Open this photo in gallery Pam Freeman sits and looks at the display case honouring her grandson, Devon Freeman, at Bayview Cemetery in Burlington, Ont. Devon disappeared from a Hamilton-area group home in 2017, when he was 16 years old. His body was found months later. Photography by Tijana Martin/The Globe and Mail

When 16-year-old Devon Freeman went missing from his group home near Hamilton in the fall of 2017, both the staff there and the police who were notified suspected he had run away again.

Devon was known as a funny, outgoing teenager who liked skateboarding, riding his bike, and who imagined eventually getting his own place and working as a mechanic.

“He had dreams,” his grandmother, Pam Freeman, said.

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He also had burdens – too many for a kid his age.

Devon, who battled a range of mental health challenges, had disappeared from the facility before. But there were signs this time was different. For one thing, he had attempted suicide months earlier. And he was gone much longer than his usual few days away.

Nearly seven months after he disappeared, another group home resident threw a ball into some trees behind the property on a warm April day and found out what happened to Devon. He had died by suicide. His body was found in a tree, mere steps away from the group home’s back door.

Open this photo in gallery A deflated basketball lies in the snow in the wooded area behind the Lynwood Charlton Centre's Flamborough site in Dundas, Ont., this past December.

The circumstances of Devon’s death and its aftermath have left his family and his First Nation, Chippewas of Georgina Island, searching for answers. Why didn’t the group home disclose an earlier suicide attempt? Why was he not taken to the hospital after he first tried to take his life? Why did the police not find his body much sooner?

These questions and more could be explored through a proper coroner’s inquest – something his family, his First Nation and the Hamilton Police are coming together to demand.

An inquest could help form recommendations to ensure the same thing doesn’t happen to another vulnerable child in care, they say – and it could determine how the system failed him.

Devon’s story is also renewing calls for mandatory inquests in all cases of children who die in the welfare system.

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Open this photo in gallery At Pam Freeman's home in Hamilton, a family photo shows her holding baby Devon and various portraits show stages in Devon's childhood. 'You could see the happy smile' at a young age, Ms. Freeman says of the child she affectionately called 'Boo Bear.'

DEVON’S STORY

Ms. Freeman remembers her grandson as a happy baby with piercing blue eyes, thick lashes and jet black hair who loved working with his hands from a young age.

He was first taken into foster care at the age of two and a half. Ms. Freeman assumed childcare responsibilities when Devon was four.

She called him “Boo Bear” – a name she knew he loved even when he was a teenager.

“You could see the happy smile,” she said.

But behind the smile, Devon struggled with pain, particularly around the eventual loss of his mother, Jaime Lynn. She died in her sleep at the age of 28 – a loss six-year-old Devon didn’t know how to grieve.

His grandmother said he didn’t cry for years and he feared his memory of her would eventually fade away. “He missed her so much,” Ms. Freeman said.

Open this photo in gallery Ms. Freeman points to a picture of her with Devon.

As a teenager, Devon’s mental health worsened. He would talk about suicide to his grandmother and would threaten to take his life.

She sought support, including emergency medical care for Devon, and connected him with a psychiatrist.

But Devon’s behaviours and mental health struggles eventually became too much for his grandmother. She believed she could no longer safely care for him.

Ms. Freeman arranged for Devon to be accepted at Jeb’s Place, a residential treatment service for teenage boys. The operation, no longer in existence, was run by Good Shepherd Hamilton and allowed Devon to come home on weekends.

She also continued to take him to his psychiatrist.

After he reached the maximum period he could spend at Jeb’s Place, Devon was eventually moved to a group home operated by the Lynwood Charlton Centre, a charitable organization in Hamilton that is funded and licensed by the Ontario Ministry of Children and Youth Services. In June, 2017, he officially became a Crown ward.

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The Lynwood has four locations in Hamilton, including the Flamborough site, which Devon attended, that houses a residential program.

The property, a light-grey building located off a quiet road outside of Hamilton in Dundas, Ont., is separated from a farmer’s field with a line of trees.

