Hamilton police weren't told of an Indigenous teen's history of suicidal thoughts or a previous suicide attempt when he went missing from a group home nearly five years ago, a coroner's inquest heard Wednesday.
Devon Freeman had already been reported missing from the Lynwood Charlton Centre in the Flamborough area of Hamilton 36 times in roughly nine months by the time he vanished on Oct. 7, 2017, the inquest heard. He was often gone for days and staff had no way of contacting him during that time, it heard.
The missing person's report filed in October showed no safety concerns or risk factors but did note the 16-year-old was a "habitual missing person," the inquest heard.
"Devon was not determined to be a high risk," which was also the case in the majority of his previous absences, coroner's counsel told jurors.
"Neither the Flamborough program nor the (Children's Aid Society of Hamilton) advised the (Hamilton Police Service) that Devon had a history of suicidality or that he had attempted to take his own life in May 2017."
The initial police search involved calling the group home and the Hamilton Regional Indian Centre, where Freeman had previously often gone during his absences, but didn't include a search of the home's property, counsel said. The home's staff had looked around the site earlier before filing the report, they said.
A media release regarding Freeman's disappearance was issued by police in late November.
Youth living at the home discovered Freeman's body in a wooded area of the property in April 2018, the inquest heard. An autopsy determined he died by hanging.
The inquest, which began Monday, is expected to look into systemic issues that played a role in the teen's death, including public policy and legal issues related to Indigenous children and youth in the child-welfare system.
Freeman was a member of the Chippewas of Georgina Island First Nation, and the first day of the inquest was held in the community. It is continuing in Hamilton.
On Wednesday, jurors heard the Children's Aid Society was involved with Freeman's family early on in his life because his father was violent towards his mother. Freeman spent some time in foster care in his early childhood, at times separated from his half-siblings, the jury heard. He eventually was placed in the custody of his maternal grandmother, Pamela Freeman.
When Devon Freeman was six, his mother died, and that loss had a "devastating impact" on him, the inquest heard.
Over the years, Freeman underwent a number of psychological, psychiatric and behavioural assessments, and was diagnosed with attention deficit hyperactivity disorder and oppositional defiance disorder, coroner's counsel said. He was prescribed medication, but didn't take it consistently.
He attended several schools, but often acted out, and eventually began having violent outbursts at home as well, counsel said. His grandmother continued to advocate for his care but grew to worry that she couldn't provide the support and help he needed, the inquest heard.
By 2014, Freeman had already begun verbalizing suicidal thoughts, the inquest heard.
While living at Jeb's Place, a residential youth program, in late 2015, he had a fight with another youth, and police who interviewed him noticed ligature marks around his neck, it heard. The teen disclosed that he felt like hurting himself, hanging himself or shooting himself about once a week, jurors heard.
Police took him to hospital for assessment, but he was released back to Jeb's Place that day after saying he no longer felt suicidal, the inquest heard. Staff there offered ongoing support and safety plans as the teen continued to make comments about wanting to end his life, it heard.
As his time at the program began to wind down, his grandmother expressed worries she couldn't care for him due to her health, the inquest heard. There were no other placement options at the time, so Freeman went into foster care, it heard. But the teen had behavioural issues and that arrangement came to an end in January 2017, jurors heard.
He moved to the Lynwood Charlton Centre the next month and quickly began leaving the premises without permission, though he would usually come back on his own, the inquest heard. The home would report him as missing to police if he didn't return by midnight, it heard.
Freeman often went to the Hamilton Regional Indian Centre while away, and staff there were in touch with the home, the inquest heard. Other times, he went to see friends, and on a few occasions, he returned facing allegations of minor criminal activity, though charges often weren't laid or were diverted, it heard.
The teen left the home on May 27, 2017, and staff filed a missing person's report the next day, the inquest heard. He was brought back by police on May 30.
In a debriefing with staff at the home, Freeman said he had attempted to hang himself with a rope from a tree and that a friend had cut him down, jurors heard. They talked about safety planning, and Freeman told staff that he had "no desire to hang himself" at that time.
That information was never shared with his grandmother, the inquest heard.
Jennifer Thibeau, a social worker at the home, told the inquest Wednesday that suicide attempt was a turning point for Freeman, spurring him to seek out help in regulating his emotions. "It scared him," she said.
Thibeau said she had a bad feeling when Freeman wasn't seen at the HRIC or on social media after he went missing in October 2017, but she didn't suspect suicide because he seemed to have moved on.
"My brain when he went missing was, 'Something has gone wrong,'" she said.
This report by The Canadian Press was first published Sept. 28, 2022.
Paola Loriggio, The Canadian Press