Suicide among youth and young adults in Canada: bereaved parents’ perspectives on the systems of care

Abstract

Background

Suicide is the second leading cause of death among youth and young adults aged 15–24 in Canada. Emergency departments often serve as the first point of contact for identifying suicide risk, particularly for youth and young adults, partly due to the inaccessibility and unavailability of community mental health services. Almost half of the youth who die by suicide visit an emergency department in the year preceding their death, and up to 90% have untreated mental health and substance use concerns. Studies have found that parents describe youth mental health services as harmful, fragmented, inaccessible, and inadequate in meeting their children’s needs. Significant gaps remain in our understanding of the experiences with the systems of care for youth who die by suicide. Parents are uniquely positioned to provide vital insights, enhancing our understanding of the role that systems of care play in addressing and preventing suicide. The aim of this study was to better understand how bereaved parents describe the systems of care that provided services to their youth prior to the suicide.

Methods

This qualitative study used a community-based participatory research approach in partnership with Eli’s Place, a rural residential treatment centre currently in development for young adults with serious mental illness. Participants were eligible if they were parents or caregivers residing in Ontario, Canada, of a youth or young adult under the age of 30 who died by suicide. Semi-structured interviews were conducted, and data were analyzed using thematic analysis.

Results

Seventeen participants took part in the study, including 12 mothers and five fathers. The ages of the youth ranged from 12 to 29 years, with a mean age of 18. Most of the youth had diagnosed mental health and addiction-related concerns, and most had received mental health services. Our analysis of parents’ experiences and perspectives identified eight key themes, highlighting critical gaps in the mental health systems involved in their youth’s care: (1) barriers in accessing services; (2) gaps in continuity and coordination of care; (3) absence of guidelines for assessments, treatment, and safety planning; (4) inconsistent quality of care; (5) inadequate training and education for service providers; (6) insufficient involvement of parents and caregivers; (7) limited psychoeducation for youth and families; and (8) experiences of bullying, racism, and discrimination, with a lack of accountability.

Conclusions

Youth suicide is a serious public health concern that requires a systems of care approach, incorporating integrated services with coordinated care and child- and family-centred approaches. In 2024, Canada introduced its first National Suicide Prevention Action Plan, marking a significant and promising advancement in suicide prevention. However, its effectiveness in reducing suicides across Canada will depend on robust implementation, supported by strong political leadership, dedicated funding and resources, and multisectoral collaboration.

Youth suicide is a serious public health issue worldwide [1]. In Canada, the youth suicide rate decreased between 2018 and 2022, but it remains the second leading cause of death among youth and young adults aged 15–24 [1]. During this period, the decrease was more significant among boys (43.17%), compared to girls (21.30%) [1], although suicide rates remain three times higher among boys [2]. The mortality rate due to suicide is 8.5 per 100,000 for 15–19-year-olds and 12.7 per 100,000 for 20–24-year-olds [2]. Girls have a higher rate of suicide attempts than boys [2, 3], and there is robust evidence that suicidal ideation, prior suicide attempts, and self-harm are risk factors and strong predictors of suicide among youth [3–5]. For sexual and gender minority youth (SGMY), suicide rates are three times higher than those of heterosexual and cisgender youth [6, 7], partly due to discrimination, marginalization, and lack of safety in society [8]. Indigenous youth in Canada have suicide rates that are 5 to 7 times higher than non-Indigenous youth, and for Inuit youth, the rates are 11 times higher [9]. High suicide rates among Indigenous youth have been linked to the loss of cultures and identities resulting from historical and intergenerational trauma, colonization, and marginalization [10, 11].

Emergency departments (ED) are often the first point of contact to identify and address suicide risk across Canada, especially for youth and young adults [12, 13]. Almost half of Ontario youth who died by suicide had presented to an ED in the year preceding their death [14], and approximately 50% had seen a primary care provider in the six months prior. Up to 90% of these youth have untreated mental health and substance use concerns [15]. The rates of mental health or addiction-related ED visits among children and youth increased by 89.1% between 2006 and 2017, with the greatest increase among those with high acuity, those with mood disorders, and those aged 14 to 21 [16].

