Paragraph five reads: "Three years ago, a court in Oshawa thought it was sending Gleb to a hospital for the assessment and told the teen he would be with a team of specialists -- nurses and doctors but through a stunning series of miscommunications, the teen wound up in jail."
Paragraph 12 reads: "Had staff members requested the file -- which some incorrectly believed they had no right to because of privacy legislation -- they would have found out he had been taking an antidepressant."
Toronto -- The Province needs to create a place in the youth justice system outside of jail where mentally ill kids can receive court-ordered psychiatric evaluations, a coroner's inquest into the death of a Pickering teen heard.
"These beds do not exist," said lawyer Daphne Jarvis, representing the Syl Apps Youth Centre in Oakville, where Gleb Alfyorov hanged himself with his shoelaces while awaiting a mental health assessment on May 13, 2008, five days after his 17th birthday.
"There are hundreds for adults."
The five-person jury was asked to consider this recommendation and dozens of others to prevent future deaths in similar circumstances as proceedings concluded on Wednesday afternoon.
Three years ago, a court in Oshawa thought it was sending Gleb to a hospital for the assessment and told the teen he would be "with a team of specialists -- nurses and doctors" but through a stunning series of miscommunications, the teen wound up in jail.
An earlier assessment of the boy revealed serious mental health issues but the court thought there was a chance he was not criminally responsible for an assault. Gleb had pleaded guilty at the first opportunity without a lawyer. He was accused of hitting his older sister in the face and insisted he be sentenced and serve his time.
His behaviour -- talking to himself and saying that he was "the God of all Gods" on a mission to save the planet -- left the judge wondering whether Gleb could "survive" in a correctional institution.
The judge ordered Gleb be assessed for criminal responsibility -- an intensive evaluation that was supposed to be conducted within 30 days by a psychiatrist.
A lawyer who co-ordinated the assessment secured a bed at what he thought was a hospital-like setting but which turned out to be a jail.
Staff members at Syl Apps would later say they never actually knew why Gleb was there. Those who were supposed to care for him did not read the assessment order from the court or a report prepared by his probation officer. Though Gleb had been at the facility nearly a month when he hanged himself, the assessment was never completed.
He was never seen by a psychiatrist or a general physician at the facility. No one requested his medical file from Brookside Youth Centre in Cobourg, a government-run jail where he had spent the previous three months awaiting sentencing.
Had staff members requested the file -- which some incorrectly believed they had no right to because of privacy legislation -- they would have found out he had been taking an antidepressant.
The jury was asked to consider a recommendation that the Ministry of Children and Youth Services review privacy laws to ensure policy does not restrict access to personal health information.
At Syl Apps, Gleb rarely left his cell. The inquest heard that when he did leave, to shower, he'd walk tentatively into the hallway and push a garbage can against the door after entering the washroom. Staff and other youth would hear him chanting in his room or screaming in the middle of the night.
The Provincial Advocate for Children and Youth, one of 12 parties with standing at the inquest, wants the province to develop a "red flag" policy around isolation. Any time a youth spends two days or more isolated from others, staff should alert the advocate and the Ministry of Children and Youth Services, the jury was told.
All parties suggested that there needs to be better communication between court staff, jail staff and probation officers to ensure that what happens at court is conveyed to the right people.
They also recommended the Ministry of Children and Youth Services and the Attorney General review how court-ordered assessments for youth are administered in Ontario.
Another joint recommendation presented at the inquest was that no facility, either government-run or privately operated, should allow youth to have shoelaces or clothes with drawstrings. Ministry-operated institutions were already following this policy before Gleb's death.
The inquest jury is not expected to return before Friday. -- Diana Zlomislic is a reporter for the Toronto Star