It took eight months for her to get her hands on the document no mother should ever see.
Squamish’s Brenda Doherty recently received the Coroner’s Report, filled out by the province’s child death coroner Adele Lambert, about the death of her daughter Steffanie Lawrence, 15, who died Jan. 22 of an overdose.
Doherty had been waiting for the report because she felt it would confirm her belief that Steffanie did not need to die.
The report goes a long way in confirming that, Doherty said.
“This is where they need to make the changes. They have got the confirmation of what happened to her, and we’ve got the recommendation. There’s got to be something that changes,” she added.
Doherty provided The Chief with the full coroner’s report.
The report confirms that Lawrence died in the early morning hours of Jan. 22 from mixed drug toxicity — an unintentional overdose of fentanyl and alprazolam, a medication for anxiety.
The coroner recommends that the province’s Representative for Children and Youth consider “reviewing the services provided to Steffanie Georgina Anne Lawrence with a view to improving services and outcomes for children in the Province of B.C.”
Minister Judy Darcy, on behalf of the ministries of Mental Health and Addictions and Children and Family Development, said that the Coroner’s Report on Lawrence is being reviewed, “to ensure similar situations do not occur in the future.”
“Steffanie’s experience and the experience of her family underscores the challenges many families across the province have when trying to navigate a mental health and addictions system that is fragmented and disconnected,” she said, in an emailed statement.
“We are looking at B.C.’s Mental Health Act and all related statutes, the suite of services that would be provided before and after any kind of involuntary admission, and the appropriateness and need for separate involuntary admission legislation. We are also looking closely at the experience in other provinces and countries as well as in B.C.”
Doherty said when she received the coroner’s report she called Darcy on a number she was given when she met with the minister late in the spring, but the call was not returned as of press deadline.
A spokesman for the Representative for Children and Youth said the office could not provide specific comment on Lawrence’s case but did provide The Chief with an outline of what happens after the coroner makes such recommendations.
“Once a recommendation has been received from the Coroner, representatives of children and youth does an initial review to determine whether the case falls within our mandate,” the spokesman said.
The office’s mandate is to conduct independent reviews and investigations into critical injuries or deaths of kids who received reviewable services. Simply stated, this means the death of children who had received government-funded services or programs.
The coroner’s report outlines that Lawrence had accessed such services and that her family requested a number of services to help their daughter, including through the Ministry of Children and Family Development.
Lawrence was in inpatient treatment in September of 2017, but was discharged “due to challenges with her behaviour.”
“Family had concerns for Steffanie’s safety and requested placement through the MCFD, but this was assessed as not being necessary at that time,” continues the report.
By October of 2017, her situation had deteriorated, but though her family desperately wanted her to get it, the girl was refusing treatment.
Her team of service providers met in November to discuss a plan for the girl, “as there were limited options available” in Squamish. In January, she was in a safe house, but left and was reported missing to the police. Lawrence’s doctor made arrangements for her to be involuntarily admitted to hospital as it was believed the girl’s life was in danger from her drug use and behaviour.
On Jan. 20, she was found by police and taken to hospital for assessment. She was discharged before her family got to the hospital. No one knew where the girl was, according to the report.
“If they labelled her high risk, why did they let her go,” Doherty said. “I just don’t understand.”
On Jan. 21 she consumed a couple of pills — her friends said they believed were Xanax — and then she and a friend fell asleep at 11 p.m.
She was dead by morning.
(In an unrelated case last week, Edmonton police put out a public warning after 3,700 pills they had seized, were fentanyl disguised as the tranquilizer Xanax.)
The RCMP investigated the death, but deemed it was not “suspicious.”
Once a comprehensive review has been completed, the Representative for Children and Family determines whether a full investigation (including, among other things, interviewing numerous witnesses) of the case will be completed.
Full investigations typically take several months to complete and result in the release of a public report.
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On Sept. 27, The BC Coroners Service released a study on overdose deaths in the province in 2016 and 2017.
Among the findings in Illicit Drug Overdose Deaths in BC: Findings of Coroners’ Investigations were that more than half of those who died had reported mental health struggles.
Approximately one in five of those who died had contact with health services in the year before their death.
More than two-thirds of those who died used drugs alone.
Fentanyl was detected in more than three out of every four deaths.
“We continue to urge those using substances to plan to take them in the company of someone who can provide help: administering naloxone and calling 911 for assistance,” said Lisa Lapointe, the chief coroner in a news release with the report.
