Inquest hears about discovery of teen’s body on grounds of group home

Warning: This story is about suicide. Resources for those who need help are listed at the bottom of this story.

On the afternoon of April 12, 2018, Ken Brill was preparing to play ball hockey with a couple of teens who were residents at the group home where he worked when the boys came up to him looking shaken.

Brill, who worked as the team lead at Lynwood Charlton Centre's Flamborough site, thought the boys had come across someone in distress while searching for equipment in the wooded area of the large Collinson Road property. He sprinted into the woods. In a pine tree, he found the body of Devon Freeman, a 16-year-old boy who lived at the home and had been missing for more than six months.

Another staff member recognized Devon's clothing and 911 was called, Brill told an inquest into the teen's death Monday. He no longer works for the organization.

In the months since Devon disappeared from the group home in Oct. 7, 2017, staff were increasingly concerned about him, but Brill said the discovery of his body and apparent death by suicide surprised him.

The large pine tree is not far from the paved basketball court on the property. But it's in an area not typically accessed because there is brush and the ground slopes, he said, adding that Devon's body wasn't visible until he was under the tree.

Brill wasn't Devon's primary worker - also called a coach - at the group home, but he did process Devon's admission in February 2017. Devon had complex mental-health needs and was a ward of the Children's Aid Society (CAS) of Hamilton, after his grandmother, Pam, was unable to care for him on her own.

Pam and the Chippewas of Georgina Island - the family's First Nation community - have been fighting for answers and to make changes to prevent similar deaths.

The inquest has heard that Devon was very unhappy at Lynwood and ran away frequently.

Brill told the inquest he didn't know about a prior suicide attempt before Devon arrived at Lynwood. But he was working on May 30, 2017, when Devon came into his office and said he had attempted suicide the day before and that he was stopped by another youth who cut him down. Brill recalled that Devon spoke calmly and said he no longer had suicidal thoughts. They went over safety planning, including how to contact a crisis line. There was no formal, documented risk assessment.

However, the inquest has heard that Devon's psychiatrist, his grandmother and his First Nation band representative were not told. Nor were Hamilton police told about the suicide attempt when Devon was later reported missing.

Lynwood was required to contact Devon's guardian - CAS of Hamilton - and other communications would flow through them, Brill said.

In a crisis, staff may decide to restrain a resident if they are a danger to themselves or others - that would require a serious incident report sent to the ministry, Brill said. Staff may also call police, who can apprehend someone under the Mental Health Act.

In other situations staff may stand between two youths to block them from each other. Another Lynwood witness previously described doing this with Devon and another teen who were fighting the day before Devon disappeared. The inquest has heard the teen was taunting Devon about his mom, who died when he was six. Brill did not recall this fight on Oct. 6, 2017, but said staff acting as a block does not require a serious incident report.

On questioning, Brill agreed that more funding for additional staff and resources at Lynwood, better communication between agencies and access to Indigenous programming - including an elder or knowledge keeper - would be helpful.

The inquest also heard Monday from Alex Thomson, who is retired after working as executive director of Lynwood Charlton for 39 years. The organization has four properties, including the Flamborough site, that offer residential care, day treatment and community outreach for child and youth mental-health services. He never interacted with Devon, but knew who he was through serious incident reports.

The inquest has heard there have already been a number of changes at organizations since Devon's death. This includes Lynwood Charlton undertaking a third-party review of its policies and procedures after Devon's death, Thomson said. The report led to nine recommendations, including enhancing the working relationship with the Hamilton Regional Indian Centre, a new policy about managing high-risk behaviour and meeting with Hamilton police about improving procedures for missing-person reports.

The five-person jury is tasked with coming to a verdict about the cause and manner of Devon's death. They can also make recommendations to prevent similar deaths in the future. The inquest continues Tuesday.

Nicole O'Reilly is a crime and justice reporter at The Spectator. noreilly@thespec.com

If you're a young person experiencing thoughts of self-harm or suicide, reach out to your parents, or guardians, or contact the Suicide Prevention Community Council of Hamilton.

Here are some resources:

COAST: 905-972-8338

Barrett Centre: 1-844-777-3571

Native Women's Centre: 1-888-308-6559

Kids Help Phone: 1-800-668-6868 (5-20)

Good2Talk: 1-866-925-5454 (17-25)

Crisis Services Canada: 1-833-456-4566

National Suicide Prevention Lifeline: 1-800-273-8255

Nicole O'Reilly is a crime and justice reporter at The Spectator. noreilly@thespec.com