First Nation teen wasn’t first to die by suicide involving Hamilton treatment centre

Tyra Williams-Dorey died in a similar manner as Devon Freeman and both were at Lynwood Charlton Centre.

Trya Williams-Dorey. Submitted photo.

Warning: This article contains discussions of suicide that may not be suitable for all readers.

The Canada Suicide Prevention Service enables callers anywhere in Canada to access crisis support using the technology of their choice (phone, text or chat), in French or English:
Phone: toll-free 1-833-456-4566
Text: 45645

When Devon Freeman walked a short distance into a wooded area behind his treatment centre and died by suicide in October 2017 the chief coroner of Ontario was organizing a panel of child welfare experts to review a similar suicide two and half years earlier involving the same organization, APTN News has learned.

Only the chief coroner didn’t know about Freeman, 16, at the time.

That’s because it would take over six months to find the First Nations boy in the woods.

He was “no more” than 35 metres from the back door of the Flamborough site, one of four operated by Lynwood Charlton Centre, a company in Hamilton, Ont. offering residential mental health services.

Freeman was considered missing until he was found hanging from a tree in April 2018.

By that point the coroner’s panel was just beginning its review of Tyra Williams-Dorey’s death Mar. 3, 2015 when she also went into a wooded area and hanged herself.

“She cared about people. She would do what she could to help people. She had a big heart,” said her father, Nygel Dorey.

“Maybe too big.”

Williams-Dorey, 17, had been placed in Lynwood’s Augusta site following multiple suicide attempts and hospitalization after being placed in care through a temporary care agreement less than two years before her death.

The panel was reviewing her child welfare file to determine if there were systemic issues that could be learned to prevent similar deaths in the future.

But the panel wasn’t just looking into Williams-Dorey’s file, it was also reviewing 11 others that died while in group or foster homes between Jan. 1, 2014 to July 31, 2017.

Eight of the children were First Nation.

The panel didn’t have the ability to ask questions of anyone, including child welfare agencies, known in Ontario as children’s aid societies, or licensed facilities like Lynwood.

Dirk Huyer, chief coroner of Ontario, previously told APTN he organized the panel because it could work faster than an inquest even if it meant operating in the dark and without the public spotlight that an inquest provides.

The panel’s report, Safe with Intervention, was released in Sept. 2018 and details failures in the system. It also provides a section for each child, including “Tyra”.

At least two of the families were upset that the report didn’t provide answers they thought they would get by participating.

See more: ‘It’s bulls–t’: families react to coroner’s report into 8 dead First Nations children

Anything the panel may have learned from examining Williams-Dorey child welfare file was clearly too late to help Freeman.

Devon Freeman. Submitted photo.

Freeman’s family was unaware of Williams-Dorey’s death when it asked the regional coroner in Hamilton Dec. 5, 2019 to reconsider an inquest.

“This only strengthens the need for an inquest into Devon’s death, so that we can get to the bottom of how these tragedies happened in the first place and put in measures to make sure they never happen again,” said lawyer Justin Safayeni, who represents Freeman’s grandmother, Pamela Freeman.

APTN asked Huyer if there was potentially more to learn about the circumstances of each death, via an inquest, and was his office aware of the connection to Lynwood when an inquest wasn’t originally called upon finding Freeman’s body.

“The Panel was reviewing for system/systemic issues and not specifically investigating individual circumstances of each death. A recent request was received by the Hamilton Regional Supervising Coroner for an inquest into Devon’s death—It is my understanding that the Regional Supervising Coroner is currently considering the request and has not provided a response yet,” wrote Huyer, in an email just before Christmas.

“Legislatively the Office of the Chief Coroner is not able to speak about individual case specific details.”

The coroner’s office has 60 days to respond to Pamela’s request from the date it was made. Inquests into deaths in care are extremely rare in Ontario, while it’s automatic in deaths of an inmate in provincial jails. It usually takes a request from family or organizations for one to be considered by the coroner’s office.

Dorey supports the Freeman’s fight for answers and believes the inquest should include his daughter in part due to the panel’s restrictions.

“Absolutely,” he said. “They should be looking at everything that happened and every situation that’s been going on.”

The panel report details Williams-Dorey’s struggles in the last year of her life despite saying she was doing well in school.

“Approximately a year after coming into care, Tyra was admitted to the children’s psychiatric unit of the local hospital as a result of suicide ideation. She was diagnosed with depression and post-traumatic stress disorder and placed on medication,” the panel wrote.

“A series of suicide attempts in the following months led to two additional in-patient admissions to the children’s psychiatric unit of a local hospital. A move to a residential treatment program operated by a children’s mental health centre was seen to be better able to respond to Tyra’s needs. While at the program she was able to stabilize and return to school.”

Yet, the panel said the self-harming, including multiple suicide attempts, continued.

Dorey said he last saw his daughter Mar. 1, 2015 when she came over to his house for dinner.

“We were just hanging out, talking. I cooked her some dinner,” he said.

Williams-Dorey went to school on Mar. 2 but took off in the afternoon according to the panel report.

“Her body was later found hanging from a tree in a wooded area off a recreation trail,” the panel wrote.

Dorey said a search party found her later that night. She was pronounced dead the following day.

After his daughter’s death he said her possessions were returned to him, including a drawing that he shared with APTN.

His daughter drew what appears to be her room with a calendar on the wall for the month of March above a desk. The 2 is clearly circled.

There’s also a girl hanging from what appears to be a ceiling fan next to a bed.

“She had set two dates before,” said Dorey.

Lynwood’s executive director, Alex Thomson, declined to comment as did its program director, Vicki Downie.

“At this time, I am not able to comment,” wrote Downie in an email.

Freeman’s story was first made public by the Hamilton Spectator last June.

The Canada Suicide Prevention Service enables callers anywhere in Canada to access crisis support using the technology of their choice (phone, text or chat), in French or English:

Phone: toll-free 1-833-456-4566
Text: 45645

Chat: crisisservicescanada.ca

Producer Nation to Nation - Ottawa

Kenneth is a journalist with nearly two decades of reporting experience who focuses on crime and social issues, including child welfare and wrongful convictions. He has worked out of APTN’s Ottawa bureau since October 2012.