Suicide audits have been conducted in Canada to better understand the trajectories of individuals who died by suicide, determine unmet needs and service gaps, and generate recommendations for suicide prevention [17–20]. The audit process examines the life trajectories of individuals who died by suicide using information from coroner files and interviews with bereaved families. Although several audits have been conducted in Québec [17, 21, 22] and one in New Brunswick [18], most have not focused specifically on youth and young adults. These audits have generated multiple recommendations, including improved training for service providers on depression, substance use, and concurrent disorders; ensuring follow-up care after emergency department visits; and increasing access to family physicians [17, 18, 21].

There have been two earlier studies that specifically examined the trajectories of youth and young adults who died by suicide: one in the province of Québec, which collected data from 2002 to 2005 [19] and one in Ontario, which gathered information between 2003 and 2014 [20]. Renaud et al. [19] conducted an audit of the suicides of 67 youth and young adults aged 13 to 25. Of these, 80% were boys/men, and 87.5% had at least one mental health diagnosis. Within the last 12 months of life, 40.3% had affective disorders and 44.8% had substance use disorders. In the same study, a little more than one-third (34.4%) had made at least one suicide attempt. Most youth had unmet mental health care needs, with 78% not receiving necessary services such as psychiatric or medical follow-up, assessment, referral to another level of services, counseling, addiction treatment, and inpatient or residential services. Many also experienced problems in the coordination of services and continuity of care. Rhodes et al. [20] conducted a population-based case control study and used data from the Chief Coroner in Ontario to examine associations between medical care for mental health or other reasons and suicide. This study found that 53% of youth accessed mental health care in the year before the suicide, with a higher percentage among females and a lower percentage among males in rural communities. They also found that 48% were seen in an ED or inpatient setting in the year preceding their death. The authors emphasized the critical role of hospitals and the need to better identify youth at risk of suicide and intervene more effectively.

The COVID-19 pandemic measures had a significant impact on child, youth, and young adult mental health and are linked with higher rates of anxiety, depression, substance use, and eating disorders [23]. In 2021, the prevalence of suicidal ideation among young adults aged 18–24 was 10.7%, more than double the 4.2% prevalence for the general adult population [24]. There has been an increase in emergency department visits for suicidal ideation, deliberate self-harm, and suicide attempts [23, 25], along with growing issues accessing mental health services [26]. Emergency department visits for self-harm increased by 7.4% in 2020 compared to 2018–2019 among 11–18-year-olds [27], with girls showing the highest increase in rates of emergency department visits and hospitalizations [25, 27].

A recent policy report on the complex mental health needs of children and youth in Ontario identified several barriers to service engagement for young people with complex needs at the individual, service, and system levels [28]. Significant gaps remain in our understanding of the experiences with the systems of care for youth who die by suicide [19]. It is crucial to explore whether youth who die by suicide had accessed services, what types of services were utilized, how these services addressed their needs, and whether their mental health care needs were adequately met [19]. Studies argue for more parent or caregiver involvement in the treatment and decision-making process for youth at risk of suicide [29, 30], noting that parents often describe youth mental health services as harmful, fragmented, and inaccessible [30]. The lack of accessible and available services and inadequate involvement of parents in treatment creates an enormous burden on families [31] and undermines trust in the mental health care system [32]. Moreover, some parents have difficulty interpreting distress signals in youth, may feel uncertain about how to respond to suicidal behaviours [33–35], and would like to better understand factors contributing to suicidal behaviour [36, 37]. Parents are uniquely positioned to provide vital insights, enhancing our understanding of the role that systems of care play in addressing and preventing suicide. Most of the research on youth suicide that has included parents' experiences has focused on bereavement [38].

There have been very few qualitative studies examining family perspectives on the formal and informal systems of care that supported a youth who died by suicide [39]. To our knowledge, no previous studies have explored the experiences of Canadian parents and caregivers in this context. Parents are often closely involved in their child’s mental health journey, navigating services, advocating for care, and witnessing variability in the quality, coordination, and responsiveness of care [29, 30]. Their insights offer a unique and essential perspective on the strengths, gaps, and barriers within the system. By placing the voices of bereaved parents at the centre of this study, we hope to fill a critical knowledge gap. This deeper understanding can help improve access to mental health services, strengthen the quality and coordination of care, guide suicide prevention efforts, and provide better support for youth and families. The aim of this study was to better understand the experiences and perceptions of bereaved parents regarding the systems of care that were involved with their youth prior to the suicide. We examined the following research question: How do Ontario parents describe the services and systems of care that engaged with their youth prior to the suicide?

