake, four to five families consisting of 10-20 members attended this three week program delivered with facilitators in Pikangikum.

Another very innovative program sponsored by SLFNHA and funded by Health Canada, First Nations and Inuit Health Branch, consisted of the training of two Pikangikum community members in Thunder Bay over two years to obtain a college education in community mental health training. Their graduation occurred in May of 2010 and they are now in the community providing full time service to Pikangikum. These two new graduates have been designated by the Pikangikum Health Authority to work with children less than 17 years of age. They are retained as Nodin Staff, and receive all the educational and training updates, including supervision and accountability reporting to ensure a high level of service.

A key feature of the mental health management of the children of Pikangikum was the lack of qualified counsellors. This situation has recently been vastly improved as noted above. However, the children of Pikangikum present with a variety of mental health, addiction, and likely, developmental problems. SLFNHA seeks to integrate services under the umbrella of the Anishnawbe Health Plan. A vital component to success will be the integrated case management for these children, whereby all mental health and linked health needs such as developmental disorders are identified, addressed, integrated and communicated to stakeholders.

C4. Sioux Lookout Regional Physicians’ Services Inc.

The newly created Sioux Lookout Regional Physicians’ Services Inc. (SLRPSI) has amalgamated all primary care physicians groups under one umbrella with a shared responsibility for all patients presenting to the emergency room as well as a hospitalist program to care for the patients once admitted. SLRPSI is governed by a nine member Board with three First Nations representatives, three from Meno-Ya-Win Hospital, and three physician representatives. Among the individual physician members represented, AMDOCS provides five full time equivalents (FTE’s), the Hugh Allan Clinic seven FTE’s, and the Northern Physician Group, ten FTE’s. SLRPSI is an independent provider of physician services and the SLRPSI Board will ensure that medical services are balanced between community and hospital needs, will provide for an equitable payment plan for all physicians, and ensure that there is accountability and oversight for medical services in the Sioux Lookout Region.

This is a significant enhancement toward seamless care for First Nations in the Sioux Lookout Zone.

C5. Sioux Lookout Meno-Ya-Win Health Centre (SLMHC)

Sioux Lookout Meno-Ya-Win Health Centre was established in 2002 as Ontario’s first First Nations’ hospital. A four-party agreement was reached to create it, and included Health Canada, the Provincial Government, the Nishnawbe Aski Nation, and the Municipality of Sioux Lookout. It has a unique mandate to respond to the “…unique, significant First Nations needs including integration of traditional healing, medicine and foods into SLMHC programming…” as a core commitment.⁷

The hospital’s catchment area is the largest of any hospital in Ontario. It provides services to approximately 30,000 people in 32 communities over an area of 385,000 km², one third of Ontario’s land mass. Their staff provides emergency, obstetrics/maternity and paediatric medicine, surgery, as well as diagnostic and therapeutic treatment services. Specialized care is provided in Thunder Bay and Winnipeg. Their staff has a mandate to become a centre of excellence of Aboriginal health care, and have published many articles in peer reviewed journals regarding Aboriginal health care.⁸

SLMHC recently opened a new facility. The new facility has 60 beds, of which, eight are complex continuing care beds. Also, there is a 20-bed extended care facility that looks after 30,000 outpatient visits annually, employs 300 people, and operates two sites.

From a psychiatric standpoint, SLMHC will not look after patients who are suicidal and are being involuntarily admitted to hospital under the Mental Health Act, but will generally admit voluntary psychiatric patients to the general medical service. On April 1, 2011, five withdrawal beds were scheduled to be opened.

This information was provided by Ms. Helen Cromarty, Special Advisor for First Nations Health, Ms. Barb Linkewich, Vice President Health Services, Dr. Bob Minty, staff physician, and Dr. Terry O’Driscoll, Chief of Staff.

There is currently only one paediatric psychiatrist for the North West of Ontario. Other paediatric psychiatric services are provided through the MCYS funded Ontario Child and Youth Telepsychiatry Program and by visiting psychiatrists. Schedule 1 beds, which are for patients involuntarily admitted to hospital due to the severity of their illnesses, such as actively suicidal or patients with very serious mental health disorders, are available in Thunder Bay and in the Lake of the Woods District Hospital in Kenora. Lake of the Woods District Hospital operates a 24/7 inpatient and outpatient psychiatric service including emergency services for those 12 years of age and older in the Town of Kenora.⁹

In addition, the Thunder Bay Regional Health Sciences Centre (TBRHSC) operates a mental health program. “The mission of acute care adult mental health services at a Schedule 1 facility is to provide intensive inpatient and outpatient care that includes: emergency services; short-term inpatient assessment; assessment, stabilization and short-term inpatient treatment; discharge planning; outpatient services; and, consultation, education, coordination and integration. TBRHSC also houses an independent inpatient Child and Adolescent Mental Health Unit through Paediatric services. This specialized program is designed to treat youth, ages 10 to 17 years, with serious and complex mental health disorders.”¹⁰

Dr. Peter Braunberger, child psychiatrist in Thunder Bay spoke of his concerns with respect to the provision of paediatric psychiatric service. In particular, he mentioned lack of continuity as a significant issue between;

Dr. Braunberger felt that key enablers for the success of paediatric mental health programs would include:

C6. The Pikangikum Health Authority (PHA)

The PHA reports to the First Nations Band, the Chief and Council, and a Board consisting of three elders. There is an Executive Director, and Health Directors, each with different portfolios under their jurisdiction. Although currently there is a striking paucity of operational programs providing measurable outcomes in terms of child and youth mental health, there is great promise that resides with the PHA. Recently, the Executive Director has become the co-chair of a committee called the Pikangikum Social Health, Education and Elders Committee created in March 2010. This Working Group has members from Indian and Northern Affairs Canada, Tikinagan Child and Family Services, Ministry of Aboriginal Affairs, Nodin Child and Family Intervention Services and the Sioux Lookout and First Nations Health Authority. This group meets generally every two months in Thunder Bay addressing an agenda developed in Pikangikum. This group was struck at the request of the PHA, following the PHA’s own investigation and review of a Prince Albert First Nations community in August 2008. They are seeking to develop integrated health services following best practices observed in the Peter Ballantyne Cree Nation in Saskatchewan. This is a significant strength and area of promise.

Operational Programs

The Pikangikum Health Authority operates 5 overarching programs:

The focus of this review is the deaths by suicide of 16 youth. As such, the Community Program review will focus on Mental Health and Addictions. There are five primary areas of service delivery. These include:

1. Mental Health Workers

There are four workers who have been functioning in the community since June 2010. Two of the health workers work out of the Community Centre and see clients less than 17 years of age. An additional two workers see clients in the Nursing Station Health Centre. The two workers seeing youth clients are employed by Nodin. The other workers are employed by the PHA. Videoconferencing at the Community Centre allows ready access to a psychologist in Kenora since March 2010.

The addition of the two trained mental health workers who are community members, reside in the community, and were trained at community college over two years, has been a tremendous new asset. They will ease, in part, a void that has existed by addressing the needs of the youth. It is contemplated that outcomes for youth will improve. This is a significant area of promise for the community. The client base is growing with assistance from the Tikinagan Child and Family Services and the police.

2. Youth Patrol

The Pikangikum Youth Patrol Program is funded by the Ministry of Children and Youth Services. In October of 2010, it was not functioning. It provides peer-to-peer support to the youth. In addition, since the 1990s, Health Canada, First Nations and Inuit Health Branch have provided annual funding as well.

3. Solvent Abuse Worker

Currently, the solvent abuse worker is a part time position. (Children) and youth who are solvent abusers must self-identify. This is a significant barrier to providing care for those in need. The incumbent usually only sees clients who have been referred by a physician or nurse. Her primary activity is to complete applications for federally funded solvent treatment programs out of the community. The community has a very large, but unknown number of youth solvent abusers. Girls in grade three and four recently completed a survey in which they self-identified that 27% had tried gasoline solvents. There is no formal mechanism for identification of these “at risk” children and youth. It can occur through the police, Tikinagan Child and Family Services and from a referral from the Nursing Station.

4. The National Native Alcohol and Drug Abuse Programs (NNADAP) Community-based Program¹¹

The NNADAP is a Health Canada funded program whose purpose is to provide prevention, intervention, aftercare and follow-up services for those suffering with drug and alcohol abuse. Prevention strategies include “…culturally appropriate programs to educate and create awareness about addictions and addictions-free lifestyles.”¹² Intervention provides assessments for entry into residential treatment centres. It also contemplates short-term crisis counselling and out-patient counselling services. Its primary function is to reduce the incidence of alcohol and other substance abuse disorders. The qualifications for service providers depend on the service being provided.

