Mother, doctors, group home staff recall events leading up to teen’s death at inquest

The mother of Brandon Schafer-Kovacs said her 14-year-old son’s cries for help fell on deaf ears before he died while in the care of Eagle’s Nest Youth Ranch, a Saskatoon group home.

Schafer-Kovacs was admitted to Jim Pattison Children’s Hospital on Nov. 25 2022, and died three days later. At the time, he was under the care of the Ministry of Social Services.

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The inquest into Schafer-Kovacs’ death began on Monday at the Travelodge in Saskatoon. The purpose of the inquest is to determine who died, when and where the death occurred, and the medical cause and the manner of death. The six-person coroner’s jury will also have an opportunity to make recommendations aimed at preventing similar deaths in the future.

Chantelle Schafer, who was the first witness to testify, said her son had multiple mental and physical challenges such as anxiety, suicidal thoughts, asthma and intestinal issues, and required 24-hour care.

Schafer said Brandon previously had cases of pneumonia, and she noticed significant weight loss in January of 2022.

Details at the inquest revealed that nine months before his death, Schafer-Kovacs had 16 medical appointments, including visits with a psychiatrist.

Schafer said her son’s case worker and staff at the Eagle’s Nest Youth Ranch didn’t keep her informed of all her son’s doctor visits or medical advice. She said she was denied a visit with her son on Nov. 21, 2022 because he was too ill.

The day before Schafer-Kovacs was admitted to the hospital, his mother said she saw him at the group home, slumped over to the side of the bed, slurring his words and “in a lot of pain.”

Schafer recalled asking staff members if he could go to the hospital, but said “there was no response.”

Dr. Meghan Garner said the teen was in septic shock when he eventually arrived at the Jim Pattison Children’s Hospital. Garner explained that septic shock occurs when there are significant cardiovascular effects as a result of sepsis. She said Shafer-Kovacs’ condition worsened, despite efforts from medical staff.

The inquest also revealed that the teen also had influenza A and streptococcus pneumoniae at the time of his death.

Garner said symptoms of influenza include fever, headache, general tiredness, vomiting and diarrhea, while the symptoms of pneumonia present more respiratory problems. Garner stressed the importance of monitoring a child’s symptoms and seeking medical care if they worsen.

She said the teen was in critical condition on Nov. 28, 2022 when her shift ended.

Dr. Gregory Hansen was involved in the case during the final day of Schafer-Kovacs’ life in the hospital’s pediatric intensive care unit.

Hansen said Schafer-Kovacs died of overwhelming sepsis and multi-organ failure, and noted that influenza A and streptococcus pneumoniae made for a “deadly combination.”

Schafer-Kovacs died at 7:31 p.m.

Kyla Dilling, the lawyer for the coroner’s office, asked Hansen if bringing Schafer-Kovacs to the hospital sooner could’ve prevented his death.

Hansen replied that when dealing with sepsis, the earlier a patient can get antibiotics, the better.

“Had he come earlier into hospital, absolutely he would have had a better chance of living,” Hansen said.

“The question that we always ask, as intensivists, is could have this kid come in earlier? And that always boils down to how these kids present at home.”

Schafer-Kovacs was ‘horribly sick’

Valentina Perrin, a youth care worker at the group home, recalled Schafer-Kovacs having a “horribly sick day” in the week leading up to his death.

When asked if a thermometer was used to check the teen’s temperature, she said there wasn’t one available.

Just days before Schafer-Kovacs died, Perrin explained she had serious concerns about his health and felt he needed to see a doctor.

Perrin said Schafer-Kovacs had dry, cracked lips and back pain, and said she told another staff member he needed to go to the hospital, and she left work under the impression he would be hospitalized.

Since Schafer-Kovacs’ death, Perrin said the group home now uses illness tracking forms to document symptoms of those under their care.

The inquest also heard from Ryan Walsh, the program manager at Eagle’s Nest Youth Ranch, who was two weeks into the position at the time of the teen’s death.

He described Schafer-Kovacs as “very funny” and “mischievous,” and noted he required a lot of supervision.

Walsh said the teen would often ask to visit the doctor for minor issues, such as colds. Walsh recalled multiple individuals at the group home having the flu the week leading up to Schafer-Kovacs death, and thought he had the flu as well.

“At that time I thought he was dehydrated from being sick all week,” he said.

“I didn’t think he needed immediate care.”

Walsh said he received a text message on the evening of Nov. 24 from a staff member expressing concern that Scafer-Kovacs wasn’t looking well, and said a plan was made to take him in for medical care the following day.

The next morning when Walsh went to check on the teen, he said he looked “clammy” and disoriented.

Case worker recalls the day teen went to hospital

Marie Digby was the case worker for Schafer-Kovacs. She said the two of them developed a good relationship, as she would take him to his appointments and play games with him.

Digby echoed Walsh’s comments about the teen’s frequent requests to see doctors.

“If not every day, every other day he wasn’t feeling well,” she said.

The case worker said she didn’t recall his mother asking for him to receive medical care.

Digby wept as she recalled the day of Nov 25, 2022, when she saw Schafer-Kovacs’ condition. She said he was disoriented and couldn’t speak.

“I immediately ran downstairs and told (Walsh) we had to get him to the hospital,” she said.

Digby recalled carrying the teen to a truck and driving as fast as possible to the hospital. She said she was holding his hand and trying to keep him awake during the trip, as he kept passing out.

When asked if there was a point in time before Schafer-Kovacs was admitted to the hospital that he needed medical care, Digby replied “no.”

The inquest into Schafer-Kovacs’ death is set to continue on Wednesday morning.