Ministry of Public Safety

File No. ;2018: 1038:0053

and Solicitor General
Bnttrsu Coroners Service
Corurunm Province of British Columbia
VeRorcr AT CoRoNERs lxqursr
FIUOIIIICS AND RECOMMENDATIONS AS A RESULT oF THE CoROruEn,s INQUEST PunsunruT To
Secnoru 38 orrnr CoRorurRS Acr, [sec 2007] c 15, INTo rHE DEArH oF

Eurchuk Elliot Cleveland

Sunruavr

The Fraser Building, University

An Inquest was held at of Victoria in the municipality of Oak Bay

in the Province of British Columbia, on the following dates June I8 through Jlune 27, 2Al9

before: MichaelEgilsorr , Presiding Coroner.

into the death of Eurchr-rk Elliot Cleveland 16 EI tY"l. n remate

(Last Name) (First Name) (Middle Name) (Ase)

The following findings were made:

Date and Time of Death: 03:30 hours

Place of Death: 2714 Lincoln Road Oak Ba),, BC

(Location) (Municipality/province)

Medical Cause of Death:

a) Mixed intoxication with f'entanyl, cocaine, heroin, and methamphetamine

(1) Immediate Cause of Death: with aspiration, pulmonary edema, and acute myocardial infarction

Due to or as a consequence of

Antecedent Cause if any: b)

Due to or as a consequence of
Giving rise to the immediate
cause (a) above, statino c)
underlyinq cause last.

(2) Other Significant Conditions

Contributinq to Death:

Classification of Death: X Accidental n Homicide n Natural n Suicide n Undetermined

The above verdict certiFied by the Jury on the 27 day of June AD, 2012

Mi"llu"l Egil*
iinted
,^&A-.il- 6"0
@oner'i ttame Preai d i n g Coro n er's Sig n a tu re

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 Ministry of Public SafetY File No. :2018:1038:0053
and Solicitor General
BRITISH Coroners Service
CoruMsle Province of British Columbia
VrRorcr AT CoRoNERS IxQuesr
FTNDINGS AND RECOMMENDATIONS RS n Resulr oF THE GORONER'S INQUEST PURSUATT ro
sECrroN 38 orTHE CORONERS ACr, ISSC 2007] C 15, INTOtne DrArn Or

Eurchuk Elliot Cleveland

GrvEr'r Nnrqrs
Suruular

pursuant to section 38 of the coroners Act, the foilowing recommendations are forwarded to the Chief coroner
of
the Province of British Cotumbta for distribution to the appropriate agency:

JURY RECOMMENDATIONS:
To: Minister of Education
within the
1. Develop processes for earl,v detection of mental health and substance Llse disorders
schools.

2. Develop and implement a plan to transition youth from acLrte care and addiction treattnent
facilities to the schools.

3. provide education to students. parents or guardians. teachers and adn-rinistrators on mental health
and substance Llse disorders.

To: Minister of Health

4. Develop and implement a plan to transition youth from health care facilities back to community
based services.

5. Streamline and coordinate access to available youth residential substance use disorder treatment
beds and youth mental health care beds within British columbia.

6. Provide youth with more long tenn residential substance use disorder treatment facilities
throughout British Columbia.

To: CEO of'Vancouver lsland Health Authority

7 . Provide youth rvith long term residential substance use disorder treatment facilities to be located
on Vancouver Island.

This document has been prepared pursuant to the authority of the chief coroner as
provided in section 53 (2) (e)
of the Coroners Act, ISBC 2OO7] C 15. lJpdated Mav 14' 2015
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