In Pikangikum, few, if any adults seek this type of help. A large number of the children involved in the death review came from families where parental alcohol abuse was a significant issue. The Office of the Chief Coroner was told that adult clients only seek help in Pikangikum before a pending court date, and principally for the purpose of appearing genuine before the courts with respect to seeking assistance to overcome their addictions.

5. Crisis Team

This program is funded provincially by the Aboriginal Health and Wellness Strategy.

It provides logistical support where or when a crisis occurs, such as the suicide of a youth. In that circumstance, support would be provided for the grieving family in terms of meal preparation, transportation, homemaking and other areas requiring support.

C7. Challenges

The members of the Pikangikum Health Authority identified several areas of concern. These included:

C8. Recent Successes

There were a number of recent initiatives that were moving forward and were a source of much promise. These included:

C9. Land-based Solvent Abuse Program

Pikangikum First Nation is reported to have experienced solvent abuse since approximately 1990. In 1997, 147 solvent abusers were identified in the community.¹⁴ The number, at present, is anticipated to be significantly higher.

Picture 2. Sign on Council Meeting Building, Pikangikum First Nation, March 6, 2010.

A land-based solvent abuse program has been operational for a number of years. It has core objectives which include:

In 1998, the creator and Director, Mr. Lachie Macfadden, M.A., wrote the following to the Chief and Council in Pikangikum:

“The work on the solvent abuse problems is just beginning in Pikangikum. It is at least a second generation problem. Many adults that I met reported that they themselves were solvent abusers as youth. Many said that they had severe problems and their use of solvents went on for several years. The danger with this is that many of these parents feel that no harm came to themselves. Many believe that there is not such a big problem in Pikangikum. The problem rests with only a few children. Some adults have the tendency to laugh at the problem with amusement and recall their own old “war stories” about what happened to them when they were high on gas. Some feel that these children should be left alone because they will just grow out of it. They feel that interference puts these children at greater risk.

It would appear that gas sniffing has come to be seen as a “right of passage.” i.e. just something you do at one point of your life, like getting drunk your first time, or having sex your first time. They think gas sniffing will not really harm you and everyone does it at least once in their life. If you leave the youth alone, they will just grow out of it.”

Mr. Lachie Macfadden has been operating a land-based program for solvent abusers in Pikangikum for a number of years. It is operated out of a 1200 square foot cabin which is across Lake Pikangikum. Over 3 years, 235 youth have enrolled in the program, 135 of them being children under the age of 12.

The program is a short term brief intervention. The camp is run for 4 seasons, with the exception of freeze up or thaw. A sharing circle is utilized, and 90% of those enrolled in the program are sniffing gas and abusing alcohol.

Macfadden reported that sniffers are ostracized by their schoolmates. They are made to feel different. Themes from them included:

Fellow sniffers become their friends and peer group.

The program is a 12-day program, involving four workers and about eight youth per rotation. The children and youth are between eight and eighteen years of age. They are assigned traditional roles in the camp including chores which are assigned in shifts. The assigned chores consist of drawing, writing, traditional outdoor activity, trap line, cutting wood, crafts, participating in a sharing circle, playing hockey, broomball and/or volleyball.

Elders are involved in the program. Upon program completion, 95-100% of the children and youth return to sniffing when they go home. They return to the same circumstances from which they came. Following the program, kids have difficulty integrating with their former peers and reportedly, parents do not provide guidance. The global effect of the program is as a respite, until placement at outside community residential treatment programs can be procured. Solvent abuse is a very difficult addiction to overcome. At 18, the youth begin to turn to alcohol as their substance of abuse.

The program was shut down at Christmas of 2009, due to lack of funding, traditionally provided through INAC. The program became operational again in 2010, but requires a sustained source of funding. For 2009-2011, one time funding was provided by Health Canada.

C10. The Nursing Station

Basic Operations

The Nursing Station operates 24/7 and has a complement of nine full time nurses. The nurses are retained on behalf of Health Canada.

The physicians are hired through a company called AMDOCS. Currently this service is supplied to the communities aligned with the Independent First Nation Alliance (IFNA) in the First Nations of Pikangikum, Kitchenuhmaykoosib and Muskrat Dam. In the past, physician services to Pikangikum were outreach programs, with a family physician visiting perhaps a few days a month or a week at a time from such locales as Sioux Lookout. The First Nation Family Physician Health Services Branch of the Independent First Nations Alliance (IFNA) contracted AMDOCS for three years.¹⁶

The physicians are available 25 days per month in the community and after hours for call-backs if necessary.

The Nursing Station Staff reported that suicidal patients rarely present for care. When patients do present with crisis, there is limited ability to access care in the community.

Themes

Common themes heard from nurses in the Nursing Station included:

A concern raised by a physician was the prevalence of incest or sexual abuse amongst female youth between the ages of 10-12. Although he could not provide hard data, he suggested that it may be playing a role in the suicide epidemic. According to a Northwest Territories survey, “…80% of girls and 50% of boys under the age of 8 had been sexually abused.”¹⁷ This was referencing First Nations in the Northwest Territories.

Theoretical Placement for a Suicidal Youth

Should a youth be brought to the Nursing Station with suicidal ideation, the nurses would perform a risk assessment, determine if the youth was intoxicated or not, attempt to contact collaterals such as the Children’s Aid Society, and determine the capacity for support and monitoring in the youth’s home. A physician would likely be called thereafter, and telephone support is available 24/7.

If the youth was intoxicated, he/she would be lodged in the police cells overnight until they were sober. Then, they would be brought back for a reassessment. The nurses commented that after becoming sober, the youth seldom express any further suicidal ideation.

If the youth was sober and had many risk factors or had been observed in a significant suicidal attempt such as being found with a rope around their neck, hospitalization might be necessary. If the youth were co-operative and agreed to the hospitalization, it could be facilitated in Sioux Lookout.

If the youth were uncooperative and refused hospitalization, a Form 1 would have to be completed by the physician under section 15 of the Mental Health Act to affect an involuntary admission to hospital.¹⁸ A search for a Schedule 1 bed under the care of a psychiatrist would begin. This might occur in either Thunder Bay or Kenora.

The complexities of placing a youth in a hospital inpatient bed from Pikangikum are complex. Transportation must be approved prior to transfer by the Non-Insured Health Benefits (NIHB) program. These benefits provide for “…medical transportation to access medical services not available on reserve or in the community of residence…”¹⁹ It was reported that at times, NIHB will decline requests to fund transport of certain patients. NAN reported that the Assembly of First Nations has passed a resolution in December 2010 calling for a review of the NIHB’s patient medical transportation health policy. An escort may have to accompany the patient, and would have to be found. The patient and the escort would then have to fly to the town where the hospitals were located.

The placement of youth with serious mental health disorders out of the First Nations community faces significant obstacles. This is juxtaposed to accessing care for a patient in southern Ontario.

C11. Relationship with the Federal Government

The nature of the federal government’s relationship with First Nations is complex and beyond the scope of this death review. The following information is provided to assist the reader in understanding briefly, Indian and Northern Affairs Canada’s mandate.

“Canada's economic and social well-being benefits from strong, self-sufficient Aboriginal and northern people and communities.

Our vision is a future in which First Nations, Inuit, Métis and northern communities are healthy, safe, self-sufficient and prosperous - a Canada where people make their own decisions, manage their own affairs and make strong contributions to the country as a whole.

Indian and Northern Affairs Canada (INAC) supports Aboriginal people (First Nations, Inuit and Métis) and Northerners in their efforts to:

INAC is one of the federal government departments responsible for meeting the Government of Canada's obligations and commitments to First Nations, Inuit and Métis, and for fulfilling the federal government's constitutional responsibilities in the North. INAC's responsibilities are largely determined by numerous statutes, negotiated agreements and relevant legal decisions. Most of the Department's programs, representing a majority of its spending, are delivered through partnerships with Aboriginal communities and federal-provincial or federal-territorial agreements.

INAC's mandate and wide ranging responsibilities are shaped by centuries of history, and unique demographic and geographic challenges. INAC is one of 34 federal departments and agencies involved in Aboriginal and northern programs and services.

Who is eligible to receive benefits?

