P.E.I. inquest's jury makes 8 recommendations to prevent deaths like Brandi Clarke's

The jury at a coroner’s inquest into the death of a young P.E.I. woman living in transitional housing has made several recommendations for the non-profit that runs the facility. 

The inquest wrapped up Thursday after hearing three days of testimony into what led to 25-year-old Brandi Clarke’s death in March 2023 from diabetic ketoacidosis. 

Clarke was living in housing run by the P.E.I. division of the Canadian Mental Health Association (CMHA) when she died.

The jurors came up with eight recommendations for the non-profit, aimed at preventing similar deaths in the future. They said the CMHA should: 

During the inquest, the jury heard that Clarke moved into a supported housing unit at CMHA’s Notre Dame Place in Summerside in 2021 because of her diagnosed schizophrenia.

Staff there said she received medical care for her Type 1 diabetes primarily from Health P.E.I.'s community mental health outreach team and a nurse educator.  

Workers at Notre Dame Place described Clarke as intelligent, and someone who would tell those invested in her care and wellness what they wanted to hear — whether it was true or not.

The team in Summerside also said they initially didn’t know how turbulent Clarke's diabetes could be. They found out when she began living with them, and found her unconscious on one occasion. 

Ultimately it was decided that Clarke was a complex client who needed to go to a different environment that had constant oversight. Notre Dame Place was not staffed on evenings or weekends.

She was referred to the CMHA’s transitional housing program in Charlottetown, which accepted her in October 2022.

The CMHA’s supervisor for that program told the jury she saw a different side of Clarke than the picture painted by the Notre Dame Place staff, noting that Clarke claimed she could do laundry, shower and clean her room, while the Summerside staff said she could not.

Within six weeks, the Charlottetown staff decided she would move from the first floor that had more staff oversight and into her own apartment on the second floor — a step in moving her towards fully independent living, as per the transitional housing program’s goals. 

There, she would receive all of her medications for the week at once, and was then responsible for administering them to herself without supervision. 

On the final day of testimony, a transitional housing staff member told the jury she received “pretty informal” training when she began as a frontline worker with the program — a few days of shadowing current staff, a handbook for the program and policies for CMHA as a whole.