Methods

Design and setting

This study used an exploratory, descriptive qualitative research design, which is suitable for topics with limited prior exploration [40] and used an inductive approach to develop a deeper understanding. This approach adopts an emic stance, starting from the perspective of research participants, empowering them to actively contribute to the advancement of new knowledge in the area of study [41]. Researchers are also deeply involved in listening to participants’ experiences and providing a platform for their voices. Our diverse research team included researchers, clinicians, students, and parents with lived experience and/or professional expertise in the field of youth suicide. The Research Ethics Boards at the University of Toronto (#43435) and Université Laval (protocol #139310) granted ethics approval for this study.

Participant sample and recruitment

This study employed a purposeful sampling strategy [42], aimed at selecting participants with an in-depth understanding of the phenomenon to effectively address the research objectives [41]. Participants were parents or caregivers of a youth or young adult under 30 who died by suicide. Eligibility criteria also included residing in Ontario, Canada, and being able to discuss the systems of care that engaged with the youth prior to the suicide.

Participants were recruited through the Ontario Distress Centres, Bereaved Families of Ontario (BFO) and its regional affiliates across the province, as well as through social media. The recruitment flyer included a link to an information and consent form hosted on Qualtrics. After providing consent, participants were contacted by a research assistant (RA: JJ or CL) and the principal investigator (TK) to schedule a virtual interview. Following the interview, participants received a resource guide with additional support services and a $30 gift card as an honorarium in appreciation of their time.

Data collection

The research team collected data from January 13, 2023, to June 5, 2023, through an online sociodemographic questionnaire and a semi-structured individual interview, approximately 90 minutes in length, conducted via Zoom. The interviews were facilitated by the PI (TK) and one of the RAs (JJ, CL). Before the interview, all participants provided informed consent to participate in the study and completed the demographic questionnaire. Both the consent form and the demographic questionnaire were administered through Qualtrics software.

The demographic survey consisted of 21 questions covering characteristics such as age, gender, sexual orientation, relationship to the youth who died by suicide (e.g., mother, father), race, ethnicity, religion, region of Ontario where they reside, education, and employment, as well as questions about the characteristics of the youth who died by suicide. Before implementation, the demographic survey was pilot tested with research team members. This process helped identify and address potential issues related to question relevance and clarity, completion time, and technical functionality.

A semi-structured interview guide was developed and reviewed by the research team, with a specific focus on ensuring it was grief-informed and attuned to the needs of bereaved parents [43]. Participants were informed that they could skip questions, take breaks, or stop the interview at any time. The guide comprised 23 open-ended questions categorized into four themes: (1) youth’s mental health and addiction-related concerns, (2) youth and parent experiences with mental health services and treatment, (3) other systems of care such as natural or informal systems, school, work, sports, cultural and community centres, spiritual or other faith-based settings), and (4) recommendations for services, policies, education, and training. The interviews were audio recorded and transcribed. The transcriptions were de-identified by assigning an ID code.

Data analysis

We used thematic analysis to identify themes and patterns, following the six stages outlined by Braun & Clarke [44]: (1) data familiarization; (2) generating initial codes; (3) generating initial themes from coded data; (4) reviewing themes; (5) defining and naming themes; and (6) interpreting and reporting. Dedoose, an online software, was used to organize, synthesize, and code the data. The analysis was conducted by the PI (TK) and two RAs (JJ, CL).

In the first phase, the research team reviewed the transcripts, noted key observations, and began developing the codebook. During this process, initial codes emerged and were identified in the subsequent stage. Each transcript was double-coded by two independent RAs and reviewed by the PI to ensure consensus and resolve any discrepancies. Any discrepancies were discussed in weekly research team meetings, with the codebook being continually updated to reflect the evolving coding process. Following the completion of coding, a thorough examination of the codes and their corresponding excerpts was conducted to identify overarching themes.