The answer is in the federal Indian Act. It defines an Indian as "a person who, pursuant to this Act, is registered as an Indian or is entitled to be registered as an Indian." To be eligible to receive benefits under the Indian Act, individuals must be registered in the Indian Register, which is maintained by the Department of Indian Affairs and Northern Development (DIAND). The recognition by the federal government of persons registered under the Indian Act is referred to as Registered Indian Status.”²⁰

Federal and Provincial Government Roles

Federal Government

Under the Constitution Act, 1867, the federal government has jurisdiction over Aboriginal peoples and lands (“Indians and Lands reserved for the Indians”).

Distribution of Legislative Powers

91. “…it is hereby declared that (notwithstanding anything in this Act) the exclusive Legislative Authority of the Parliament of Canada extends to all Matters

Coming within the Classes of Subjects next hereinafter enumerated; that is to say,--

24. Indians and Lands reserved for Indians.” ²¹

Section 35 of the Constitution Act, 1982 “recognizes and affirms” the “existing” Aboriginal and treaty rights in Canada. These Aboriginal rights protect the activities, practice, or traditions that are integral to the distinctive culture of the Aboriginal peoples. These rights extend to people who make up First Nations, Inuit and Métis peoples. ²²

Provincial Government

The provincial government must ensure all citizens, including Aboriginal peoples, have access to provincial programs and services. Traditionally, Ontario does this by cost-sharing delivery of programs and services with the federal government (e.g. delivery of policing in First Nation communities). Ontario can also develop policies and programs specific for Aboriginal peoples, as long as they do not infringe on Aboriginal and treaty rights.²³

Recommendations

Government of Canada, Health Canada

1. The Government of Canada, working with the Provinces, Territories and Aboriginal Leadership groups such as the Assembly of First Nations, should create a National Suicide Prevention Strategy, as currently exists in other developed countries.
2. The Government of Canada, in developing its National Suicide Prevention Strategy, should liaise with Aboriginal Leadership to ensure that the Strategy considers, accepts and respects cultural diversity, and specifically acknowledges the extraordinary excess contribution of Aboriginal Peoples to the Canadian national suicide rate.
3. In developing its National Suicide Prevention Strategy, an exploration of the catastrophic contribution of First Nations mortality of adolescents and youth living on reserve should be considered, the reasons for the excess mortality clearly understood, and recommendations evolved which address this issue.
4. As a component of its National Suicide Prevention Strategy, the Government of Canada should consider the development of population level mental health indicators so that future decisions on mental health strategies will be data driven. An example would be to develop the capacity, through Health Canada, First Nations and Inuit Health Branch of tracking, in real time, deaths due to suicide in Aboriginal communities. This would allow for the identification of those communities including First Nations reserves, where deaths due to suicide occur in excess and therefore, targeted strategies and enhanced resources may need to be provided to assist these communities in crisis.
5. The Government of Canada, through Health Canada, First Nations and Inuit Health Branch should provide targeted funding to communities and reserves experiencing excess cases of child and adolescent suicides, including First Nations reserves to assist in developing solutions directed to the prevention of these deaths. The current National Aboriginal Youth Suicide Prevention Strategy is not apparently meeting the needs of these individual First Nations.
6. This funding should be appropriated to create comprehensive suicide prevention programs in these communities and reserves, led by the local health authority, in partnership with representatives from Health Canada, First Nations and Inuit Health Branch, and the provincial Local Health Integration Network.
7. Qualified expertise to create and implement comprehensive suicide prevention programs in communities and reserves should be retained. Healthcare experts, such as nurses educated to a Masters Degree level in health science with an interest in project management would ensure that the components of the comprehensive suicide prevention programs were implemented, and that the children, youth and families in these communities would benefit from the provision of enhanced resources. Data should be collected, and benchmarks and key performance indicators developed to track and measure outcomes, and accountability targets should be set. (Cross referenced to recommendations 24, 25 and 29.) Funding for these nurse manager experts could come from the newly created National Aboriginal Youth Suicide Prevention Strategy.²⁴
8. Health Canada, First Nations and Inuit Health Branch should develop an electronic medical record (EMR) which can link health systems to ensure proper transfer of information between all care providers operating in the “circle of care.” This system should be created in consultation with the provincial Local Health Integration Network and eHealth Ontario and is vital to proper care of all Aboriginal peoples who receive components of their health care from both federal and provincial providers.

Canada, unlike several other industrialized nations has not developed a national suicide prevention strategy to date. Finland developed the first national suicide prevention program in 1986. Norway, Finland, Slovenia, Sweden, France, Australia, Ireland, New Zealand, United States, England and Scotland have developed national suicide prevention programs. Canada is one of the few developed nations without a national strategy.

9. Health Canada, First Nations and Inuit Health Branch should provide funding to ensure that Pikangikum’s Comprehensive Mental Health and Addictions Program, including the Community Suicide Prevention Program, can be created and function. (Cross referenced to recommendation 24.)

Government of Ontario, Ministry of Health and Long-Term Care

10. The Province of Ontario, Ministry of Health and Long Term Care (MOHLTC) in collaboration with other ministries should create a Provincial Suicide Prevention Strategy.
11. The Province of Ontario, Ministry of Health and Long-Term Care (MOHLTC) in developing its Suicide Prevention Strategy, should liaise with Aboriginal Leadership groups to ensure that the strategy considers, accepts and respects cultural diversity, and specifically acknowledges the extraordinary excess contribution of Aboriginal peoples to the national suicide rate. The province should not allow jurisdictional tensions over First Nations between the federal government and the province to delay the creation of its Suicide Prevention Strategy.
12. The Province of Ontario, Ministry of Health and Long-Term Care (MOHLTC) in creating its Suicide Prevention Strategy, should liaise specifically with:

to identify communities and reserves where the rate of suicide for children and youth is excessively high.

13. The Province of Ontario should cultivate its strategic direction with respect to enhancing mental health and addiction services²⁵ over the next ten years to ensure that this includes the development of a provincial suicide prevention plan, and the reduction of suicides in children and youth. Components of this plan should consider promotion, prevention and early intervention in mental health for children and youth, with targeted efforts to reduce the stigma and discrimination associated with mental and substance abuse disorders.
14. As a component of its Suicide Prevention Strategy, the Province of Ontario should develop population-level mental health indicators so that future decisions on mental health strategies will be data driven. An example would be to develop the capacity of tracking, in real time, deaths due to suicides in Aboriginal communities including First Nations on reserves.
15. The Province of Ontario, Ministry of Health and Long-Term Care should create a telehealth consulting service for psychiatric care to remote First Nations communities. This service should allow for prompt (same day) access to child and adolescent psychiatrists for children in crisis. To ensure availability of psychiatrists to fulfill this role, the Ministry should provide a significant premium to physicians. The Ministry should partner with academic health science centres to create this service.

The Ministry of Health and Long-Term Care has set a strategic direction with respect to mental health and addiction services for the next 10 years. These recommendations are synergistically aligned with this Ministry direction, and call for the development of a provincial suicide strategy, such as exists in the Province of Alberta.

“The Alberta Suicide Prevention Strategy document was formally launched in September 2006 and is the result of the commitment of many Albertans, including family members/survivors, service providers, researchers, representatives from government ministries, non-government community agencies and others. The purpose of the strategy is to reduce suicide, suicidal behaviour and the effects of suicide in Alberta over the next 10 years. Significant actions which are aimed at the general population as well as those targeted at identified priority groups are essential to providing a comprehensive approach to suicide prevention.”²⁶

Ontario could benefit from a provincial strategy as well.

16. The Province of Ontario, Ministries of Children and Youth Services and Health and Long-Term Care should develop an integrated mental health service strategy stressing accessibility and program delivery for children and youth in northern Ontario (Northern Ontario Aboriginal Child and Adolescent Psychiatry Outreach Program). Some stakeholders identified to assist in the development of this strategy would be:

• North West and North East Local Health Integration Networks
• Health Canada
• Ministry of Children and Youth Services
• A representative from the Sioux Lookout Regional Physicians’ Services Inc. (SLRPSI)
• Representatives from Meno-Ya-Win, Thunder Bay Regional Health Sciences Centre, Lake of the Woods District and Weeneebayko Hospitals
• Representatives from the Sioux Lookout First Nations Health Authority and the Weeneebayko Area Health Authority
• A representative from Nodin Child and Family Intervention Services
• A paediatric psychiatrist who provides service to First Nations Youth in the North West
• Health Canada, First Nations and Inuit Health Branch
• Indian and Northern Affairs Canada
• Non-Insured Health Benefits (NIHB)
• Tikinagan Child and Family Services, Dilico Anishinabek Family Care, and other children’s aid societies
• A representative from the Ontario Child and Youth Telepsychiatry Program
• A representative from the Nishnawbe Aski Nation
• A representative from each of the Tribal Councils of the north

17. This Northern Ontario Aboriginal Child and Adolescent Psychiatry Outreach Program should be resourced jointly by the Ministry of Children and Youth Services, MOHLTC and Health Canada, First Nations and Inuit Health Branch and should endeavour to deliver culturally competent evidence-based child psychiatry incorporating flexible mixed models of service delivery, including:

• Triaging of direct referrals for children and youth in crisis
• Indirect referrals including support to family physicians and therapists
• Shared-care models
• Telepsychiatry, available 24/7, including ready access for children and youth in acute crisis at risk for suicide
• Mechanisms for communication between therapists, family physicians and psychiatrists

The conceptualized model might consider a primary care family physician for each client, as well as an identified mental therapist acting as case manager, with psychiatry consultation available through a visiting psychiatrist, or telepsychiatry through Thunder Bay or Toronto.

