The circumstances that allowed an Indigenous teenager to take his own life metres from his group home and go undiscovered for months can only be remedied by an inquest from the Ontario coroner, according to a request from the boy’s loved ones.
Devon Freeman’s grandmother and members of the southern Ontario First Nation where he was born said a communication breakdown resulted in a particularly horrifying death for the teen, who died by suicide while under the government’s care.
An official complaint filed to the regional supervising coroner in Hamilton said the 16-year-old was last seen alive in October 2017 near the Flamborough, Ont., group home where he had spent much of that year. Seven months later, in April 2018, his body was found in a wooded area roughly 35 metres from the home.
The complaint from Pamela Freeman and the Chippewas of Georgina Island First Nation said communication breakdowns marred the case from beginning to end, with key players being kept in the dark about such crucial details as his mental health history and the length of time he was believed to be missing.
“It is important for his full story to be investigated and told to the public, in its entirety and in detail, through the vehicle of an inquest,” the letter reads. “…The public has an interest in being made aware of the many systemic gaps and problems in a child welfare system that ultimately failed Devon, contributed to his death, and puts other children in similar circumstances at risk — especially if those children share Devon’s Indigenous heritage.”
Ontario’s Office of the Chief Coroner will “duly consider the family’s request for an inquest review,” according to spokeswoman Cheryl Mahyr. She declined to offer further comment on the case.
The letter requesting a public inquiry outlines Devon’s long history of mental health struggles and suicidal ideation, dating back to his mother’s sudden death when he was six.
The letter said the ensuing years were marked by escalating mental health challenges, increasingly erratic behaviour, and limited efforts to secure support and treatment.
Pamela Freeman remained Devon’s primary caregiver for much of his life, but he officially became a Crown ward months before he died, it said.
At that time, the letter said, he was living at the Lynwood Charlton Centre group home not far from Hamilton.
The letter said Devon tried to kill himself that spring, but was stopped by a friend. It said both group home staff and child protection officials learned of that attempt, but did not offer him meaningful supports at the time and did not share what they knew months later when Devon went missing for good.
The letter argued lack of information on his mental health history tainted the way Hamilton Police responded to his disappearance in October 2017, repeatedly characterizing him as a runaway rather than a teen at risk of self-harm.
Hannah Anderson, a spokeswoman for Ontario’s Associate Minister of Children and Women’s Issues, declined to comment on Devon’s case but called the death of injury of any child “unacceptable.” Hamilton police did not respond to request for comment.
The letter said Devon’s grandmother did not learn he had gone missing until three weeks after he was last seen, adding she was notified by police rather than group home staff.
The letter said that neither she nor members of the First Nation were told of his prior suicide attempt until after his body was found in the forested area on the Lynwood property.
Devon’s body was not found until fellow resident happened upon it by accident while chasing a ball into the woods, the letter said. It noted that evidence showed his body had been exposed to the elements, suggesting it had been there since he was first reported missing.
Devon’s case bares similarities to a dozen other files recently reviewed by the chief coroner’s office last year.
After a panel analyzed the deaths of 12 young people in the care of the province’s child welfare system, Dr. Dirk Huyer concluded poor communication between key players risked leaving kids without the care they need.
Two thirds of the children whose cases were reviewed were Indigenous, most died by suicide, and all contended with mental health struggles while living away from home.
Freeman and the First Nation said Devon’s death fits the same pattern, arguing an inquest is necessary to protect others from the same fate.
“Without an inquest, it will not be possible to fully understand the systemic issues that contributed to Devon’s death, how they threaten the safety of other children in care and what steps can be taken to ensure that what happened to Devon never happens again.”