Early psychological overall health intervention could have served Beau Baker, coroner’s inquest hears

WARNING: This write-up addresses suicide and self hurt

Beau Baker, 20, showed signals of emotional and behavioural troubles as a younger youngster that were recognized but not appropriately tackled, a coroner’s inquest into Baker’s loss of life read on Monday. 

“There is no issue that early onset of psychological behavioural troubles is a pink flag for later on issues in later childhood and adolescence and we know the previously 1 intervenes the greater the very long time period end result,” said Dr. Peter Szatmari, a psychiatrist and expert witness in the coroner’s inquest into Baker’s death. 


Beau Baker, 20, was shot and killed by a Waterloo Regional Police Service officer in April 2015 exterior Baker’s property on Brybeck Crescent in Kitchener, Ont. Baker experienced identified as 911 threatening to get rid of himself and harm others. Baker’s spouse and children have stated he had “documented psychological health and fitness difficulties.”

Ontario’s police watchdog, the Distinctive Investigations Unit, reported the were no affordable grounds to cost the officer in Baker’s death. The jury in a coroner’s inquest makes tips to protect against upcoming similar fatalities. Browse all of CBC’s protection of the coroner’s inquest here.


Szatmari reviewed 6,000 pages of paperwork from little one welfare companies in London, Ont. and Kitchener-Waterloo, as very well as Baker’s university data and clinic data to keep track of his psychological wellbeing trajectory from the age of two, when he entered the boy or girl welfare process, until his loss of life in 2015. 

Baker displays signs of ADHD at an early age, and by early adolescence Szatmari said he designed melancholy, anxiousness and suicidal ideation. 

“All of this is accompanied by some instability in his home natural environment and his residing arrangement from property to a group household,” said Szatmari, who is also the chief of Kid and Youth Mental Overall health Collaborative between The Centre for Dependancy and Psychological Overall health, The Clinic for Sick Young children and the College of Toronto.

Staff-based treatment can help youthful persons with elaborate needs 

In 2010, as a youthful teenager, Baker’s very first major suicide try sent him to the crisis department, a incident that Szatmari mentioned need to have alerted every person that Baker was higher threat for further makes an attempt. 

I have by no means, in my 50 years of my job… never hear of anybody make 26 visits in a yr,– Dr. Peter Szatmari, psychiatrist

What Baker essential was a wraparound care program, a comprehensive, workforce-based prepare that associated the youngster welfare technique, his family physician, his school and his loved ones to get the job done alongside one another to support him, but what Szatmari saw in Baker’s history is a disjointed technique of treatment. 

“What I see is that the health care method in London prescribes treatment and provides counselling, pretty ideal, but I don’t see discussion with the baby welfare process and the faculty. With the family members health care provider. It really is this treatment co-ordination that is seriously required for quite large hazard, elaborate youthful men and women.” 

Baker requested for assist several times. In the 12 months before his death, Baker frequented unexpected emergency departments in Waterloo location 26 periods for suicide ideation, suicidal behaviour and non-suicidal self injuries. 

“I have never, in my 50 a long time of my profession in practice being on connect with in the emergency office, in no way listen to of any one make 26 visits in a year,” Szatmari explained. 

He turned psychological when speaking about Baker’s scenario. 

“I find it really distressing that someone would have to go by way of this pain and agony.” 

Baker would often skip comply with up appointments, a pattern found right up until his demise. Szatmari mentioned the onus was put on Baker to keep to his schedule but extra that the complexity of psychological wellness signs and symptoms in a youthful particular person tends to make it tough to follow via with counselling appointments. 

“It is unrealistic to anticipate for him to acquire accountability for his mental overall health all on his very own devoid of guidance from 1 of the businesses,” he additional. 

In the yrs just before his dying, Baker showed indicators of escalating mental wellbeing signs and growing substance use. Szatmari explained Baker often recognized that he required assistance, and at the time said he just wanted someone to converse to. He wanted workforce-centered care with a aim on his making on his strengths, like his curiosity in building art and turning into a tattoo artist. 

“Beau is the community’s accountability. We have a collective obligation to guidance persons like Beau,” Szatmari stated. 


If you or someone you know is battling, here is exactly where to get assistance:

If you happen to be nervous another person you know may well be at possibility of suicide, you need to discuss to them about it, claims the Canadian Association for Suicide Avoidance. Below are some warning signals: 

  • Suicidal ideas.
  • Compound abuse.
  • Purposelessness.
  • Panic.
  • Feeling trapped.
  • Hopelessness and helplessness.
  • Withdrawal.
  • Anger.
  • Recklessness.
  • Temper variations.