North West and North East Local Health Integration Network (LHIN)

18. The North West and North East LHIN, working with Health Canada, First Nations and Inuit Health Branch, the Nishnawbe Aski Nation and other political First Nations leadership, should create an integrated and seamless Mental Health and Substance Abuse Strategy. This program should identify all service providers, both federally and provincially, and create care paths for First Nations living on reserve, particularly for youth who require placement out of their home communities.

19. The North West and North East LHIN working with Health Canada, First Nations and Inuit Health Branch should endeavour to create a crisis telephone line and/or Internet service for the North West and East regions.

This line and/or internet service should allow for youth in crisis to access counselling and contacts to discuss their current stressful situations. This service could be identified and made readily available to communities like Pikangikum. This service could be modelled after other existing programs, and should be created with a toll-free number offering commonly spoken First Nations languages.

The lack of the children attempting to access care in the community in the month prior to their deaths suggests that alternate methods of providing services should be evolved. Crisis telephone lines are utilized in locales in southern Ontario. Given the broad expanse of the north, a larger project providing this service to First Nations in the North West and North East may be of benefit. It also could be provided on-line, and would ensure a level of confidentiality and/or privacy not currently available in the First Nation.

Sioux Lookout First Nation Health Authority (SLFNHA), Nodin Child and Family Intervention Services

Nodin is funded through the Ministry of Children and Youth Services, the Ministry of Community and Social Services, and Health Canada, First Nations and Inuit Health Branch. It provides service to approximately 33 First Nations from Treaties 3, 5 and 9. In addition, it provides service to clients in the Town of Sioux Lookout.

Nodin provides a counsellor to Pikangikum 5 days per month. This counsellor will fly in to Pikangikum, and stay for 5 consecutive days. This has posed a challenge both in Pikangikum and other First Nations communities. Facilities to meet with clients are limited. The demand for service far exceeds Nodin’s capacity. In March 2010, the Director of Treatment Services had 18 counsellors and 5 supervisors providing service to more than 1,000 clients, with a waiting list of 1,500 within their entire catchment area. Each counsellor was trying to provide service to as many as 50 clients, with benchmarks to provide service set at approximately 25. Service demand is so great, that crisis counselling is all that can be provided. Counsellors are qualified with college and/or university degrees. A proper qualification for mental health counsellors is a commitment that the Sioux Lookout First Nation Health Authority has made and sustained.

In 2008-2009, Nodin provided counselling to 983 clients in Sioux Lookout, and 1208 in Northern services.

20. The Sioux Lookout First Nations Health Authority, Nodin Child and Family Intervention Services should conduct a review of open and waiting list cases, for the purpose of benchmarking with other organizations providing these types of services, to determine an acceptable caseload for its counsellors.
21. Based on this benchmarking exercise, SLFNHA should create a business case to present to the Ministry of Children and Youth Services, the Ministry of Community and Social Services, and Health Canada, First Nations and Inuit Health Branch, who fund Nodin, to ensure that adequate resourcing is provided to address the needs for the enormous backlog that currently exists. This will likely require additional full time equivalents for both counselling and supervising.
22. Nodin Child and Family Intervention Services should consider developing a model, (when adequately resourced), that is not limited to crisis intervention, as currently exists. Given their dedication to ensuring duly qualified staff, with accountability and supervision processes, consideration should be given to Nodin providing overall mental health case management to children and youth from the First Nations communities it currently services, including Pikangikum.

SLFNHA, with its vision, leadership and menu of integrated services should seek enhancements in its resourcing so that Nodin Child and Family Intervention Services could become the provider of case management services for individual children and youth, working arm-in-arm with community mental health workers and other providers, such as Tikinagan Child and Family Services.

Pikangikum First Nation and the Pikangikum Health Authority (PHA)

23. The Pikangikum Health Authority should develop a mission statement and clearly define its vision and values.
24. The Pikangikum Health Authority should develop a Comprehensive Mental Health and Addictions Program for children, youth and adults. This program should consider,

• a Comprehensive Community Suicide Prevention Program,
• developing plans to address the solvent and alcohol abuse crises, and
• the need for integrated provision of mental health services including models which incorporate traditional practices, defined by the Pikangikum First Nation.

25. In developing its Comprehensive Mental Health and Addictions Program, the PHA should retain nursing expertise to assist in the development of the Program. Funding for this nurse manager expert could come from the newly created National Aboriginal Youth Suicide Prevention Strategy, the Health Canada First Nations and Inuit Health Branch, and/or the Aboriginal Health and Wellness Strategy. Invited participants to ensure a truly integrated program might include:

• Representatives from the Pikangikum Social Health, Education and Elders Committee
• Representatives from the Pikangikum Nursing Station
• Representatives from Pikangikum Mental Health and Addictions Programs including a mental health worker, youth patrol, solvent abuse worker, NNADAP, crisis team and community health nurse
• A representative from AMDOCS
• A representative from the Sioux Lookout Regional Physicians’ Services Inc. (SLRPSI)
• Representatives from Meno-Ya-Win Hospital
• A representative from the Sioux Lookout First Nations Health Authority
• A representative of the First Nation Family Physician Health Services branch of the Independent First Nations Alliance (IFNA)
• A representative from Nodin Child and Family Intervention Services
• A paediatric psychiatrist who provides service to First Nations youth in the North West
• Health Canada, First Nations and Inuit Health Branch
• Indian and Northern Affairs Canada
• Non-Insured Health Benefits (NIHB)
• The Ministry of Children and Youth Services
• The Ministry of Aboriginal Affairs
• The Ministry of Health and Long-Term Care
• The North West Local Heath Integration Network
• Tikinagan Child and Family Services
• Ontario Provincial Police

26. Until the Comprehensive Mental Health and Addictions Program is functional, the NNADAP, Solvent Worker and Youth Patrol programs should be examined and either augmented or reconstituted to provide meaningful assistance to the community. Job descriptions should be written so that targets and accountability expectations are clearly set out.

These services are far too critical not to be fully functioning in this community. In addition, Health Canada, First Nations and Inuit Health Branch should provide funding to ensure that the Comprehensive Mental Health and Addictions Program, including the Community Suicide Prevention Program, can be created and function.

27. The Pikangikum First Nation, Chief, Council and the Pikangikum Health Authority should create a Community Suicide Prevention Program, to be delivered as a community program, under the Health Authority’s current Chair and Directorship, funded by Health Canada, First Nations and Inuit Health Branch.
28. The creation of the Community Suicide Prevention Program will require nursing expertise in health care and project management that currently does not exist within the community. To achieve the necessary level of expertise, the Pikangikum Health Authority under its current Directorate, should partner with Health Canada, First Nations and Inuit Health Branch, and the North West Local Health Integration Network for the planning and delivery of the program.
29. The Pikangikum Health Authority should approach Health Canada, First Nations and Inuit Health Branch to provide funding to retain medical expertise, such as a nurse manager educated to a Masters Degree level in health science with expertise in project management to assist with creating and implementing the Community Suicide Prevention Program. The job specifications, qualifications, accountabilities and contract should be agreed upon by all three members of the tripartite partnership, that is, the Pikangikum Health Authority, Health Canada, First Nations and Inuit Health Branch, and the North West Local Health Integration Network.

The Pikangikum First Nation was characterized in the press as having the highest suicide rate in the world in 2000. In 2007, the rate was estimated as 417 per 100,000 for its youth, based on 10 suicides occurring in a population of approximately 2,400.

