CANADA • Female, 16 (deceased) ~ Victoria BC

Police probe death of girl who vanished from facility
December 29, 2010

Saanich police are investigating the death of a 16-year-old girl who went missing from a psychiatric facility.

Staff at Ledger House, part of the Queen Alexandra Centre for Children's Health, reported the girl missing late in the afternoon on Dec. 19.

She was found dead nearby less than two hours later.

Neither the girl's name nor the cause of death have been released, but police do not suspect foul play.

The police investigation will examine how the girl was able to leave the facility, as well as whether there was an appropriate response to her disappearance, Sgt. Dean Jantzen said.

Saanich police resources were "maxed out" investigating a stabbing that occurred three hours before the girl was reported missing, Jantzen said.

As a result, the department had yet to assign officers to look for the girl by the time her body was found -- more than 90 minutes after the first call to police.

It is the first inpatient death of a child or youth at Ledger House in the facility's 23-year history, said Shannon Marshall, a spokeswoman for the Vancouver Island Health Authority. There will be an internal review by the health authority, in addition to the police and B.C. Coroners Service investigations, Marshall said.

The case was not made public until the Times Colonist received a tip this week from a caller who wished to remain anonymous.

Marshall said VIHA does not normally issue news releases about fatalities or sudden deaths at its facilities.

Jantzen said the girl was reported missing to police at 5:36 p.m. on Dec. 19.
She was last seen about 45 minutes earlier.
Staff searched the grounds and buildings before calling police, he said.

The girl had been taken to the 14-bed facility by her family and had yet to be assessed by a doctor, so she had more freedom than if she had been committed, Jantzen said.
"She was a voluntary admission, is my un-derstanding. She did have some freedom of movement."

Jantzen said the police call-taker would have searched databases and perhaps made initial inquiries of other agencies to try to find the girl. But, otherwise, Saanich police resources were tied up investigating a serious stabbing, which happened about 2 p.m. at a subsidized family housing complex on Bethune Avenue, he said.

"We were maxed out with the Bethune investigation," Jantzen said.
The Saanich watch commander had already alerted Oak Bay and Victoria police departments that he might have to draw on their resources in an emergency.

Although there was some indication that the missing girl might be at risk of harming herself, it was not viewed as an urgent case, Jantzen said.
"If this was felt to be an issue of immediacy, we would have tapped into those resources and sent them over there."

Instead, the report was still unassigned when police received a 911 call at 7:10 p.m. reporting the girl had been found by a relative in the beach area near Ledger House.

http://www.vancouversun.com/news/Police probe death girl vanished from Vancouver Island facility/4036006/story.html

This dear child and her family were failed on so many levels

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B.C.'s child watchdog to review teen death
December 30. 2010

VICTORIA — The death of a 16-year-old girl who went missing from a Victoria psychiatric facility will be the subject of an independent review by B.C.'s child watchdog.

John Greschner, chief investigator for Children's Representative Mary Ellen Turpel-Lafond, confirmed
Wednesday the case meets the criteria for a death review by her office.

Turpel-Lafond reviews critical injuries and deaths of children and youth who received services from the Ministry of Children and Family Development in the previous year.

The girl disappeared from Ledger House at the Queen Alexandra Centre for Children's Health late on the afternoon of Dec. 19. She was found dead less than two hours later in a nearby beach area. Neither the girl's name nor the cause of death has been released, but police do not suspect foul play.

In addition to Turpel-Lafond's review, Saanich police, the B.C. Coroners Service and the Vancouver Island Health Authority have launched inquiries.

The case has raised questions about how the girl was able to leave the facility, as well as about the timeliness of the police response. Saanich police Sgt. Dean Jantzen said this week the department was "maxed out" dealing with a stabbing incident, and as a result, the department had yet to assign officers to look for the girl by the time her body was found.

The case could also be the subject of a fifth review if the children's ministry decides to examine its involvement in the file.

The ministry declined comment Wednesday, citing privacy rules.

Read more: http://www.timescolonist.com/news/child watchdog review teen death/4042562/story.html#ixzz19ebhoPQm

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Teen's death tied to 'broken' policing
Heed says girl might be alive today if a regional force had been in place
January 4, 2011

The delayed search for a 16-year-old girl who died after going missing from a Saanich psychiatric facility is yet another example of the gaps in B.C.'s fractured policing system, former solicitor general Kash Heed said.

"You might as well get used to it ... because these incidents will continue to happen, and it's a symptom of the police system we have here in British Columbia," said Heed, a former West Vancouver police chief.

