Only 1 piece of evidence linked Colton Clarkin with suicide before his 2023 death, inquest hears
Clarkin checked off a box saying he had attempted suicide, unknown to hospital team
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.
Testimony wrapped up Friday at the coroner's inquest into the death of Colton Clarkin in July 2023, but the process will now stretch into an unplanned fourth day on Monday.
Clarkin died by suicide after fleeing the Hillsborough Hospital grounds while walking there with his father. He was in the Charlottetown facility as an involuntary patient under an order from the province's Criminal Code Review Board, despite the psychiatric hospital team believing he was not a good fit for their facility.
On Friday the inquest jurors heard the only piece of evidence that linked the 27-year-old Emyvale man with suicide before his death: a checkbox on an admission form.
A month before his death in July, Clarkin checked "yes" when answering the question: "Have you attempted to kill yourself in the past?" That was during the intake process for the Transition Unit at the Provincial Addictions Treatment Facility in Mount Herbert, north of Stratford.
The inquest heard that he had checked "no" when filling out the same form earlier that year, but the manager of transitional programs working out of Mount Herbert testified Friday that the change in response was not flagged.
There was no software to do so automatically, and the priority was to screen people for current thoughts of suicide. There was a box on the form for that too, and Clarkin responded "no" to it each time he did the paperwork.
I have been asked multiple times over the last 615 days if I had siblings … How do you say you "had" a brother?... It is my most dreaded question now.— Alana Campbell, Colton Clarkin's sister
The manager told the jurors that addiction treatment staff like himself were able to read Hillsborough Hospital files and could see the case notes for Clarkin.
But that access did not go both ways, so staff at Hillsborough Hospital would not have seen that checked box about a previous suicide attempt, unless it was brought to their attention.
'Very positive' time with Clarkin, counsellor says
On Thursday, the psychiatrist who treated Clarkin throughout his 10-month stay at Hillsborough told the inquest he was 'flabbergasted' to hear his patient had died by suicide.
Clarkin had never expressed thoughts of suicide to that team — a sentiment echoed by Clarkin's addictions counsellor on Friday.
"He was funny, he was smart, he was always helpful," Kristine Sutherland said during her testimony, speaking directly to Clarkin's family, seated in the front row of the Charlottetown courthouse. "My time with Colton was very positive."
Sutherland was the last addictions counsellor to work with Clarkin, seeing him one-on-one from April 2023 until his death that July. She told the inquest that they connected, which she thought would help engage him in his recovery process.
She described Clarkin as someone who was starting to see how his drug use had negatively impacted his life, and was coming to understand that sobriety and treatment were his way out of the hospital, not the disruptive behaviour and escapes that had marked his stay to that point.
Sutherland saw him for the last time at the Hillsborough Hospital nine days before he fled the facility for the final time. They discussed why things had not worked out during his most recent attempt to take the 21-day Mount Herbert program.
Clarkin had been admitted and discharged from the program three times by that point: once when he was no longer allowed to leave the hospital to attend, once when he would not sign the required paperwork, and the month before, when he was discharged for his inappropriate behaviour.
Sutherland said they discussed strategies so that would not happen again: listen more, talk less and try to keep to himself.
"He was really motivated this day," she said, recalling how she was about to leave on vacation and he reassured her: "I've got this."
Clarkin did return to that program the next week and was again discharged after his behaviour made a female co-patient uncomfortable. He ran away from the hospital's grounds that day, and his body was found a short while later near the Confederation Trail in Winsloe.
'I need to be the best'
A psychologist working out of Hillsborough Hospital told the inquest that someone with Clarkin's complex personality disorder — which he described as narcissistic with anti-social traits — would likely struggle in a therapy environment.
Dr. Jancke Pienaar assessed Clarkin. He told the inquest Friday that the young man tended to "charm and exploit others" and would likely struggle with making himself vulnerable before a counsellor.
He said a group therapy environment might also make Clarkin act out, feeling like he had to pull the room's attention toward himself.
"There's a sense of 'I need to be the best' — which can be channelled well, but also can be channelled to do things like break out of the hospital," Pienaar said.
Closing statements
After testimony wrapped late Friday afternoon, lawyers for the Crown's office, the Clarkin family and Health P.E.I. gave their closing statements.
"It is not your responsibility to make any findings of fault or legal responsibility... It is, however, your responsibility to consider the evidence over the last few days," Crown prosecutor Chee Ng told the six-person jury.
"What you can do… is make recommendations that you believe will be of assistance in preventing similar deaths."
That creates an inherent problem. Colton wasn't necessarily set up for success.— Lawyer Joseph Ur
The lawyer for the family used his time to highlight a gap: the Criminal Code Review Board's ability to commit Clarkin to an institution that could not treat him, while the addiction facility that offered the treatment he needed was able to refuse and discharge him.
"That creates an inherent problem," Joseph Ur told the jurors. "Colton wasn't necessarily set up for success."
Health P.E.I.'s lawyer used her time to recap testimony that pointed to the health authority's commitment to improving care for Island mental health and addiction patients.
Clarkin's two sisters also spoke. Jayce Clarkin started by describing the day her brother was committed, after having been found not criminally responsible on four weapons offences in September 2022.
"I thought to myself, 'Colton is finally going to get the help he so desperately needs and deserves'… He would receive the care and attention he needed to find his way back to himself," she told the jury.
"Instead of being treated as a person deserving of dignity and compassion, Colton was too often seen only through the lens of his struggles. He was isolated, vulnerable and ultimately left without the support he desperately needed."
"I have been asked multiple times over the last 615 days if I had siblings … How do you say you 'had' a brother?" Alana Campbell said.
"Small things like that… They dig up such raw emotions any time someone asks. It is my most dreaded question now."
The jury will begin compiling its recommendations on Monday morning.
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.
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