The jury in a coroner’s inquest concerning the demise of a young woman from Prince Edward Island who resided in transitional housing has put forth several suggestions for the non-profit organization managing the facility. The inquest concluded after a three-day examination into the circumstances surrounding the passing of 25-year-old Brandi Clarke in March 2023 due to diabetic ketoacidosis. Clarke was living in transitional housing provided by the Prince Edward Island division of the Canadian Mental Health Association (CMHA) at the time of her death.
Following the inquiry, the jurors outlined eight recommendations for the non-profit organization with the goal of averting similar tragedies in the future. The recommendations included establishing protocols for individuals with severe non-mental health-related illnesses such as Clarke’s diabetes, training staff about these medical conditions, conducting team meetings when clients transfer between facilities, sharing client information among all staff post-relocation, implementing formal training and improved onboarding for staff, conducting skill assessments of patients before transitioning to independent apartments, implementing probationary periods for individuals moving into independent living arrangements, and providing ongoing supervision for clients in independent units if their skills are deemed insufficient.
Throughout the inquest, it was revealed that Clarke moved into a supported housing unit at CMHA’s Notre Dame Place in Summerside in 2021 due to her diagnosed schizophrenia. Staff at the facility mentioned that Clarke primarily received medical attention for her Type 1 diabetes from Health P.E.I.’s community mental health outreach team and a nurse educator. Described as intelligent, Clarke was noted to provide responses that people involved in her well-being wanted to hear, regardless of their accuracy. Staff at Notre Dame Place acknowledged a lack of awareness about the severity of Clarke’s diabetes until she started residing there, experiencing a health crisis that led to her being discovered unconscious on one occasion.
Recognizing Clarke’s complex needs, it was decided that she required a more supervised environment, prompting her referral to CMHA’s transitional housing program in Charlottetown in October 2022. The program supervisor in Charlottetown observed a different perspective of Clarke compared to the impressions from the Summerside staff, noting discrepancies in Clarke’s self-sufficiency capabilities. Within a short period, Clarke was transitioned to her own apartment on a higher floor in Charlottetown, with increased independence and responsibility for managing her medications without direct supervision.
During the final day of testimonies, a staff member from the transitional housing program mentioned receiving informal training upon joining as a frontline worker, with limited interaction with Clarke due to the assignment of residents to specific workers. The inquest did not include testimonies from key personnel such as the housing complex’s manager, coordinator, frontline staff member directly working with Clarke, or senior leadership from CMHA at the time of Clarke’s passing.
On the day of her demise, Clarke was found unresponsive in her unit after missing her usual afternoon break, leading to the discovery of her passing. The cause of death was determined to be diabetic ketoacidosis, a condition resulting from insulin deficiency, causing a shift in blood acidity levels and affecting organ function. Subsequent analysis revealed minimal monitoring of Clarke’s blood sugar levels in the months leading up to her death, raising concerns about the adequacy of her medical care.
The chief coroner of Prince Edward Island, Dr. Brandon Webber, presided over the inquest and will forward the jury’s recommendations to the provincial justice minister for further action and monitoring. Clarke’s mother, Heidi, also expressed her desire for systemic changes to prevent similar incidents in the future during the closing statements of the proceedings.