B.C. coroner’s panel urges urgent reforms to prevent youth suicides
Noah Chen
10/15/20252 min read


A report commissioned by B.C.’s chief coroner has found that little progress has been made in understanding and preventing youth suicide in the province, calling for sweeping reforms to address what it describes as a persistent and preventable loss of young lives.
The death review panel, led by Dr. Jatinder Baidwan, examined 435 suicides of people aged 9 to 25 between 2019 and 2023. It identified major gaps in mental health care, data collection, and support systems for vulnerable youth.
“While the number of young lives lost to suicide in British Columbia has remained relatively unchanged over the last several years, little progress has been made in understanding, recognizing and reducing risk,” the report states.
Five key recommendations
The panel issued five recommendations, including:
A provincial suicide risk reduction framework focused on youth and young adults.
Mandatory training for medical professionals to better identify and follow up with at-risk youth.
Improved data collection to guide prevention programs.
A review of student mental health resources to ensure consistent support across schools.
Stronger coordination between ministries to track outcomes and share information.
The report highlights that suicide is the second leading cause of death among B.C. children and youth, and the third among young adults aged 19 to 29.
Higher risk for Indigenous youth
The rate of suicide among status First Nations youth in B.C. is four times higher than the provincial average. The panel attributes this to the intergenerational trauma of colonization, racism, and systemic barriers to care.
“The lack of appropriate understanding and response extends to other underserved groups, including racialized and 2SLGBTQIA+ youth,” the report notes.
It says these challenges are intensified by a strained health-care system, particularly in rural and remote communities, where access to consistent mental health care remains limited.
If you need help
If you or someone you know is struggling:
Call or text 988 — Canada’s Suicide Crisis Helpline (available 24/7).
Kids Help Phone: 1-800-668-6868 or text 686868.
Visit the Canadian Association for Suicide Prevention to find a local crisis centre.
Warning signs include: suicidal thoughts, hopelessness, withdrawal, substance use, anger, or sudden mood changes. Talking openly and offering support can save a life.
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