Rigor and trustworthiness were enhanced through credibility, dependability, confirmability, and transferability [45]. Researcher triangulation, facilitated by using multiple coders for analyses, strengthened credibility. Prolonged engagement with participants and data, as well as regular research team meetings increased credibility, dependability, and confirmability. Transferability was enhanced through thick descriptions of participants’ stories and experiences. Dependability and confirmability were increased through peer debriefing, the use of an audit trail, and detailed notes throughout the study. Reflexive analysis by the research team members also enhanced dependability. To minimize bias, research team members wrote reflexive memos during analysis, regularly debriefed throughout the coding process, and kept detailed notes of all meetings.

Results

The sample included 17 parents of youth who died by suicide, consisting of 12 mothers and five fathers. Twelve parents spoke about their sons and five about their daughters. In terms of gender, parents identified the youth as boys/men (n = 12), girls/women (n = 3), nonbinary/trans (n = 1), and questioning (n = 1). The ages of the youth ranged from 12 to 29 years, with a mean age of 18. Eight youth died between 2014 and 2019, while nine during or after the pandemic (2020–2023). Seven of the nine parents believed that their youth’s difficulties were caused or exacerbated by pandemic measures. Four youth underwent medication changes with no follow-up immediately before their suicide, and parents believed these medication changes contributed to the suicide. All but one of the youth had mental health concerns, and most had multiple diagnoses. Two female youth diagnosed with borderline personality disorder were believed by their parents to have been misdiagnosed. Six male youth had psychosis, four of which were cannabis-induced. Ten youth had previously attempted suicide. Among the seven who had not, four had experienced suicidal ideation, and two had engaged in self-harming behaviours that posed a risk to their safety. All but one youth had received mental health or social services at hospitals/EDs, community mental health agencies, schools, private clinics, or child welfare settings. Tables 1 and 2 present the sociodemographic characteristics of the parents and the characteristics of the youth and young adults who died by suicide, respectively.

Table 1.

Characteristics of parent participants (N = 17)

Characteristics	n (%)
Gender
Women	12 (71%)
Men	5 (29%)
Age
30–39	2 (12%)
40–49	5 (29%)
50–59	7 (41%)
60–69	2 (12%)
70–79	1 (6%)
Ethnoracial identity
White	14 (82%)
South Asian	2 (12%)
Jewish	1 (6%)
Region of Ontario
Southwestern Ontario	10 (59%)
Central Ontario	7 (41%)
Youth or Young Adult Who Died by Suicide
Son	14 (82%)
Daughter	3 (18%)

Table 2.

Characteristics of youth and young adults who died by suicide (n = 17)

Characteristics	n (%)a
Age
12–14	2 (12%)
15–16	4 (24%)
17–18	1 (6%)
19–20	4 (24%)
21–22	1 (6%)
23–24	1 (6%)
25–26	2 (12%)
27–29	2 (12%)
Gender
Boys / men	10 (59%)
Girl / women	5 (29%)
Trans	1 (6%)
Questioning	1 (6%)
Sexual orientation
Heterosexual	10 (59%)
Questioning	3 (17%)
Lesbian/ Gay /Queer	2 (12%)
Parent believed youth was Queer & not out	2 (12%)
Period of death
Pre-pandemic (2014–2019)	8 (47%)
During or post pandemic (2020–2023)	9 (53%)
Previous suicide attempts
Yes	10 (59%)
No (n = 5 had suicidal ideation, n = 2 had self-harming behaviours)	7 (41%)
Mental health concerns
Yes	16 (94%)
No	1 (6%)
Previous mental health, addiction or social services
Yes	16 (94%)
No	1 (6%)
Mental health or neurodevelopmental disorderb
Depression	10 (59%)
Anxiety	6 (35%)
Psychosis (4 had cannabis-induced psychosis)	6 (35%)
Bipolar disorder	4 (24%)
Attention-deficit/hyperactivity disorder	3 (17%)
Autism spectrum disorder	2 (12%)
Eating disorder	2 (12%)
Obsessive compulsive disorder	2 (12%)
Borderline personality disorder	2 (12%)
Post-traumatic stress disorder	1 (6%)
Oppositional defiant disorder	1 (6%)
Substance use and behavioural addictions
Cannabis use	13 (76%)
Use of other substances in addition to cannabis	5 (29%)
Video gaming	6 (35%)

Note. ^aPercentages may not total 100 due to rounding. ^bMost had more than one diagnosis and some of these were co-occurring with substance use

How do Ontario parents describe the services and systems of care that engaged with their youth prior to the suicide?