The current membership of the Pikangikum Health Authority has expressed a clear vision, which embraces an integrated model of service delivery. To this end, the Health Chair is currently co-chairing a group called the Pikangikum Social Health, Education and Elders Committee. Members include Indian and Northern Affairs Canada, the Ministry of Children and Youth Services, Tikinagan Child and Family Services, Nodin, the Ministry of Aboriginal Affairs, the Sioux Lookout First Nations Health Authority, and Health Canada. It is without question, an enlightened approach and a significant strength for the community.

The community does not currently have a suicide prevention program. Although the Pikangikum Health Authority delivers several programs in its Mental Health and Addictions portfolio, the level of benefit the clients actually receive is unknown. An expert in program creation and delivery working arm-in-arm with the Pikangikum Health Authority, would provide the requisite expertise to assist the community in developing a comprehensive suicide prevention program, while ensuring the components and delivery of the program were conducted in a culturally acceptable model reflecting the values and principles of the Pikangikum First Nation.

30. The Community Suicide Prevention Program should be created by the Pikangikum Health Authority and their Nurse Manager Expert incorporating a steering committee model with invited participants and stakeholders including such interests as,

• representatives from the Pikangikum Nursing Station,
• representatives from Pikangikum Mental Health and Addictions Programs including a mental health worker, youth patrol, solvent abuse worker, NNADAP, crisis team and community health nurse,
• a representative from the Pikangikum Education Authority,
• a representative from AMDOCS,
• a representative from the Sioux Lookout Regional Physicians’ Services Inc. (SLRPSI),
• representatives from Meno-Ya-Win Hospital,
• a representative from the Sioux Lookout First Nations Health Authority,
• a representative of the First Nation Family Physician Health Services branch of the Independent First Nations Alliance (IFNA),
• a representative from Nodin Child and Family Intervention Services,
• a paediatric psychiatrist who provides service to First Nations youth in the North West,
• Health Canada, First Nations and Inuit Health Branch,
• Indian and Northern Affairs Canada,
• Non-Insured Health Benefits (NIHB),
• the Ministry of Children and Youth Services,
• the Ministry of Aboriginal Affairs,
• the Ministry of Health and Long-Term Care,
• the North West Local Heath Integration Network,
• Tikinagan Child and Family Services,
• Ontario Provincial Police,
• Lachie Macfadden land-based detoxification program.

Effective suicide prevention requires prevention, intervention and postvention at the individual, family and community level. It is a complex integrated exercise, which should seek as its outcome, seamless care for the child or youth, family or community in crisis. All of the above parties play a role in some aspect of service provision for mental health and addiction services. These groups need to speak to each other, and work toward a common goal of improved mental health outcomes for children and youth.

31. The Community Suicide Prevention Program should seek methods to de-stigmatize the seeking of help by clients for mental health-related issues, and improve health privacy. Community members must be ensured of confidentiality in counselling sessions so that they will be more willing to seek out help and confide their concerns.

Community members will remain reticent to employ services without meaningful changes in policies and practices that ensure that they will have privacy and will not be the subject of ridicule or harassment. This theme was conveyed about Pikangikum from the nurses at the Nursing Station, as well as a paediatric psychiatrist in Thunder Bay, who spontaneously proffered that this was a significant issue at Pikangikum.

Much of what follows is extracted from Suicide among Aboriginal People in Canada, 2007 by the Aboriginal Healing Foundation, prepared by Laurence J. Kirmayer and associates²⁷, and Acting On What We Know: Preventing Youth Suicide in First Nations, The Report of the Advisory Group on Suicide Prevention.

To address the child and youth suicide epidemic in Pikangikum, a multifaceted approach should be implemented. As the individual cases demonstrate, the issues affecting the children are trans-generational. Challenges and tensions exist at the individual, family and community level. The essential components of an effective strategy need to involve prevention, intervention and postvention directed at four levels; the child or youth, the family, community and region.

The essence of any suicide prevention approach requires the identification and treatment of an individual at risk before an attempt takes place. Resources do exist within the community, but how they are accessed, and how they are utilized to assist the individual, family or community, needs to be addressed to ensure that children and youth suffering with mental illness, personal crisis, substance abuse and/or family crisis are identified and treated. Many of the themes arising from the review of the deaths suggested that the youth who may have been identified were not referred for treatment.

Primary Prevention Strategies

School-based Prevention: The Pikangikum Education and Health Authority

32. The Pikangikum Education and Health Authority should cooperatively develop as a component of the Community Suicide Prevention Program, a school-based student health and suicide prevention program. This program should be a component of the health education curriculum, and should include a variety of health and social issues of which suicide would be one. The program should seek to enhance the capacities of the children in coping with stress, conflict resolution, problem-solving and communication. The fundamental purpose would be to build resiliency and self-esteem in the children, so that they would be better able to withstand the rigours of the crises and conflicts that may arise in their lives.
33. The school-based curriculum should incorporate traditional and cultural knowledge and should utilize the resource of incorporating elders when teaching the youth about such issues as cultural identity and self-pride. It should focus on mental, emotional, spiritual and physical well-being, and particularly discuss the dangers of solvent abuse and emphasize the recognition of suicidal behaviours.
34. The school-based health program should address such issues as alcohol and substance abuse, depression and suicide, domestic violence, sexual and/or physical abuse, and bullying. It must convey and communicate, in plain language to the children, strategies for help-seeking where these issues exist in their lives, and de-stigmatize and dispel attitudes and dispositions which portray the seeking of help in a negative light.
35. The school-based health program should seek to identify high risk youth for suicide by developing and utilizing a school-based screening program and refer high risk youth for intervention. Intervention for children who are identified as high risk for suicide might include one-to-one counselling, as well as small-group interventions based on skills building.²⁸

A strategy that is delivered through the school system has a variety of advantages. A theme that emerged in interviews was that suicide is a “taboo” topic. Apparent in the deaths reviewed, was that community members did not understand the significance of a meaningful parasuicidal gesture such as being found with a rope around one’s neck. Education is necessary. Delivered by the school as a component of health education, it has the advantage of being relatively inexpensive, year round and consistent, and would be delivered by educators who are experts in reaching the children. However, it requires that the children are actually present at school to achieve the potential benefit.

“For some youth, suicide can be viewed positively as an effective means of protest or a heroic gesture pointing to social wrongs and injustices. Suicide education can challenge this romanticized view of suicide and point to alternate responses to interpersonal crisis and despair.”²⁹

A noteworthy strength in the community has been the delivery of a Youth Conference, from March 25-27, 2008 delivered at the Eenchokay Birchstick School. Approximately 360 children from grades 5 to 12 took part, and attended workshops on topics such as grief, impact of family violence, teen addictions, Foetal Alcohol Spectrum Disorder and solvent abuse.

The American Indian Life Development Curriculum was developed for the Zuni Pueblo in New Mexico and seeks to enhance skills to prevent youth suicide. The curriculum covers 7 major areas:

1. Increasing self-esteem
2. Learning to identify emotions and stress
3. Improving communication and everyday problem-solving
4. Identifying and reducing negative thoughts and anger reactivity
5. Information about suicide risk
6. Suicide intervention training
7. Personal and community goal setting.³⁰

The format was classroom sessions occurring three times a week for 30 weeks.

Peer Support Programs

36. The Pikangikum Education Authority and the Pikangikum Health Authority should develop a peer support program operated through the school by senior students, called the Peer Support Youth Council. This program should seek to engage children who are identified as “at risk” for suicide and create bridges and ease for the “at risk” child to seek assistance appropriately. The peer counsellors should be trained in basic listening skills and identified as resource people for the youth in crisis. Oversight, management and debriefing for the Peer Support Youth Council could be provided by Nodin Child and Family Intervention Services.

One of the compelling findings of our review was that not one of the sixteen children sought care from a qualified professional in the month before taking their lives. It may have been that they did not know how to access help, or that they were simply not disposed to seeking it. Children are far more likely to speak to a peer, than an adult in authority. Youth trained and educated to refer youth to appropriate community resources would be ideal.