Devon often ran away from the secluded property and would hitchhike into Hamilton, where he would frequent the Hamilton Regional Indian Centre – a cultural centre he considered his “safe space,” said Vanessa Henry, who works there with youth aged 13 to 18.

She said Devon would come in to get something to eat and to just talk before he would have to return to the Lynwood.

During a visit at the beginning of October, 2017, Devon asked if he could leave his skateboard in Ms. Henry’s office before he was picked up by one of his group home workers.

She said he could as long as he promised to pick it up.

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“He never did come back for it,” she said.

That was the last time she would see Devon alive.

Days later, Devon was once again missing but was never heard from again.

Open this photo in gallery Ms. Freeman stops along Burlington's Cherry Tree Gate trail, where she and Devon took their last walk together before his death.

LINGERING QUESTIONS AFTER DEVON’S DEATH

Ms. Freeman had spent the winter of 2018 agonizing about what could have happened to her grandson.

After police informed her of his death, the dead boy’s belongings were sent home to her. She wrapped herself in his winter jacket and imagined she was getting a final hug.

In the period of intense grieving that followed, Ms. Freeman said she became consumed by panic attacks and extreme anxiety.

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She rarely left her apartment, except to get necessities. Even going to the grocery store was an emotional undertaking because, despite knowing better, she would find herself still looking for Devon on the street. Whenever she heard a skateboard or noticed a group of boys riding bikes, she would approach hopefully.

She remains haunted by outstanding questions, including why no one found Devon sooner when his body was on the group home property.

She also wants to know why she wasn’t made aware that Devon tried to take his life May, 2017, while in the care of the Lynwood, months before he died by suicide.

Ms. Freeman’s lawyer, Justin Safayeni, and the lawyer for the Chippewas of Georgina Island, Sarah Clarke, said in their submission to the coroner to request an inquest that they learned of his previous attempt through a disclosure from the Children’s Aid Society after his death.

Devon was saved by a friend, they said in the document, adding Devon had told a worker at the Lynwood about the incident in a moment of “courage, resilience and an unequivocal call for help.”

“Sadly, the actions of those around him reflected back to him his own self-worth: there was no trip to the hospital, no immediate crisis services put in place, no visit or phone call from [Devon’s grandmother] Pamela (who didn’t even know about the incident), no visit or phone call from his First Nation (who didn’t know about the incident), and no change in the care provided to him by the Society or the Lynwood,” they wrote.

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Open this photo in gallery The Lynwood site, shown on Dec. 17 last year.

Neither the CAS nor the Lynwood advised Hamilton Police Services of Devon’s past history of suicide attempts and suicidal ideation, Ms. Clarke and Mr. Safayeni added.

“Based on their response, the HPS assumed that Devon had run away and was hiding because he had an outstanding warrant for his arrest,” they said.

Devon had been charged with property damage and mischief following an incident at the Lynwood, they added, suggesting a narrative took hold with the police, who referred to Devon as a runaway when speaking with Ms. Freeman.

“In fact, the HPS expressly told her he was not a priority, given his prior history of ‘AWOLS’ and the HPS’s theory that he was hiding,” they wrote.

A spokesperson for Hamilton Police’s corporate communications branch said the force would not make any comments on Devon’s case, noting the family has requested an inquest and the police must “respect this process.”

Ms. Clarke and Mr. Safayeni also said the Children’s Aid Society of Hamilton had a legal obligation to contact his First Nation about his suicide attempt and his disappearance, adding that neither happened.

A child’s Indigenous community is a key player to ensure access to appropriate services, they noted.

Shannon Crate, a band representative for Devon’s community, said she was alerted to his death after Ms. Freeman mailed the Chippewas of Georgina Island a copy of the death certificate in the spring of 2018. She said she went to the bush and cried for three days after she learned the news.

She said she then told Ms. Freeman she would do everything she could to address how the system failed Devon.

The community should have been included in helping to provide supports for him, she added.

“An elder told me that whenever a young person loses their life, they leave behind a message,” she said.

“And he said perhaps this inquest is the only way that Devon’s message is going to be heard and that people are going to do something about it.”

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Open this photo in gallery More family photos from Ms. Freeman's home shows Devon, middle right, as a teenager. His family are pressing for an official inquest into his death.

