A Pelly Crossing man with a brain injury and seizure disorder died after the treatment team ordered to monitor him failed to do so, the Yukon’s chief coroner has found.

Robin Sam, 33, was found dead on Two Mile Hill on Jan. 13, 2014. His body lay about six metres (20 feet) from the road, near the Public Safety Building on Range Road.

He died of hypothermia, concluded a forensic pathologist who examined his body in Vancouver. There were no illicit drugs or alcohol or in his system.

The temperature in the days leading up to his death hovered between -10 and -26 C.

“It was so cold that day,” remembers chief coroner Kirsten Macdonald, who was on-scene to investigate.

Sam was wearing a hoodie, camouflage pants and one shoe.

“We never found the other shoe,” Macdonald said.

Through interviews with witnesses, she managed to piece together that Sam had been downtown in the days leading up to his death. The last known sighting of him was near the McDonald’s restaurant on Jan. 11.

Macdonald doesn’t know why he ended up on Two Mile Hill, or exactly what time on Jan. 13 he died.

A contributing factor in the death was his generalized seizure disorder, the Vancouver pathologist found. He hadn’t been taking the medication prescribed to control his seizures.

A treatment team formed by the Department of Health and Social Services was required to monitor him.

It did not do so, Macdonald found in her investigation into Sam’s death, the results of which she released this week.

“A generalized seizure disorder, when symptomatic and not well controlled, can predispose one to, or impair one’s ability to escape from, life threatening environments/situations such as exposure to cold weather,” she wrote.

At the time of his death, Sam was a client of the Yukon Review Board, an independent panel that deals with accused people who’ve been found unfit to stand trial or not criminally responsible due to a mental disorder.

Sam was found not criminally responsible by a territorial court judge at least twice – once in 2010 for assaulting his uncle, and again in 2011, after being charged with assault.

Judge Karen Ruddy cited the testimony of a forensic psychiatrist in her 2010 decision:

“...while not a traditional disorder, the cognitive deterioration suffered by Mr. Sam as a result of likely neo-natal exposure to alcohol, traumatic childhood experiences, brain injury and epilepsy amounts to a mental disorder.”

As a result of the ruling, Sam appeared regularly before the Yukon Review Board.

Its members were responsible for assessing his well-being, determining whether he was a risk to the public and deciding how he should be managed.

The board may order a not-criminally-responsible person to be released with or without conditions, or kept in custody at a hospital.

Since 2010, Sam was allowed to live in the community on conditions.

In February 2013, he appeared before the board for a regular check-in. The three-person panel found he “continues to pose a significant risk of significant harm to the safety of the public,” but noted he had good community support, was working and completed “a number of courses.”

In the evenings and on holidays, he’d fill in for the Selkirk First Nation’s regular firekeeper, one letter stated.

There had been “considerable success” in helping Sam develop the skills to deal with difficult situations and his anxiety, the board wrote.

It decided he could continue living in the community, on revised conditions.

The board ordered the Yukon government’s director of social services to develop and implement a plan for counselling, treatment and rehabilitation aimed at reintegrating Sam into society.

The social services director should consult with the Northern Tutchone Council’s (NTC) director about how to implement the plan while Sam lives in Pelly, and the NTC director will have primary responsibility for monitoring Sam daily, the board wrote.

The plan must specifically address Sam’s medical and psychological needs, “including his seizure disorder and the medication associated with it,” the board’s Feb. 7, 2013, decision states.

If his treatment team became aware that he was breaching his conditions, or was not taking his medication, they were required to immediately notify everyone involved in his case, as well as the board.

“We want to make it clear that Mr. Sam clearly needs continued strong support and that all of the hard work and excellent progress that has been made could easily be undermined if his support level is let down,” the board wrote.

Sam had another check-in with the board one year later, three days before his death, on Jan. 10, 2014.

He was “disoriented, frightened, moaning, rocking back and forth, and clenching his fists,” Macdonald writes in her report.