Community-Based Programs: The Pikangikum Health Authority

37. The Pikangikum Health Authority should develop a community-based program to address suicide as a component to their suicide prevention strategy. The components could consist of:

• Education programs for youths and adults on topics including suicide, parenting and life skills. The educational programs directed toward suicide prevention should have mental health literacy tools for parents promoting the identification of undiagnosed or untreated mental health disorders so that professional assistance will be accessed.
• Creating peer counsellors to respond to young people in crisis, and bringing them to the attention of healthcare providers.
• Outreach to families after a suicide or traumatic death.
• Immediate response to a youth at risk.
• Creating suicide risk screening programs in mental health, addiction and social service programs.³¹

A program such as this was implemented in New Mexico in 1990 and involved leaders, healthcare providers, parents, elders and youth. It reported a reduction in suicidal acts immediately upon program implementation and after 12 years, had a 70% reduction in suicidal attempts.³² As stated in the Royal Commission on Aboriginal Peoples, 1995:

“…strategies aimed at community and social development should promote community cohesion and local control, collective esteem and identity, transmission of Aboriginal knowledge, language and traditions and methods for addressing social problems that are culturally appropriate.”³³

38. As a component of the community-based program, the Pikangikum Health Authority and Education Authority should develop and deliver workshops on life skills, parenting and problem solving, and communication with the children and youth, to parents and young adults in the community. These should be based on culturally sensitive models of roles and responsibilities.

A recurrent theme in the lives of the children examined was a lack of engagement of the parents in actively setting boundaries for the children, or addressing their self-harming and destructive behaviours, such as sniffing gasoline.

Means Restriction

39. Given that means restriction, or eliminating access to specific lethal means of suicide has been proven to be effective in reducing suicide rates, and given that hanging was the method used in all the suicides examined, educational programs directed toward prevention should acknowledge the roles of limiting access to items that could be utilized as ligatures in children expressing suicidal ideation. It is acknowledged that given the ready availability of these items in a household environment, for example, shirts, sheets, and shoelaces. it is likely to play a limited role.

Gatekeepers

40. The Pikangikum Health Authority should develop a role for community gatekeepers, such as elders, community leaders, police, social workers, counsellors, teachers and clergy to be taught to identify youth at risk for suicide, and refer them for treatment. The community-based gatekeeper training programs should seek to improve identification and recognition of suicidal behaviour to allow for prompt referral.

Two of the children whose deaths were reviewed were suffering with apparent auditory and visual hallucinations, yet were not brought to the immediate attention of physicians. It may have been that they did not understand the magnitude of risk associated with the symptoms of these children. An educational program delivered to individuals within the community whereby they are taught to identify concerning symptoms for suicide risk, and then compel the youth to seek care, may have a positive role.

Communication and Media Handling of Suicides in Pikangikum: The Pikangikum First Nation, Chief and Council

41. The Pikangikum First Nation should convene a committee for the purposes of reviewing and developing policies on how it will communicate to the community the tragedy of suicides when they occur. Invited stakeholders might include the proprietors of the local radio station and newspaper, and representatives from the Pikangikum Nursing Station, the Pikangikum Mental Health and Addictions Programs, Nodin Child and Family Intervention Services, Tikinagan Child and Family Services, and the Ontario Provincial Police. The policy should be directed at diminishing the intense community focus on the death, and promoting mental health and coping strategies around suicide.

A theme, heard repeatedly from educators, police, and members of the community was that the entire First Nation “shuts down” when a suicide occurs. In a community where cluster suicides are common, service and supports should actually be enhanced when a suicide occurs. Effectively, shutting down services created the impression that the children received a significant amount of attention at the time of their deaths, attention that may have been absent in life. The review of the youth suicide deaths demonstrated that they occurred in clusters. The creation of policies and strategies to handle communication around the deaths should aggressively seek to reduce further suicides. It is well recognized that “news reporting of suicide in the media leads to an increase in the rate of suicide in subsequent weeks, and that this increase is a true addition to the total number of suicides…”³⁴ Efforts in the community should be directed to the avoidance of a contagion effect, particularly so since three clusters occurred which accounted for a majority of the youth deaths at Pikangikum.

Programming for Children: The Pikangikum First Nation, Chief and Council

42. The Pikangikum First Nation should develop a project to create, with the assistance, support and aid from INAC, an athletic field with a children’s playground, including a basketball court and baseball and soccer fields to allow for children’s programming.

A key issue identified was a lack of programming for the children. Sporting events are integral, and have been curtailed since the school burned down. These types of programming for children and youth combat alienation and “foster peer support and a sense of belonging.”³⁵

Secondary Prevention: Early Intervention and Treatment

Health Care Professionals and Mental Health Services: Health Canada, First Nations and Inuit Health Branch

43. The Pikangikum Nursing Station should develop an emergency room suicide response protocol. This protocol should contemplate identification of those who require emergent hospitalization and how this will be achieved, and those that can be discharged from the Nursing Station. Where appropriate, discharge from the Nursing Station should consider;

• notification of the child or youth’s parent and guardian,
• creation of a safety plan,
• immediate notification of the community mental health team, and Tikinagan Child and Family Services, where permitted by the Personal Health Information Protection Act,
• provision of the discharge summary to the community mental health team, and Tikinagan Child and Family Services,
• follow-up with the community mental health team within 24 hours.

Stakeholders who should be considered to assist in the development of the emergency room suicide response protocol should include:

• Representatives from the Pikangikum Nursing Station
• Representatives from Pikangikum Mental Health and Addictions Programs including a mental health worker, crisis team and community health nurse
• A representative from AMDOCS
• A representative from the Sioux Lookout Regional Physicians’ Services Inc. (SLRPC)
• Representatives from Meno-Ya-Win Hospital
• Representatives from the Sioux Lookout First Nations Health Authority
• A representative of the First Nation Family Physician Health Services branch of the Independent First Nations Alliance (IFNA)
• A representative from Nodin Child and Family Intervention Services
• A paediatric psychiatrist who provides service to First Nations Youth in the North West
• Health Canada, First Nations and Inuit Health Branch
• Non-Insured Health Benefits (NIHB)
• The North West Local Heath Integration Network
• Tikinagan Child and Family Services
• Ontario Provincial Police

Review of some of the deaths of these children demonstrated opportunities for enhancement with respect to provision of emergent care to suicidal youth and children. For example, a suicidal youth found with a rope around her neck was ultimately sent to jail for the night, as she was under the influence of solvents.

44. Nurses working in the Pikangikum Nursing Station should receive specialized training and education with respect to assessing those at risk for suicide, including when patients should be referred for emergent psychiatric inpatient treatment in a Schedule 1 facility. This could be achieved by the nurses obtaining certification in mental health.
45. AMDOCS, the principal physician service provider to Pikangikum should develop an educational module for its physicians with regard to suicide prevention and treatment. This program should discuss:

46. The Pikangikum Health Authority, the North West LHIN and the Pikangikum Nursing Station should develop an agreement with paediatric and adolescent psychiatric service providers whereby prompt consultation for youth presenting with suicidal ideation and/or risk factors can access this psychiatric expertise via telehealth video linkages.

None of the children involved in the death review had accessed mental health services in the month before their deaths. The reasons for this are not entirely known. Of interest was the fact that not a single youth that took their life by suicide was being treated with a psychotropic medication, despite good evidence of the benefits of this treatment. An opportunity may exist for enhanced education for the nurses and physicians providing care to Pikangikum.

Crisis Telephone Line: North West and North East LHIN

See recommendation 19.

Mental Health Crisis Response Teams

47. The Pikangikum Health Authority should develop a Mental Health Crisis Response Team through its Mental Health and Addictions Programs for those identified as suffering with parasuicidal ideation. This service should have the capacity to mobilize counsellors to respond to youth in crisis 24/7.

This recommendation is resource intensive. Some of the youth had family members who did not bring them to care, even when they were discovered in events clearly indicating self-injury and a desire to die. An alternative method for providing care might have been for the family, friend or community member to contact a Mental Health Crisis Response Team member who could visit the youth in their home, and assess the youth for necessary next steps.

Solvent and Substance Abuse Treatment

48. The Pikangikum First Nation, and the Pikangikum Health and Pikangikum Education Authority should seek to identify all children and youth <19 years of age involved in solvent abuse. This could be facilitated through screening programs in the school, and with the assistance of the OPP and the Nursing Station. All youth and children identified as suffering with solvent abuse, who are age appropriate based on the criteria of the Child and Family Services Act, should be referred to Tikinagan Child and Family Services. All youth, regardless of age, should also be referred to the Solvent Abuse Worker.
49. The Pikangikum Education Authority should augment the school’s current curriculum on solvent abuse to ensure that education begins in kindergarten with developmentally appropriate modules throughout elementary school.