"When are people going to wake up and realize that the system for policing in British Columbia is broken?"

Heed, a Liberal MLA, noted that police knew the young girl might harm herself, yet there was no officer assigned to the case for more than an hour and a half.

"That's unacceptable," he said.

It wasn't until the girl's body was found by a family member near the psychiatric facility that officers were dispatched. The cause of death has not been released.

It's not known whether a swifter police response might have saved the girl. But Heed said a regional force would have been better equipped to handle the case than the jumble of
seven departments and detachments that serve 350,000 people in Greater Victoria.

The Saanich police department says it was "maxed out," dealing with a stabbing incident, at the time the girl was reported missing from Ledger House at the Queen Alexandra Centre for Children's Health on Sunday, Dec. 19.

Police alerted other departments and agencies, such as B.C. Transit. But the call was not deemed to be an "issue of immediacy" and was put into a holding queue to be assigned as
an officer became available.

Saanich police Chief Mike Chadwick did not respond to an interview request. But Saanich Mayor Frank Leonard, who was briefed by police, said the real issue was not resources, but how the call was categorized.

Leonard said he hopes the reviews underway will give police guidance on how to classify missing people who were voluntarily admitted to a facility, and had some freedom to come and go.

Leonard disputed that Saanich police were "maxed out," and said the department could have pulled in other resources or asked for help from neighbouring forces. "If [the call] had been given a different category, the response would have been more immediate," he said.

But Heed said a regional force, with greater resources and more flexibility, would not be overwhelmed by a single stabbing incident and could have responded more easily to the
disappearance. A regional supervisor would simply pull officers from another district and send them to look for the girl without jumping through bureaucratic hoops, contacting other departments, or calling in off-duty officers, he said. "You would have the ability just to shift
the resources around right then and there."

Under the current system, "smaller departments are reluctant at times to go outside and get the help that's needed," Heed said.

Saanich police did alert Victoria and Oak Bay police departments that they might have to tap
into their resources in the event of an emergency. But it was deemed the missing girl could wait, despite the fact there were officers in adjacent departments dealing with relatively routine calls.

The Victoria police, which has anywhere from 14 to 20 officers on a Sunday day shift, had members doing traffic stops and answering a complaint about loud music at the time of the girl's disappearance. Oak Bay police also had a fairly quiet day with no calls of particular urgency, Chief Ron Gaudet said.

It's the second time in three years that a child's death has raised questions about policing in Greater Victoria. In 2007, six-year-old Christian Lee and four of his family members died in an Oak Bay murder-suicide that exposed numerous problems with the fractured policing system.

"You will have chiefs and leaders of policing and advocates for the current system come out and talk about, 'Oh well, we're working together. We're addressing the problems,' " Heed said. "But those are just Band-Aid solutions to something that we need to fix once and for all in B.C."

lkines@timescolonist.com

Read more: [url=http://www.timescolonist.com/news/Teen death tied broken policing/4056035/story.html#ixzz1A7eHcXmt]http://www.timescolonist.com/news/Teen death tied broken policing/4056035/story.html#ixzz1A7eHcXmt[/url][/color]

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Multiple investigations follow teen’s death
January 10, 2011

The Dec. 19 death of a 16-year-old Vancouver Island girl who walked away from a Saanich psychiatric facility has sparked four separate investigations.

The teen’s body was found at a nearby beach, less than two hours after she was reported missing from Ledger House at the Queen Alexandra Centre for Children’s Health.

The girl had voluntarily entered the hospital – the date was unspecified – and she was deemed to be at risk of harm.

Staff noticed the girl’s absence within five minutes, said Shannon Marshall, spokesperson for the Vancouver Island Health Authority, which runs Queen Alexandra.

The facility’s protocol dictates that police are not notified of a voluntary patient’s disappearance until after a search of the building and grounds is conducted by staff.

“When a client leaves our facility without authorization, our response is determined by the risk of the client and whether they are certified under the Mental Health Act,” said Elaine Halsall, manager of Child, Youth and Family Health at Ledger House. “If a client is at risk or is certified, we notify the police.”

Marshall said the health authority is conducting an internal review.

“It’ll very likely involve every aspect of the care of this child’s experience (with VIHA),” she said. Additionally, it will look at systems, protocols and procedures to see if they can be improved. “The aim is to prevent similar occurrences in the future…”

Because the incident occurred on a Sunday, the Saanich Police Department had fewer staff on duty than they would have on a weekday. When the call came in, police were also dealing with a stabbing case.

