Inquest into Dorchester school bus death of 13-year-old girl ends with 12 recommendations

WARNING: This story contains distressing details

A New Brunswick coroner's jury examining the death of a 13-year-old girl who died after she jumped from the emergency exit of her moving school bus in Dorchester two years ago has made 12 recommendations aimed at preventing similar deaths.

The jury took about five hours to deliberate at the Moncton courthouse Wednesday after hearing two days of testimony from 15 witnesses about the death of Hailey Pierce.

The teen was sitting with a friend at the back of the bus on her way home from Dorchester Consolidated School on April 12, 2022, when she suddenly stood up, opened the back door and jumped out, the inquest heard.

She was pronounced dead at the Moncton Hospital the next day at 11:24 a.m.

Coroner David Farrow determined her cause of death was a traumatic brain injury and ruled it a suicide.

The five-member jury reached the same conclusions and delivered recommendations dealing with school buses, mental health supports in schools, as well as the health-care system after hearing Hailey visited the emergency department for mental health issues nine times in the months leading up to her death, often because of suicidal thoughts.

The recommended changes for school buses include an additional adult seated at the back, assigned seating for students, based on needs and a mechanical interlock to prevent emergency doors from being opened while a bus is travelling over a certain speed limit.

The bus driver, Michael McIntyre, testified he was travelling about 53 kilometres an hour in an 80 km/h-zone at the time of the incident.

With respect to schools, the jury recommended more training for teachers or other professionals dealing with students with mental health issues, more supports within schools, such as additional resource teachers, guidance counselors, and educational assistants and alternative learning environments outside schools for students struggling with mental health and school-environment stress.

Hailey was assigned a child and youth counsellor through the province's integrated service program and had access to a quiet room at the school if she was having a conflict with another student or was feeling overwhelmed, school officials testified.

A single primary psychiatrist should be appointed to be in charge of a patient's medications, the jury said, and better resources should be available to mental health patients deemed high-risk, such as admittance to a psychiatric hospital for an extended period of time to monitor progress and reactions to medications, with follow-up appointments and evaluations by an assigned psychiatrist.

Hailey was taking up to four different medications at one point — some prescribed by her regular psychiatrist, while two other psychiatrists on-call at the ER prescribed other drugs or changed doses. In December 2021, when she was admitted to pediatric intensive care for four days due to fainting spells, a pediatrician took her off her psychiatric medications to determine if they were the possible cause.

There should be separate, more private and calm areas within ERs for mental health patients waiting to be seen, better communication between Horizon and Vitalité regarding patients' medical history, and a more proactive approach among professionals dealing with mental health patients to identify changes and potential gaps in their care, the jury said.