Volatile substances such as gasoline when inhaled are absorbed through the blood stream and travel to the brain where they are felt immediately. The user will feel euphoric, light-headed with distorted vision, impulsiveness and lack of inhibition. They may develop ataxia or staggering, dizziness and flushing. Users will usually inhale periodically to maintain a high and avoid the side effects which include a depressant effect and feeling down.³⁶

The peak age for inhalant abuse is thought to be about 14 to 15 years. Chronic use tends to be endemic in “…remote communities coincident with unemployment, poverty, substance abuse and dysfunctional families. It is noteworthy that inhalant abuse is epidemic in some remote communities, and virtually absent in others.”³⁷ Chronic inhalant abuse can be associated with school failure, delinquency and an inability to achieve societal adjustment.³⁸ Chronic abuse leads to central nervous system damage including dementia, cerebellar dysfunction, loss of cognitive and higher brain functions and gait disturbance. Computed tomography will show a loss of brain mass. Death can occur due to asphyxia, suffocation, dangerous behaviour, aspiration and sudden sniffing death syndrome.³⁹ The hydrocarbon in the inhalants sensitizes the myocardium to the effects of adrenaline, and a startle reflex will cause a surge in this hormone which can lead to a fatal heart arrhythmia.

Of interest, the Canadian Paediatric Society notes that disinhibition while under the influence of inhalants may cause dangerous behaviour. The striking association of suicide with solvent abuse in this death review, where 10 of 16 children and youth were abusing solvents on the day of their deaths suggests that this might at least, be contributory to the reasons why the youth killed themselves. Solvent abusers may suffer with short attention spans, poor impulse control and poor social skills, with impaired decision making skills.⁴⁰

The extremely high correlation between solvent abuse and suicide in the community, where 87.5% of the youth who killed themselves were known solvent abusers necessitates the identification of these youth at risk. The presence of this disorder in the community is staggering. Estimates of 200 and possibly even as many as 300 or more children and youth are suspected of abusing solvents. Fourteen of the youth who took their lives in this review were known solvent abusers, and 11 were under the influence of an intoxicant (10 solvent and one alcohol and two exhibiting both ) at the time of their deaths. Some of the youth had been apprehended by police for being publicly intoxicated with solvents, but were not referred to the Children’s Aid Society and hence, not followed.

The likely effects of cumulative stress and trauma, and the resultant impact of hopelessness on children are poignantly depicted in a recent troubling youth survey completed in Pikangikum titled “How do you feel about yourself.” Seventy-five percent (75%) indicated that they felt sad most of the time. Seventy-three percent (73%) “felt hurt inside and could not make that hurt go away.” Sixty-three percent (63%) thought about suicide and 56% had tried to commit suicide or hurt themselves. Another very significant and disturbing finding was that close to one-half of the youth (48%) felt “like nothing will change or get better for them in the future.⁴¹

Girls in grades 3 and 4 recently completed a survey in which they self-identified that 27% had tried solvents. Currently, there is no formal mechanism for identification of these “at risk” children and youth. A Solvent Abuse Worker is employed as a part-time position in Pikangikum. The principle function of this worker is to complete applications for residential treatment programs.

A requisite component of healing and education in the community should be the understanding that children and youth that abuse solvents are at risk for death and/or permanent lasting neurological damage. It can be a life threatening addiction, and the gravity of this addiction should be appreciated by all members of the Pikangikum First Nation. It should not be accepted or treated as a minor concern, at any time.

50. The Pikangikum Health Authority, with the assistance of Health Canada, Youth Solvent Abuse Program (YSAP), Tikinagan Child and Youth Services, the Ministries of Children and Youth Services and Health and Long-Term Care and the Local Health Integration Network should develop a comprehensive in-community Solvent Abuse Program. Medical expertise on solvent abuse should be retained for this exercise. This program should incorporate support of the children before and after treatment in residential solvent abuse programs, adopting holistic approaches to treatment, including aftercare programs delivered in the community.
51. The Pikangikum Health Authority, Health Canada, First Nations and Inuit Health Branch, Youth Solvent Abuse Program (YSAP), Tikinagan Child and Family Services, the Ministries of Children and Youth Services and Health and Long-Term Care and the Local Health Integration Network, in developing the comprehensive in-community Solvent Abuse Program, should liaise with residential solvent abuse providers such as White Buffalo Youth Inhalant Treatment Centre (WBYITC) to develop comprehensive after-care and follow-up to residential treatment programs. This should include outreach programs delivered at Pikangikum whereby a provider such as WBYITC delivers a community intervention including such items as identifying protective factors in the community such as the school system, community support groups, and connecting with elders.
52. Pikangikum First Nation should develop a Healing Treatment Centre with funding provided by Health Canada, Inuit and First Nations Health Branch. The Centre could house multiple providers of health services under one roof including Tikinagan Child and Family Services, the community mental health workers, NNADAP workers and the solvent abuse workers. In addition, children who are apprehended by police for solvent intoxication would not be lodged in police cells overnight, but rather, would be brought to a safe sheltered environment in the Centre to be monitored by peace keepers until they are no longer intoxicated. The comprehensive in-community Solvent Abuse Program after-care program could be delivered at this location.
53. Social workers, mental health workers and solvent abuse workers will need to proactively reach out to involved families of solvent abusing children and youth, and should consider adopting models of home visits to ensure confidentiality and diminish the stigma attached to help-seeking which has emerged in the community.

Picture 3. A typical cell, where the youth who are apprehended for intoxication with solvents would be lodged overnight pending release in the morning. A new jail has been opened since March 2010 when this photo was taken.

Currently, police cells are the only place in the community where safety of intoxicated children and youth can be guaranteed. It is the only available option at this time. This was a common occurrence in children who were the subject of this suicide review.

A recurrent theme in the deaths examined was that even when the youth returned to the community following extensive residential stays for solvent abuse treatment, they became involved in solvent abuse again. The rate of recidivism approached 100%. The reasons for this are multiple.

“A key assumption leading to the establishment of the YSAC programs was that young solvent abusers needed a safe place for detoxification separate from their home communities. This is because it was evident that families were not always supportive and were often highly dysfunctional…the work of Matthew Owen Howard and Jeffrey Jensen found that inhalant users were more likely to have low family support and cohesiveness, low self-esteem and substance abusing parents and peers.”⁴²

A recent OPP incident in Pikangikum occurred where an officer entered a residence, and the family was boiling gasoline on the stove.⁴³

The National Youth Solvent Abuse Program (NYSAP) was established in 1996 between First Nations people and Health Canada. It is for youth between 12-26 years of age. This residential treatment program operates 9 sites across Canada with 112 residential beds. The Youth Solvent Addiction Committee (YSAC) provides culturally appropriate, therapeutic inhalant treatment and community intervention programming for First Nation youth and their families.⁴⁴

Fundamental to the health of First Nations people is their spiritual, emotional, physical and mental well being. Resiliency is an individual’s ability to cope with significant adversity or stress in effective ways.⁴⁵ Solvent abuse programs have identified a range of stresses for their clients, “…parental alcoholism, a range of forms of abuse, multiple losses, and lack of connection to schools and other support networks.”⁴⁶

54. The Pikangikum First Nation and Health Authority should liaise with Health Canada, First Nations and Inuit Health Branch and the Government of Canada to explore the feasibility of introducing Opal fuel in their community, a type of gasoline that will not make users intoxicated when sniffed.

This fuel, developed by British Petroleum Australia, has been used in Aboriginal populations in Australia, with good effect. It is more costly than traditional fuel, and in Australia, the price has not been passed onto consumers as the government has absorbed the added cost. It is reported that when utilized in Australian communities, “gas sniffing stopped.”⁴⁷ It is a comparable substitute for regular unleaded gas, and has been effective in reducing rates of sniffing by 94% in communities where it has been introduced.

The community has strengths. Recognition of these strengths and how they could be developed are fundamental to addressing solvent abuse. The solution to Pikangikum’s solvent abuse problem is intimately linked to its youth suicide problem. The solutions must be developed and delivered within the community itself.

“Some argue that if the community is not fully engaged in the recovery process and the individual does not recover directly in the home community, the individual is destined to fail.”⁴⁸

Postvention: The Pikangikum First Nation Health Authority

55. The Pikangikum First Nation Health Authority, as a component of its Community Suicide Prevention Program should develop a postvention program directed at the youth of the community.
56. The postvention program should be developed for delivery both in the school, and in the community. School engagement is a protective factor for preventing suicide and as such, the program should specifically consider addressing the isolated community of solvent abusers, who make up the largest percentage of suicide victims.
57. The components of the postvention program might include, but not be limited to, the following elements:

• Mobilization of a Crisis Response Team.
• The victim’s family should be contacted, empathy and support provided, and an inventory of those who are most likely to be affected by the death developed.
• A determination of what information is appropriate for release. This should ensure that the victim is neither glorified nor vilified.
• Identify those who are most likely affected by the death, including those who discovered the decedent.
• The Crisis Response Team should seek to meet all those who have been identified individually, providing support and counselling.
• Drop-in counselling centres following the suicide should be established to allow those who are experiencing distress to gain ready access to mental health services.

