P.E.I. coroner's jury calls for changes in how people found not criminally responsible are treated
Province urged to send patients like Colton Clarkin to off-Island forensic hospitals
Warning: This story deals with suicide. If you or someone you know has been struggling with mental health, you can find resources for help at the bottom of this story.
The six jurors who heard evidence in the coroner's inquest into the 2023 death of Colton Clarkin have returned with 12 recommendations aimed at preventing future deaths.
Their advice was presented in a Charlottetown courtroom Monday after three days of testimony and several hours of deliberation. It will be sent to P.E.I.'s justice minister for action, and the provincial coroner's office will check on progress in a year's time.
"It's been a heavy few days, emotional, with a lot of information that's been presented, especially watching the Clarkins here attending every day," said Dr. Brandon Webber, P.E.I.'s chief coroner, who presided over the inquest.
"But I'm really happy with how we told the story of what happened to Colton over the period of his involuntary admission. And I think it really played out with the jury and they were able to make some good recommendations from that."
Clarkin, 27, had been an involuntary patient at Hillsborough Hospital in Charlottetown for 10 months by the time he died by suicide in July 2023.
He fled from the grounds while walking there with his father, and his body was found near the Confederation Trail the next day.
Forensic hospital treatment a key
Monday, the six jurors urged the province to either set up its own forensic hospital or strike arrangements with forensic psychiatric hospitals in other provinces to have them required to accept Island patients who have been found not criminally responsible for offences.
Prince Edward Island is the only province in Canada without its own forensic hospital or forensic ward.
"It really stands to be determined if we have the internal capacity or if we need to develop more external capacity, but I'm hoping that when we are developing these agreements, that at least these inquest findings might be a bit of a stronger bargaining tool and help to bolster any agreements or legislation that we develop," Webber said.
The inquest was told such a facility would have better tools for treating Clarkin than the Hillsborough Hospital had, including medical personnel specially trained to treat people who have committed crimes believed to have involved mental illness or addictions.
Security is tougher as well, so it would have been much harder for Clarkin to flee the premises, as he did several times while at Hillsborough Hospital.
'Doing him a disservice'
Clarkin ended up at Hillsborough after a judge found him not criminally responsible (NCR) for several weapons offences in September 2022. His criminal record before that had included armed robbery and assault.
The NCR finding sent his case to P.E.I.'s Criminal Code Review Board, which ultimately sent him to Hillsborough after receiving a report from an out-of-province forensic psychiatrist who had assessed Clarkin.
Before his death, Clarkin's treatment team had approached the Waterford Hospital in St. John's, N.L., and the East Coast Forensic Hospital in Dartmouth, N.S., about transferring him there. His psychiatrist, Dr. Declan Boylan, warned in a letter to P.E.I.'s Criminal Code Review Board that "it is doing a disservice to Mr. Clarkin to not provide him with treatment in an appropriate facility."
Boylan told the inquest that Clarkin likely did not have an underlying psychotic illness, since his symptoms faded when he abstained from heavy opioid and stimulant use.
But Clarkin's own lawyer objected to such a transfer, according to the board's ruling.
"Mr. Clarkin has no interest in leaving the province for treatment as he believes it would not be helpful to him, and he does not wish to leave his family," Trish Cheverie was quoted as saying.
Hunt for a treatment program
Treating his addictions on P.E.I. proved to be fraught with difficulty, in large part because of his own behaviour.
When he absconded from Hillsborough Hospital or left on approved family passes, Clarkin sometimes used drugs while he was gone and smuggled drugs and drug paraphernalia back into the hospital on at least two occasions.
He was signed up several times for an intensive 21-day program at the Provincial Addictions Treatment Facility in Mount Herbert, 10 kilometres away, meaning a solo cab ride each way.
However, he refused to sign the paperwork on one occasion, he wasn't allowed to leave Hillsborough Hospital on another because he was considered a flight risk, and was kicked out at least twice for behaving badly to other participants.
"There was no real treatment going on to get him help with his addictions," Boylan told the inquest last week. "We weren't getting anywhere."
Clarkin eventually did start going to a program at Mount Herbert, but on the day he absconded from Hillsborough for the last time, July 28, he had been told he was no longer welcome at the addictions treatment centre because of his behaviour toward a woman taking the same program.
He was found dead on July 29.
Joseph Ur, the Clarkin family's lawyer at the inquest, summed up the issue this way: The Criminal Code Review Board could commit the young man to an institution that could not treat him. The addiction facility that offered the treatment he needed was able to kick him out. Finally, forensic hospitals in nearby provinces had the discretion to refuse to admit him.
"That creates an inherent problem," he said. "Colton wasn't necessarily set up for success."
Among the jury's recommendations on Monday: That a patient's personality and mental health diagnosis, if any, play a larger role in their personal treatment plan, and that more effort be made to provide treatment to them in a timely manner.
Among the other recommendations:
- The new psychiatric hospital being built in Charlottetown to replace the Hillsborough Hospital should strive to be designated as a forensic facility. If that's not possible, it should have increased security measures to prevent patients from fleeing, as well as onsite in-patient addictions and withdrawal treatment.
- Health P.E.I. should improve communication between teams when a patient changes a response on a suicide screening tool, as Clarkin did in the spring of 2023 on an addictions centre form. That information was not passed on to his team at Hillsborough.
- All institutions within Health P.E.I. should use the same record-keeping system so information can be accessed across treatment teams.
- Health P.E.I. should train all staff in its institutions on a new screening tool called Waypoint Elopement Risk Scales, or WERS, that is becoming the industry standard to determine flight risk.
- Patients deemed a flight risk should be denied passes to leave the hospital until their case is reviewed.
- All addictions and mental health staff should receive training on how to deal with forensic patients.
If you or someone you know is struggling, here's where to get help:
- Canada's Suicide Crisis Helpline: Call or text 988.
- Kids Help Phone: 1-800-668-6868. Text 686868. Live chat counselling on the website.
- Canadian Association for Suicide Prevention: Find a 24-hour crisis centre.
- This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.