THE PUSH FOR AN INQUEST

Devon’s family, a growing number of advocates, including the provincial NDP and the Hamilton Police Service, are now pushing for an inquest into his death in hopes recommendations could be issued to prevent this from ever happening again.

They believe the process affords an opportunity to consider communication and search protocols to serve and protect children “in the context of a situation where the lines of communication clearly and repeatedly broke down,” the lawyers said in their submission to the coroner.

Police search efforts were “seriously flawed,” they added.

Hamilton Police have declined to comment on the extent of those efforts.

Inquests are not mandatory for children who die in the foster care system in Ontario. Former provincial children’s advocate Irwin Elman says they should be. Mandatory inquests in Ontario currently must meet specific requirements, like if a death occurs on the job at construction site or mine, or if someone dies in custody.

“It seems outrageous to me that children do not receive the same respect as people in our prisons,” Mr. Elman told The Globe. “Children in care are the responsibility of the entire province.”

Inquests may also be called at the discretion of the coroner, but one was not granted in the case of Devon. A section of the Coroner’s Act is now being used by the family to make an appeal.

Neither the Children’s Aid Society of Hamilton nor the Lynwood have taken a formal position to support the inquest but both organizations have said they will fully participate, should one be called by the coroner.

Hamilton Police Chief Eric Girt supports the push for an inquest. In a letter dated Dec. 11, Mr. Girt wrote to the Ontario Coroner’s Office to confirm his support for an inquest to come up with recommendations to prevent future deaths.

Assembly of First Nations National Chief Perry Bellegarde said in an interview that his organization backed a resolution to support the family’s request for an inquest, adding it is a tragic example of a system that failed.

Nygel Dorey, the father of 15-year-old Tyra Williams-Dorey, who died by suicide in 2015 while in the care of the Lynwood at a different facility in Hamilton, told The Globe he supports the inquest into Devon’s death.

Mr. Dorey said the question of what can be done differently must be explored to ensure “this never happens to another child in distress.”

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Meanwhile, the Children’s Aid Society of Hamilton and the Lynwood say they have both conducted reviews, following Devon’s death, to evaluate what happened.

The Lynwood’s executive director, Alex Thomson, said a review, completed in August, 2018, identified improvement areas, including better communication with the Hamilton Children’s Aid Society and stronger engagement with Indigenous partners. He declined to share the report with The Globe, saying it was an internal document.

Bryan Shone, the executive director of the Children’s Aid Society of Hamilton, said his organization followed a process mandated by the province and the coroner that unfolds when a child dies in care.

In Devon’s case, there was a request for further review and recommendations have since been implemented, he said. Mr. Shone declined to disclose specifics.

He said the information from the required review is confidential but the recommendations are “fully reviewed and received by the coroner.”

The society is working with community partners, the Lynwood and police to better respond when a child goes missing, Mr. Shone said, adding it has undertaken a review of the needs of Indigenous children in care to make sure they receive supports and services.

Open this photo in gallery At the Burlington cemetery, Ms. Freeman touches the glass box housing Devon's and his mother's ashes.

REMEMBERING DEVON

The last time Ms. Freeman saw her grandson was at an event held to mark the 10th anniversary of Jaime Lynn’s death, when he sent a blue balloon into the sky with the words “I’ll Love You Forever." She used to read to her son the Robert Munsch book carrying the same name. A copy is now tucked into a glass box they now share at Bayview Cemetery in Burlington, Ont.

There could have been a funeral if “things had have been different,” she said. “If they had found him right away, it could have been properly done.”

Instead of a funeral, one of Devon’s friends at the Hamilton Regional Indian Centre organized a ceremony to remember him and he was cremated.

“I put him in with his mom on Mother’s Day,” Ms. Freeman said.

Devon and his mother’s ashes are inside a heart-shaped double urn with the words “Back in Mama’s Arms” engraved on the outside.

If you are having thoughts of suicide, call Kids Help Phone at 1-800-668-6868 or Crisis Service Canada at 1-833-456-4566, or visit crisisservicescanada.ca.