Ledger House staff called the police non-emergency line at 5:36 p.m., 45 minutes after the teen went missing, said Sgt. Dean Jantzen.

Since all on-duty officers were investigating the stabbing, the missing person call was “captured, categorized and triaged.”

“If we felt resources were needed at Queen Alexandra immediately we would’ve scheduled for assistance,” he said. After the stabbing, Saanich put Oak Bay and Victoria police on notice in case a priority call came in.

Saanich police responded immediately to the Ledger House call by issuing a ‘be on the lookout for’ notice, with a description of the missing teen, to all regional police officers as well as B.C. Transit, Jantzen said.

The police department is conducting an internal review of its response to the call and “we’re asking hard questions of ourselves,” he said.

Additionally, the B.C. Coroners Service is investigating, as is the Office of the Representative for Children and Youth in B.C.

Vancouver Island regional coroner Matt Brown said his office’s investigation will look at the circumstances leading up to the death, gaining information from all parties involved. After that it will determine whether a coroner’s inquest should be held to address a greater community concern, he said.

The results of both the investigation and inquest can lead to binding recommendations put forward to government and non-government bodies to prevent similar deaths.

John Greschner, chief investigator for the Representative for Children and Youth, said the final coroner’s report will be reviewed to decide whether to launch a full investigation into the file.

“We do that in cases where we think there’s something in particular that needs to be brought to the public’s attention, or think there’s some aspect, based on the file review, where public services need to be further investigated,” he said, “or where there’s an opportunity for the system to learn.”

The Representative for Children and Youth investigation will focus on services and policies that had an impact long before the death. Its results are not binding.

The teen’s death is the first inpatient client death in Ledger House’s 23 years of operation.

http://www.bclocalnews.com/vancouver_island_south/oakbaynews/news/113229944.html

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Saanich psychiatric facility calls given extra priority during review following girl's death
More urgent response introduced during review following girl's death
January 12, 2011

All calls to police from a Saanich psychiatric facility for children will now be categorized as priority two, requiring immediate police action. The urgent response will be in place until a review into the death of a 16-year-old girl, who went missing from the facility, is completed, Saanich police Chief Mike Chadwick told police board members Tuesday.

"That gives us some comfort while the review is going on," Mayor Frank Leonard said in an interview. The mayor asked police investigators to have the review completed by Feb. 15.

The girl was taken by her family to Ledger House, a 14-bed facility at the Queen Alexandra Centre for Children's Health, on Dec. 19. There was concern that she was at risk of harming herself. She was admitted, but before being assessed by a doctor, she disappeared.

Staff searched the grounds and buildings and about 45 minutes later called Saanich police. Still, no officers were dispatched. All on-duty officers were investigating a stabbing.

Saanich police had yet to assign officers to look for the girl by the time her body was found -- more than 90 minutes after the first call to police.

Chadwick said the call "may have been [categorized] as priority three" which relates to "routine" calls. Whether that was the fault of police or Ledger House staff, or a combination of both, will be determined in the review, he said.

Chadwick estimated there were about 10 officers working at the time of the missing report.

"I am of the opinion it was not a resources issue," Chadwick said. "It was call receipt and call prioritization ... it's more a case of what was the immediacy conveyed to us."

Read more: http://www.timescolonist.com/Saanich+psychiatric+facility+calls+given+extra+priority+during+review+following+girl+death/4096054/story.html#ixzz1Asyn1BxK

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Ledger House case leads to change in Saanich police procedure
March 1, 2011

Saanich police have modified their response to missing youth reports, after an internal review of a case in December, in which a teenager died before a search for her had been mounted.

The case involved a 16 year old girl who walked away from Ledger House, a VIHA mental health facility...but police Sergeant Dean Jantzen says the policy amendment goes far beyond the handling of calls from Ledger House...to include all reports of missing teens. They will in future be "dispatched" immediately...although he stresses that doesn't necessarily mean an officer will be sent immediately...

"Where an officer is not immediately available that file will then be sent to an on-street supervisor, for their review. If some adjustment in the response is felt appropriate, i.e., a higher level of response or a lower level of response, that will be the purview of the on-street supervisor and the officer who might be reviewing that call"

Jantzen says the review concluded that in the particular case in December, nothing that any police officer or civilian employee did contributed to the girl's death.

http://www.cfax1070.com/index.php?option=com_content&view=article&id=237:ledger-house-case-leads-to-change-in-saanich-police-procedure&catid=45:mainlocal-news&Itemid=113