Early mental health intervention could have helped Beau Baker, coroner's inquest hears

WARNING: This article addresses suicide and self harm

Beau Baker, 20, showed signs of emotional and behavioural problems as a young child that were identified but not properly addressed, a coroner's inquest into Baker's death heard on Monday. 

"There is no question that early onset of emotional behavioural difficulties is a red flag for later difficulties in later childhood and adolescence and we know the earlier one intervenes the better the long term outcome," said Dr. Peter Szatmari, a psychiatrist and expert witness in the coroner's inquest into Baker's death. 

Beau Baker, 20, was shot and killed by a Waterloo Regional Police Service officer in April 2015 outside Bakers' home on Brybeck Crescent in Kitchener, Ont. Baker had called 911 threatening to kill himself and harm others. Baker's family has said he had "documented mental health issues." Ontario's police watchdog, the Special Investigations Unit, said there were no reasonable grounds to charge the officer in Baker's death

An inquest into Baker's death is mandatory under the Ontario Coroners Act. The inquest into Baker's death began on March 20, 2023 and is being held virtually out of Toronto. The jury in a coroner's inquest makes recommendations to prevent future similar deaths. Read all of CBC's coverage of the coroner's inquest here.

Szatmari reviewed 6,000 pages of documents from child welfare services in London, Ont. and Kitchener-Waterloo, as well as Baker's school records and hospital records to track his mental health trajectory from the age of two, when he entered the child welfare system, until his death in 2015. 

Baker shows signs of ADHD at an early age, and by early adolescence Szatmari said he developed depression, anxiety and suicidal ideation. 

"All of this is accompanied by some instability in his home environment and his living arrangement from home to a group home," said Szatmari, who is also the chief of Child and Youth Mental Health Collaborative between The Centre for Addiction and Mental Health, The Hospital for Sick Children and the University of Toronto.

Team-based care helps young people with complex needs 

In 2010, as a young teenager, Baker's first serious suicide attempt sent him to the emergency department, a incident that Szatmari said should have alerted everyone that Baker was high risk for further attempts. 

I have never, in my 50 years of my career... never hear of anybody make 26 visits in a year,- Dr. Peter Szatmari, psychiatrist

What Baker needed was a wraparound care system, a comprehensive, team-based plan that involved the child welfare system, his family doctor, his school and his family to work together to support him, but what Szatmari saw in Baker's history is a disjointed system of care. 

"What I see is that the medical system in London prescribes medication and offers counselling, quite appropriate, but I don't see discussion with the child welfare system and the school. With the family doctor. It's this care co-ordination that is really required for very high risk, complex young people." 

Baker asked for help many times. In the year before his death, Baker visited emergency departments in Waterloo region 26 times for suicide ideation, suicidal behaviour and non-suicidal self injuries. 

"I have never, in my 50 years of my career in practice being on call in the emergency department, never hear of anybody make 26 visits in a year," Szatmari said. 

He became emotional when speaking about Baker's situation. 

"I find it very distressing that somebody would have to go through this pain and agony." 

Baker would often miss follow up appointments, a pattern seen until his death. Szatmari said the onus was put on Baker to keep to his schedule but added that the complexity of mental health symptoms in a young person makes it challenging to follow through with counselling appointments. 

"It is unrealistic to expect for him to take responsibility for his mental health all on his own without support from one of the agencies," he added. 

In the years before his death, Baker showed signs of escalating mental health symptoms and increasing substance use. Szatmari said Baker often identified that he needed help, and once said he just wanted someone to talk to. He needed team-based care with a focus on his building on his strengths, like his interest in making art and becoming a tattoo artist. 

"Beau is the community's responsibility. We have a collective responsibility to support people like Beau," Szatmari said. 

If you or someone you know is struggling, here's where to get help:

• Talk Suicide Canada: 1-833-456-4566 (phone) | 45645 (text between 4 p.m. and midnight ET).

• Kids Help Phone: 1-800-668-6868 (phone), live chat counselling on the website.

• Canadian Association for Suicide Prevention: Find a 24-hour crisis centre.

• This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.

If you're worried someone you know may be at risk of suicide, you should talk to them about it, says the Canadian Association for Suicide Prevention. Here are some warning signs: 

• Suicidal thoughts.
• Substance abuse.
• Purposelessness.
• Anxiety.
• Feeling trapped.
• Hopelessness and helplessness.
• Withdrawal.
• Anger.
• Recklessness.
• Mood changes.