A 16-year-old teenager with a hearing disability was left in a cell in a Prince Albert, Sask., youth facility "trembling and whimpering quietly" despite his deteriorating health and a number of requests to take the boy for medical help.

By the time a supervisor agreed that 911 should be called and an ambulance arrived, Dylan Lachance had urinated on himself and was vomiting blood.

He died that same day, Sept. 19, 2013 of acute bronchopneumonia with associated sepsis.

In a special report tabled Wednesday afternoon in Saskatchewan's legislative assembly, the province's children's advocate, Bob Pringle, said the system failed the boy.

"While every situation cannot be foreseen, all child and youth-serving programs in the province must have policies and practices in place to accommodate young people with disabilities," Pringle told reporters.

Dinah Lachance, the mother of 16-year-old Dylan, looks on as the children's advocate delivers his special report into her son's death. (Neil Cochrane/CBC) Family members, including Dylan's mother Dinah, listened on as Pringle outlined the series of events that led up to Lachance's death.

The teenager was picked up by the RCMP on Sept. 11, 2013 after police responded to reports of boys fighting outside the high school on the Big River First Nation, about 100 kilometres northwest of Prince Albert.

He was on remand at the Prince Albert Youth Residence, a secure facility for young offenders run by the provincial corrections ministry.

Five days later, on Sept. 16, Lachance was complaining of a sore back and was taken to see a doctor who noticed minor swelling on Dylan's back and prescribed ibuprofen for the pain.

Teenager 'noticeably shaky and pale'

But the teenager's condition continued to deteriorate. Two days later, deputy sheriffs who were transporting Lachance to a court appearance thought he was "noticeably shaky and pale" and returned him to the youth facility for treatment.

The advocate's report says the facility's director dismissed the concerns of the deputy sheriffs and returned Lachance to his cell.

Later that evening, workers in the facility also expressed their concerns to a supervisor about Lachance's deteriorating health and she decided to reassess the situation in the morning.

Just before midnight, workers noticed that Lachance was vomiting blood and advised the night supervisor that an ambulance should be called.

The ambulance arrived at hospital after midnight on Sept. 19, 2013. Lachance died later that day.

Family friend of the Lachance's, Arnold Blackstar, says it has been a very difficult few years for Dylan's parents and brothers. (Neil Cochrane/CBC)

Lachance's mother wonders why more effort was not made to understand her son.

Family friend, Arnold Blackstar, says Dylan's mother could have intervened — if officials had allowed someone who understood Dylan to communicate with him.



"Who knows better than a mother's care for their child in terms of illness?" Blackstar asked. "She has had 16 years of caring for her child and not to be included in that process is absolutely horrendous."

Blackstar says the family is satisfied with the advocate's report and hopes it may prevent a similar death in the future.

Drew Wilby, executive director with Saskatchewan's corrections ministry, says the death of Dylan LaChance has prompted many changes, including putting a nurse on staff at the youth correctional facility in Prince Albert. (Neil Cochrane/CBC)

The provincial government says it has accepted recommendations from a coroner's inquest which reviewed Lachance's death as well as its own internal review.

"We want to empower our staff to make decisions," said Drew Wilby, executive director with the Ministry of Corrections in Saskatchewan.

"We want our frontline staff to have the ability to make those calls if and when they think they're needed. As well to improve the lines of communication. I mean it's obvious in this case, that communication was a big thing," Wilby said.