58. The Pikangikum First Nation should establish an appropriate and culturally sensitive approach to funereal and memorial activities. Of paramount importance, is that the activities do not “…romanticize or sensationalize the death.”⁴⁹ Youth “…should not view suicide as a way to obtain incredible amounts of attention”.⁵⁰
59. The Pikangikum First Nation should consider developing a community cemetery. In this way, permanent physical memorials are placed in an appropriate locale, away from residential areas to avoid the constant recognition and reminder of suicidal deaths.

Picture 4. The photo was taken in Pikangikum First Nation on March 6, 2010. This is the yard of a resident who had 14 children, 5 of whom killed themselves by suicide.

The goals of postvention are to assist survivors of a suicide, including family, friends and vulnerable persons in the community with distress that arises from the suicide. It should also seek to identify those who may be at risk for imitative behaviour and refer them for counselling. The deaths which were the subject of this review were largely a result of clusters of deaths occurring within a contagion. Therefore, postvention exercises and planning are crucial to prevent further clusters of deaths. A resident of Pikangikum spoke of the current practice of death immobilizing the entire community, “Death always takes centre stage, life gets shut down.”

An important component to prevent clusters is to ensure, particularly amongst youth, that their deaths will not generate a significant amount of attention. Panel members were told that for some of the youth, the only time they may view themselves as having significance was at the time of their deaths. The importance of clusters contributing to the deaths of these youth can not be overstated. In the review of the deaths at Pikangikum, 3 clusters accounted for the deaths of 10 of the 16 youth. Recognized risk factors for youth suicide include the presence of mental illness, abusing substances such as solvents, previous attempts, recent loss such as the loss of a loved one through relationship break-ups or death and being a victim of violence or sexual assault. In the United States, local suicide rates in adolescents will increase by 7%, and in adults by 2-3% due to imitation of suicidal behaviour.⁵¹ Although a rare phenomena in society in general accounting for about 5% of adult suicides,⁵² in First Nations youth in Pikangikum, the contagion of clustering is the method of propagation of suicidal acts. Hence, the extraordinary importance of strategies around preventing the next act, such as Crisis Response Teams.

Pikangikum is unique in that it is the only First Nations community in NAN territory where the dead are buried in the yards of the homes of the living. Consideration should be given to stopping this practice, and constructing a formal cemetery. Permanent physical memorials to deceased victims of suicide mark the landscape of residential areas, and serve as constant reminders of the youth that have passed. There is a profound need for the community to move forward and cease to be mired in constant thought of departed loved ones. In one of the deaths of the youth, the decedent was seen visiting the grave of his mother moments before taking his own life.

Postvention interventions should avoid:

“Avoiding sensationalism, glorification, and vilification essentially means making sure that unnecessary attention is not given to this act and that information about the death is not presenting in such a way that individuals might identify with the suicide victim.”⁵³

C12. Concluding Remarks

This chapter has provided recommendations at both a systemic level, and also at an individual level for the purpose of providing some guidance into areas where the expert panel convened by the Office of the Chief Coroner was of the opinion that opportunities for enhancements existed. The emotional, spiritual, physical and mental well-being of the children and youth and the community are intrinsic to reducing the high rate of suicide. Accordingly, recommendations have been directed with respect to the individual, family, community and region in areas of prevention, intervention and postvention in the hope of addressing suicide and parasuicidal behaviours. The key to preventing suicide in Pikangikum lies in education.

¹ Reading, LP., and Wien, F., Health Inequalities and Social Determinants of Aboriginal Peoples’ Health, National Collaborating Centre for Aboriginal Health, 2009, p.15.

² Integrated Health Services Plan, North West LHIN, 2010-2013, p. 9.

³ Ibid., p. 10.

⁴ Leading Health System Transformation in Our Communities, 2010-2013 North West LHIN Strategic Directions, June 2010, North West LHIN, p. 23.

⁵ Aboriginal Health Programs and Services Inventory, North West LHIN, June 2010.

⁶ Sioux Lookout First Nations Health Authority, Annual Report, 2008-2009, p. 4.

⁷ Sioux Lookout Meno-Ya-Win Health Centre; A backgrounder, First Nations Services, July 23, 2004, p.1.

⁸ Meno-Ya-Win Health Centre, Research Compilation, 2007-2009.

⁹ http://www.lwdh.on.ca/index.php/Programs-and-Services/schedule-1.html

¹⁰ http://www.tbrhsc.net/programs_&_services/mental_health.asp.

¹¹ First Nations and Inuit Health Program Compendium, Health Canada, March 2007, p. 12.

¹² Ibid., p. 12.

¹³ http://www.wawataynews.ca/node/12374

¹⁴ Macfadden, L., Pikangikum First Nation, Land Based Traditional Healing Program Proposal, 1997/98, submitted to Health Canada, Medical Services Branch, Ontario Region, December, 1997.

¹⁵ Ibid., p.6.

¹⁶ http://www.wawataynews.ca/node/12374.

¹⁷ Brown, Ian. Main Problems in Aboriginal Mental Health, www.niichro.com/mental%health/men_2.html.

¹⁸ Mental Health Act, R.S.O. 1990.

¹⁹ First Nations and Inuit Health Program Compendium, Health Canada, March 2007, p. 57.

²⁰ Indian and Northern Affairs Canada [website] Ottawa, ON: Indian and Northern Affairs Canada; 2009. Available from : www.ainc-ainc.gc.ca/index-eng.asp.

²¹ The Constitution Act, 1867.

²² Ministry of Aboriginal Affairs, December 2010.

²³ Ibid.

²⁴ Borsillino, M., Health Canada on Ottawa’s native health role, The Medical Post, January 18, 2011, p. 31.

²⁵ North West Local Health Integration Network, Integrated Health Services Plan, 2010-2013

²⁶ http://www.albertahealthservices.ca/2738.asp.

²⁷ Kirmayer, L., et al, Suicide among Aboriginal People in Canada, The Aboriginal Healing Foundation, 2007.

²⁸ Kirmayer, L., et al, Suicide Among Aboriginal People of Canada, The Aboriginal Healing Foundation, 2007, p. 88.

²⁹ Ibid.

³⁰ Ibid., p. 89.

³¹ Ibid, p. 91.

³² Ibid.

³³ Ibid, p. 92.

³⁴ Hazell, P., Adolescent Suicide Clusters: Evidence, mechanisms, and prevention.

³⁵ Acting On What We Know: Preventing youth suicide in First Nations. The Report of the Advisory Group on Suicide Prevention.

³⁶ Youth volatile solvent abuse, Canadian Centre on Substance Abuse.

³⁷ Inhalant abuse, First Nations and Inuit Health Committee, Canadian Paediatric Society, www.cps.ca/english/statements/ll/ii97-01.htm

³⁸ Ibid., p. 36

³⁹ Ibid.

⁴⁰ Inhalants. National Inhalant Prevention Coalition, www.inhalants.org/guidelines.htm.

⁴¹ Finlay, J, and Nagy, A, Pikangikum – Root Causes of Youth Suicide Within a Remote First Nation, January 17, 2011, p.22, in publication.

⁴² Dell, AD, et al., Resiliency and Hollistic Inhalant Abuse Treatment, Journal of Aboriginal Health, March 2005, p.8.

⁴³ Personal communication, Superintendent Brad Blair, October 2010.

⁴⁴ Dell, AD, et al., Resiliency and Hollistic Inhalant Abuse Treatment, Journal of Aboriginal Health, March 2005, p. 6.

⁴⁵ Ibid., p. 5.

⁴⁶ Ibid.

⁴⁷ http://www.cbc.ca/canada/newfoundland-labrador/story/2007/05/24/gas-sniffing.html.

⁴⁸ Ibid., p. 8.

⁴⁹ Brock, S.E., Suicide postvention. May 2003 Paper presented at the DODEA Safe School Seminar.

⁵⁰ Ibid., p. 4.

⁵¹ De Leo D, Helter T, Social Modeling in the transmission of suicidality. Crisis 29(1) 11-19, 2008.

⁵² Ibid.

⁵³ Brock, S.E., Suicide postvention. May 2003 Paper presented at the DODEA Safe School Seminar.