Inquest jury makes recommendations after teen denied help at Fredericton hospital

A coroner’s jury has made 10 recommendations to try to prevent deaths similar to Lexi Daken’s.

The 16-year-old Fredericton-area girl died by suicide within days of days of being turned away from the Dr. Everett Chalmers Hospital in February 2021. 

Testimony at the inquest into Daken’s death wrapped up Wednesday morning, and the jury of three women and two men began deliberations before noon.

By 3 p.m., they returned with their recommendations. 

They began by endorsing 12 recommendations made by the Horizon Health Network in March 2021 after an internal review of Lexi’s death, then added 10 of their own.

Much of the focus is on better public education about mental health resources, including making the information more readily available to the public, using brochures to help with communication.

A player card of a softball player in uniform with her hair tied back.
Lexi Daken, shown here in her player card from her 2020 softball season, took her own life in February 2021 after reaching out for help multiple times. (Submitted by Chris Daken)

On Wednesday afternoon, Lexi’s father, Chris Daken, said he’s relieved the process is over and hopes that Horizon Health continues to make improvements to how mental health care is delivered.

He said his goal all along has been to ensure that no other family experiences what his has. 

“It’s never really over. I still lost a child but I’m happy this process is done and some recommendations have been made and hopefully more changes can be made and we don’t have to be going through this in another two or three years for another child.”

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Lexi Daken was a Grade 10 student at Leo Hayes High School in Fredericton. She was a gifted athlete and a high achiever academically.

But once COVID hit, without sports, social activities and only going to school every other day, Lexi’s mental health began to falter, her father, Chris Daken, testified on Tuesday. 

He said he didn’t realize how much she struggled until she tried to take her own life in November 2020.

Turned away at emergency department

On Feb. 18, 2021, a guidance counsellor at her school noticed a deterioration in Lexi’s mental health and took her to the emergency department of the Dr. Everett Chalmers Hospital at lunchtime. She wasn’t seen by an emergency room doctor until about 7:20 p.m.

After talking with the doctor and waiting for the results of blood tests, the doctor returned around 9 p.m. and asked if Lexi would “contract” with her — to make a promise not to hurt herself — and be safe at home. 

Lexi’s guidance counsellor, Shelley Hansen, testified the doctor said, “Lexi, if you don’t contract with me, I’ll be forced to call in a psychiatrist.”

Hansen said she was “shocked” at the use of the word “force.” She said she saw something change in Lexi’s face when she heard it. 

Hansen said she told the doctor she believed Lexi really needed to see a psychiatrist. She said she wasn’t comfortable with Lexi going home that night, and they even talked in the car as they sat in the parking lot about returning to the emergency room and asking to page the psychiatrist. 

But they didn’t. Lexi went home that night and died by suicide on Feb. 24.

Lexi’s death sparked public outcry and was the catalyst for a review of mental health services. That review included a report released in September 2021 by New Brunswick’s child and youth advocate, who concluded her death could have been prevented

16 witnesses over 3 days

The last of 16 witnesses at this week’s inquest in Fredericton was Rachel Boehm, Horizon Health Network’s executive regional director of addictions and mental health. 

Boehm led the inquest through a list of 12 recommendations that were made in March 2021 after an internal review of the circumstances surrounding Lexi’s death. 

She said the process involves a meeting of all of the people who were involved and the goal is to come up with system improvements that could prevent similar incidents in future. 

Essentially, explained Boehm, “what can we learn to do better next time.” 

Many of the recommendations centred around improved training for emergency room staff. Some of the recommendations were rejected because they were already underway, explained Boehm. 

She said several changes were made immediately following Lexi’s death, including better training for ER staff in treating mental health problems and identifying high-risk patients. 

Flowers, candles and pictures lay in the snow as a bag pipe player stands in the background in front of an official looking building.
Lexi Daken’s death sparked a public outcry and led to a review of mental health services. The review by New Brunswick’s child and youth advocate concluded her death could have been prevented. (Gary Moore/CBC)

One of the biggest changes, said Boehm, was the addition of a dedicated mental health team in emergency departments. She said patients still have to wait to be triaged, but once mental health problems are identified, patients are diverted to a separate, quiet area where they wait to be seen by a multidisciplinary team of professionals. 

Boehm said a gap was also identified in transferring patients to community-based services. Recommendations included creating a standardized system for transferring patients, which includes steps to ensure patients don’t fall through the cracks. 

Related to that, Boehm said, emergency room staff were reminded about the mobile crisis unit and how it can be used. Similarly, staff members were reminded that “urgent” time slots were always reserved for next-day referrals for mental health services. 

The group also suggested establishing a standardized system for transferring patients from private care to the public system. Boehm said the recommendation was rejected because Horizon doesn’t have the authority over the private system, and each profession would have its own regulatory body. 

Although rejected, Boehm said the public system can still reach out in individual cases and make every effort to obtain permission to get private counselling records. 

She said the transfer of services “is a time of risk,” and the aim is to reduce the possibility of gaps in service or being lost. 

Summarizing the effectiveness of changes that have been made since Lexi’s death, Boehm said mental health patients are now seen by specially trained intervention teams much more quickly when they present at emergency departments.

Jury makes 10 recommendations

The jury’s recommendations focused heavily on education — better educating the public about resources available and patients about what exactly is available to them and keeping them informed through every step of the diagnosis and treatment stages.

They recommend:

  • Increasing awareness and educating youth and the public about what mental health services are available.
  • Available mental health services should be marketed and information should be easily accessible.
  • The hospital should improve communication with patients and brochures should outline services and contact information.
  • A standardized patient discharge information sheet should be given to patients with relevant medical information from their visit, such as diagnosis, medications and care plan.
  • Hospital clerks should confirm contact information with patients.
  • The “contract for safety,” an agreement between the patient and health-care providers, should use consistent and specific wording.
  • A parent or legal guardian should be present and involved with the “contract for safety” if the patient is a youth.
  • Community mental health services should specify the next follow-up appointment, with date and time.
  • Signage in the waiting room should be displayed to reassure and support patients who are waiting.
  • Additional resources should be made available for community mental health services.

If you are in crisis or know someone who is, here is where to get help:

CHIMO hotline: 1-800-667-5005  /

Kids Help Phone: 1-800-668-6868,  Live Chat counselling at

Canada Suicide Prevention Service: 1-833-456-4566

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