PEIThe jury at a coroner’s inquest into the death of a young P.E.I. woman living in transitional housing has made several recommendations for the non-profit that runs the facility.25-year-old died of diabetic ketoacidosis in 2023 while living in transitional housingListen to this articleEstimated 6 minutesThe audio version of this article is generated by text-to-speech, a technology based on artificial intelligence.Inquest into Brandi Clarke’s death produces 8 jury recommendations, all for Canadian Mental Health AssociationThe inquest into the death of Brandi Clarke has wrapped up after three days of testimony. Clarke died of diabetic ketoacidosis in 2023 while living in a transitional housing program run by the Canadian Mental Health Association. As CBC’s Nicola MacLeod reports, jurors came up with eight recommendations to help prevent future deaths like Clarke’s from happening, and all are directed at the non-profit. The jury at a coroner’s inquest into the death of a young P.E.I. woman living in transitional housing has made several recommendations for the non-profit that runs the facility. The inquest wrapped up Thursday after hearing three days of testimony into what led to 25-year-old Brandi Clarke’s death in March 2023 from diabetic ketoacidosis. Clarke was living in housing run by the P.E.I. division of the Canadian Mental Health Association (CMHA) when she died.The jurors came up with eight recommendations for the non-profit, aimed at preventing similar deaths in the future. They said the CMHA should: Create policies for people with severe illnesses not related to their mental health, like Clarke’s diabetes.Train staff about those medical conditions, or not admit clients with those illnesses.Have team meetings when clients move between facilities.Share client information with all staff after those moves.Formal training and better onboarding for staff. Skill assessments of patients before they move to independent apartments.Place people moving into independent living arrangements on a probation period.Ongoing supervision of those clients in independent units if their skills are deemed to be lacking. An intelligent but turbulent clientDuring the inquest, the jury heard that Clarke moved into a supported housing unit at CMHA’s Notre Dame Place in Summerside in 2021 because of her diagnosed schizophrenia. Staff there said she received medical care for her Type 1 diabetes primarily from Health P.E.I.’s community mental health outreach team and a nurse educator. Staff at Notre Dame Place in Summerside described Brandi Clarke as ‘a wonderful young lady’ who struggled with her mental health and medical issues. (Submitted by Heidi Clarke)Workers at Notre Dame Place described Clarke as intelligent, and someone who would tell those invested in her care and wellness what they wanted to hear — whether it was true or not.The team in Summerside also said they initially didn’t know how turbulent Clarke’s diabetes could be. They found out when she began living with them, and found her unconscious on one occasion. Ultimately it was decided that Clarke was a complex client who needed to go to a different environment that had constant oversight. Notre Dame Place was not staffed on evenings or weekends.WATCH | Inquest hears Brandi Clarke adjusted well to transitional housing, but could mask her symptoms:Brandi Clarke seemed to adjust well to transitional housing, but could mask symptoms, inquest hearsJurors heard from Canadian Mental Health Association staff during the second day of the inquest into 25-year-old Brandi Clarke’s death in the non-profit’s assisted living facility. Workers in Summerside painted a picture of a woman who struggled, while those in Charlottetown saw positive adjustments.She was referred to the CMHA’s transitional housing program in Charlottetown, which accepted her in October 2022.The CMHA’s supervisor for that program told the jury she saw a different side of Clarke than the picture painted by the Notre Dame Place staff, noting that Clarke claimed she could do laundry, shower and clean her room, while the Summerside staff said she could not.Within six weeks, the Charlottetown staff decided she would move from the first floor that had more staff oversight and into her own apartment on the second floor — a step in moving her towards fully independent living, as per the transitional housing program’s goals. There, she would receive all of her medications for the week at once, and was then responsible for administering them to herself without supervision. I’m just calling for some change in the future so that it doesn’t happen to someone else.- Heidi Clarke, Brandi’s motherOn the final day of testimony, a transitional housing staff member told the jury she received “pretty informal” training when she began as a frontline worker with the program — a few days of shadowing current staff, a handbook for the program and policies for CMHA as a whole.She and another staff member told the jurors Thursday they did not know Clarke well, since residents were matched to a worker. Neither of the two witnesses were matched to Clarke. The inquest did not hear from the transitional housing complex’s manager or co-ordinator at the time of Clarke’s death, the frontline staff member who worked most closely with her, or anyone from the CMHA senior leadership.P.E.I.’s chief coroner, Dr. Brandon Webber, presided over the inquest and will now deliver thejury’s recommendations to the provincial justice minister. (Nicola MacLeod/CBC)On the day of her death, staff noted Clarke had not been seen for her usual afternoon smoke break. It was then that they entered the unit and found her laying on her bed. The paramedics who arrived at the scene noted she was “obviously dead.”Clarke’s cause of death was diabetic ketoacidosis, a metabolic state where a person’s blood turns acidic due to a lack of insulin. The inquest heard the condition causes loss of blood pressure control, organ function and the inability to fight infections.Clarke’s glucose monitor later revealed her blood-sugar levels were only tested twice in the four months leading up to her death: once on Dec. 1, 2022, and again almost two months later, on Jan. 29, 2023. She died on March 19. Health P.E.I., the CMHA and Clarke’s mother, Heidi, were all granted standing during the inquest. That means they could make statements and ask the witnesses questions after the original probe by the Crown attorney.WATCH | Heidi Clarke wants answers about her daughter Brandi’s death:Heidi Clarke wants answers to her questions about her 25-year-old daughter Brandi’s deathBrandi Clarke died from a lack of insulin while living in government-funded transitional housing. Fifteen months later, her mother is still searching for answers.During closing statements Thursday, the lawyer for the CMHA reiterated that the organization does not operate health-care facilities and that Brandi Clarke was an autonomous resident receiving health care from outside the transitional housing program.He said it was not correct to say no one was paying attention to Clarke, and used the example that she had received a home visit just days before her death from her community mental health nurse, who did not note anything out of the ordinary.Health P.E.I.’s lawyer also spoke about the team wrapped around Clarke: her psychiatrist, family doctor, diabetic nurse educator and community mental health outreach teams — all of whom had Clarke’s consent to communicate with each other.Clarke’s mother Heidi also made a closing statement. “I’m just calling for some change in the future so that it doesn’t happen to someone else,” she said.The province’s chief coroner, Dr. Brandon Webber, presided over the inquest. He will deliver the jury’s recommendations to P.E.I.’s justice minister and any other relevant parties, then follow up on their progress in a year.
P.E.I. inquest’s jury makes 8 recommendations to prevent deaths like Brandi Clarke’s
