(Joshua is a pseudonym, which Bernard used at the request of the teen’s family.)

Joshua showed signs of serious mental illness as a toddler and — despite his mother’s frequent requests for help from the children’s ministry, school staff and health professionals — his behaviour worsened over time.

At age two, he hit himself and banged his head against a wall. At age eight, when his mood could swing from kind-hearted to erratic, he told school staff he wanted to die. At just 11 years old, he tried to commit suicide for the first time. Although a bright student, he struggled socially, and at age 13 locked himself in his room, refusing to go to school. He began harming himself at 16, including cutting his arms and holding his hands under hot water until they burned.

This boy, described repeatedly throughout the report as intelligent and kind, was diagnosed with chronic disordered moods, obsessive tendencies and persistent suicidal ideation. It was nearly impossible for the people in his life, including his mother who “loved him deeply,” to meet his needs, Richard said.

In March 2015, after being airlifted from an isolated forest during his third suicide attempt, he was admitted to B.C. Children’s Hospital. He languished there for four months because health and child welfare officials disagreed on a plan for where and how he could be safely released from the hospital.

He kept a diary during this time, that “included his step-by-step plan to get out of the hospital so that he could end his life.” He also vowed to help others like him, if he ever got better. But there was no indication he was getting any better.

On July 31, Joshua got permission to visit the hospital’s fenced-in courtyard. But, undetected, he walked back inside and escaped the hospital through an unlocked door. He climbed a fence into a construction site on hospital grounds and took his life. His body, which contained high levels of prescription medication, was found four days later.