Social safety net failed Pelly Crossing man: coroner

A Pelly Crossing man who died of exposure on the street in Whitehorse was not being properly monitored by those responsible for taking care of him, according to Yukon's coroner.

A Pelly Crossing man who died of exposure on the street in Whitehorse was not being properly monitored by those responsible for taking care of him, according to Yukon’s coroner.

Robin Sam, 33, was found dead on the south side of Two Mile Hill on Jan. 13, 2014. He died of hypothermia.

The temperature in the days leading up to his death hovered between -10 and -26 C, according to chief coroner Kirsten Macdonald’s report.

Sam was found not criminally responsible by reason of a mental disorder after pleading guilty to an assault in 2010.

A 2010 territorial court decision describes “significant cognitive limitations, likely resulting from a number of causes.”

He had possible FASD, and a severe beating when he was 16 likely caused a seizure disorder.

Since pleading guilty in court, Sam’s case was being handled by the Yukon Review Board.

He’d been allowed to live in the community, on conditions, and had to regularly check in with the board.

Since he started being seen by the board, a team of people, led by the director of social services, was supposed to come up with a plan to help Sam with treatment, rehabilitation and education.

The plan was supposed to address Sam’s medical and psychological needs, including his seizure disorder and the medication associated with it. The actual details of what that plan looked like are not public. No one from the Department of Health and Social Services is talking about it, citing privacy concerns.

The plan called for social services staff to consult with the Northern Tutchone Tribal Council’s director while Sam lived in Pelly Crossing. The council’s director had primary responsibility for monitoring Sam day-to-day, according to the most recent board report in 2013.

If this treatment team became aware that Sam was not taking his medication, they were required to immediately notify everyone involved, as well as the board. Yet, according to the coroner’s report, this didn’t happen.

When the review board’s 2013 report was prepared, it appeared that Sam was doing well. “Although there are significant issues regarding Mr. Sam’s capacity, he has enjoyed an excellent level of support in the community and has responded well to those supports,” the report noted.

In January 2014, three days before his death, Sam was back in Whitehorse for another annual hearing.

According to Macdonald’s report, he was disoriented, frightened, moaning, rocking back and forth and clenching his fists when he appeared before the board.

He left the hearing not long after it started, which is not uncommon in review board hearings, and could not be found afterwards.

In her investigation, Macdonald found that Sam was not taking his medication as directed. Support workers and medical professionals knew about it, but no one immediately told the board, as they were required to do.

He had multiple seizures that required hospitalization in October 2013.

“In October 2013 it was clearly documented that Mr. Sam was not taking his medication as directed. Mr. Sam also told his support workers that he was not taking his medication,” Macdonald wrote.

No one ensured that Sam was checked on daily, she says. “No one ensured that the monthly blood levels of the anti-seizure medication was performed.”

The pathologist who examined the body called Sam’s seizure disorder a contributing factor to his death.

“A generalized seizure disorder, when symptomatic and not well controlled, can predispose one to, or impair one’s ability to escape from, life threatening environments/situations such as exposure to cold weather,” Macdonald wrote.

She recommends that the health department, if it is involved with a review board case, ensure that all conditions are vigorously monitored and implement a process to make sure that’s happening.

No one from the department would agree to be interviewed about what happened to Sam.

“The department hasn’t completed discussions with the coroner regarding the report, but we can confirm that we have accepted her recommendations,” said spokesperson Marcelle Dube in an email.

“We are not in a position to discuss personal, case-related matters. We never discuss individuals and their cases, to protect their privacy.”

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