The panel gave Sam permission to leave, upon his lawyer’s request. In Sam’s absence, the lawyer continued to represent him, as sometimes occurs in review board hearings.

Sam did not return.

After his death, the board released a brief summary of the hearing, noting this “sad and unfortunate development.

“The Review Board extends its condolences to Mr. Sam’s family, supports, the Selkirk First Nation, and the community of Pelly Crossing,” wrote chairperson Darcy M. Tkachuk.

Sam was born Sept. 8, 1980.

His childhood was “traumatic, characterized by exposure to domestic violence, emotional, physical and sexual abuse,” wrote Judge Ruddy in 2010.

As a toddler, he nearly drowned when left unattended in a bathtub. When he was five, he played with matches and burned the family home down.

His grandmother died as a result of the fire, according to a report by forensic psychiatrist Dr. Shabehram Lohrasbe.

Sam was bulled in Pelly over the years, Ruddy wrote in her 2010 decision. When he was 16, five people attacked and beat him, leaving him with a head injury thought to be the cause of his seizure disorder.

Lohrasbe testified in 2010 that “it would be reasonable to hypothesize that the beating Mr. Sam suffered at age 16 caused brain damage which caused seizures which, in turn, caused and continues to cause further brain damage, with the increasing onset of psychotic symptoms.”

Though he wasn’t diagnosed with fetal alcohol spectrum disorder, Ruddy said reports suggested it was likely he was exposed to alcohol in the womb.

Sam had an “extensive history” with the mental health system over the years, she wrote. He became involved in the criminal justice system in 2001, and was convicted of assault three times by 2010.

Lohrasbe believed that, “while not a traditional disorder, the cognitive deterioration suffered by Mr. Sam as a result of likely neo-natal exposure to alcohol, traumatic childhood experiences, brain injury and epilepsy amounts to a mental disorder,” Ruddy wrote.

She noted Sam’s “severely compromised” mental functioning.

He also exhibited paranoia; when a nurse voiced concerns about his mental state, a psychologist met with Sam at the Pelly health centre in the weeks before he assaulted his uncle in December 2009.

Sam was agitated and disoriented, the psychologist testified. He voiced concerns about people in the community and showed compulsive cleaning behaviour, appearing to be angered by lint he found on the carpet.

After weighing the evidence, Ruddy found Sam was not criminally responsible for assaulting his uncle – that is, he was suffering from a mental disorder that made him incapable of knowing what he was doing was wrong.

The coroner’s report on Sam’s death paints a picture of a man who fell through the cracks.

Even though Sam told his support workers he wasn’t taking his anti-seizure medication, his treatment team didn’t notify the review board, Macdonald writes.

In October 2013, he suffered multiple seizures – serious enough that he had to be hospitalized. At that time, it was clearly documented that he wasn’t taking his medication.

“No one ensured that Mr. Sam was checked on daily,” Macdonald writes.

“No one ensured that the monthly blood levels of the anti-seizure medication was performed. No one informed the parties or the Yukon Review Board ‘forthwith’ that Mr. Sam was not taking his medication.”

As a result of his death, Macdonald has made two recommendations for Health and Social Services.

First, the department should ensure that all conditions dictated by the Yukon Review Board are “vigorously monitored” and that all breaches are reported immediately.

Second, the department should implement a “robust process for oversight” of its responsibilities and require ongoing reporting, monitoring, and written documentation that shows how the responsibilities are being fulfilled and meeting clients’ needs, she wrote.

A Health and Social Services spokeswoman said this morning the department accepts the recommendations.

What the review board ordered in Sam’s case “was unique in that it was a collaborative effort between Health and Social Services and the delegated authority” – the Northern Tutchone Council – Pat Living said in an email.

“The relationship between the two monitoring agencies was collaborative and positive but the department recognizes the need for more rigorous tracking if it receives a similar joint disposition in the future.”

Tkachuk, the review board chair, declined to comment on the coroner’s report. He said the board doesn’t comment on specific cases, other than in its decisions which are public.