Eighteen months plus a day after the overdose death of her son, Maggie Plett received the report that detailed the coroner’s findings regarding the tragedy.
It had no surprises, the South Surrey mom said: Zach, 21, died of a fentanyl overdose; he didn’t set out to kill himself; and, the recovery home where he died had no shortage of complaints against it regarding its failure to keep its residents safe and supported.
“There was nothing that I didn’t already know,” Plett told Peace Arch News.
It also made no recommendations to prevent similar tragedies in the future – a fact Plett, who first spoke to PAN about Zach’s death in May of 2019, said only reinforces a sense she’s had since her son died, that while officials have vocalized condolences and agreement with the need for change, “it’s almost like nobody really cares.”
The effectiveness of amendments implemented last December to improve oversight of regulated recovery homes is yet to be proven, she added.
“Did I do anything in Zach’s name (by sharing his story publicly)? Did anything good come out of it?”
In her report signed May 29, 2020, coroner Susan Stapleton classified Zach’s Dec. 15, 2018 death as accidental, a result of “acute fentanyl toxicity.”
He was found face-down in bed at around 4 p.m. that day, in a Step by Step recovery house located just west of Queen Elizabeth Secondary.
According to Stapleton’s report, Zach’s roommate alerted other tenants of the recovery home after noticing that Zach, more than 12 hours after going to bed at 1 a.m., hadn’t moved from the position he went to sleep in.
The report notes that Zach had been abstaining from substances when he entered the recovery home, and that the coroner found no paraphernalia commonly associated with illicit drug use at the scene, nor any sign of traumatic injury or foul play. A naloxone kit was located in a bathroom just outside of Zach’s bedroom.
The report also includes the history of the Step by Step recovery house where Zach died.
It was one of five homes associated to the same operator that had been registered as ‘assisted living mental health and substance use’; a registration that required an agreement to be bound by the health and safety standards and guidelines of the Assisted Living Registrar.
According to the coroner’s report, however, in both 2018 and 2019, the homes “were found to be operating in a manner that put the health and safety of their residents at risk.”
“They were found to be non-compliant in numerous areas, including, but not limited to, failure to properly screen residents for suitability, failure to protect residents who overdose and unqualified staff,” the report states.
“The home where Mr. Plett was residing had been inspected in 2018, due to complaints regarding building safety, food safety, site management, staffing and psychosocial supports.
“This home was found to be non-compliant in all areas. Further complaints were made in 2019, and further findings of non-compliance were found.”
The registration of all five homes was cancelled last November, just a few days before amendments to the Community Care and Assisted Living Act (CCALA) took effect on Dec. 1.
The amendments increased the ALR’s ability to monitor recovery homes, and gave it authority to move immediately on complaints, as well as inspect without a complaint “if there are reasonable grounds to believe that there is an immediate risk to the health and safety of a resident.”
Following the announcement, Plett expressed disappointment in how long it took for changes to come about, and pledged to keep a close eye on how the facilities were monitored going forward.
According to information received from the Ministry of Mental Health and Addictions on Monday (July 13), no immediate action to suspend or attach conditions to a recovery home’s registration has taken place since Dec. 1. The initial focus has been to help operators understand the new requirements, and provide the support needed to meet them, an emailed statement explains.
Between Dec. 1, 2019 and the March public-health emergency declaration due to COVID-19, 12 site visits were conducted, including four in response to possible unregistered residences. Due to safety concerns, no short-notice inspections have been conducted since the public-health declaration, the statement notes.
While there are presently no ALR staff in Surrey, they are available to travel to the city on short notice, and will get involved with complaints concerning unregistered recovery homes “when there is an allegation of an unlawfully operating/unregistered residence,” the email adds.
Unlicensed recovery homes are an ongoing concern in Surrey.
Acting manager of public safety operations Kim Marosevich said as of July 6, the city had logged 16 complaints this year of alleged unlicensed supportive recovery homes.
Of those, nine were deemed to be invalid, as inspection “determined that they were not operating as supporting recovery homes,” Marosevich told PAN by email.
There are open investigations on the remaining seven complaints, she added.
Six years ago, city officials shut down more than 100 unregulated operations in a seven-month period. In May 2019, the city confirmed 33 open files against “alleged unregistered recovery or rooming houses.”
Plett said she believes the city is trying, but that continued operation of such homes has her “not really” feeling better when it comes to changes implemented by the province since Zach’s death.
“Clearly, there’s still places running without a business licence,” she said.
“The bottom line is that nobody should be dying in these places.”