Through our analysis of the parents’ experiences and perspectives on the systems of care that engaged with their youth or young adult prior to the suicide, eight significant themes emerged, highlighting critical gaps in these systems, particularly within the mental health care system: (1) barriers in accessing services; (2) gaps in continuity and coordination of care; (3) absence of guidelines for assessments, treatment, and safety planning; (4) inconsistent quality of care; (5) inadequate training and education for service providers; (6) insufficient involvement of parents and caregivers; (7) limited psychoeducation for youth and families; and (8) experiences of bullying, racism, and discrimination, coupled with a lack of accountability. These themes are summarized in Fig. 1.

Fig. 1.

Themes reflecting parents’ perspectives on the systems of care that engaged with youth who died by suicide

Barriers in accessing services

The first theme that emerged highlighted the challenges related to accessing mental health services for youth with a wide range of needs. Parents identified many barriers, such as the lack of available services, long waitlists, and narrow admission criteria. One mother emphasized that she had to seek private services due to the unavailability of public options: “Immediate care is needed now. If we’re here, then we need the help now, not six months from now, not a year from now… I had to get her private care” (P16).

A father shared his frustrating experiences:

There was no help. When she needed help, she got turned away. When we needed help, we got turned away. Even to the point where she got turned away in an emergency room because she wasn’t 16… Every time we tried, it was a circus. You have to call this number. You call that number. And you finally get to actually talk to somebody, but, “Oh, that’s not my field”… And a walk-in clinic that you need appointments. What is that? That’s not a walk-in clinic. If this kid’s walking off the street like, yeah, hello, open the f***ing door! And the worst part is, these walk-in clinics are once a week. When you do finally get somebody that actually will help you, it costs too much. (P17)

Parents described additional barriers, including restrictive admission criteria, which often excluded youth with specific diagnoses or those deemed to be unstable. As one mother explained:

She lost hope in the system, and she was discouraged too, because we were trying to get her into programs like [name of local mental health agency] and we couldn’t even access them. She just didn’t fit the box. Her experience would be, it’s really difficult, if not impossible, to get help in this system. (P8)

Similarly, a father added:

We wanted to get her in [name of local mental health agency]. [They] wouldn’t take her. Everywhere we tried was like, “No, she’s gotta be stable” …Where do you go if you’re struggling? “Sorry, you don’t fit the criteria”…“ You’re almost bipolar, but you’re not bipolar, so you don’t check the box, so therefore, you don’t get this program. But we saw you. You’re off our list now…We don’t know how to help you, and we don’t know what program to put you in.” (P7)

Parents described the lack of residential or inpatient mental health services, as well as the unavailability of more intensive outpatient services for young adults, as outlined by this mother:

Canada is so far behind in that there’s no residential programs like therapeutic programs. There is only one, but only for 18 and under. So again, there are barriers…Most of the mental health issues don’t surface until they’re adolescents. So, I was trying since he was 8 to get services for him…They need transitional age youth programs, to transition these kids who are turning 18, not throw them in adult services that don’t meet their needs…There needs to be more of a protective mechanism where they’re being cared for in a safe environment. (P11)

Gaps in continuity and coordination of care

Parents described the lack of continuity between hospital and community mental health agencies and the impact this gap in services had on their youth’s treatment. One mother explained this problem:

There needs to be more continuity between hospital and community and that’s really where it fell apart. The hospital is saying that a patient’s not high risk and the community is saying they’re too high risk…That’s what happened to our [daughter]. She fell through the cracks…It was just like “you’re out the door, call the crisis line”…There needs to be more continuity…Community agencies seem to have a lot of power and control to say no, I’m not gonna take you. You only have these symptoms, not these symptoms.”’ There needs to be much more communication between community and hospital when it comes to discharge planning. (P8)

Building on this, parents also pointed out the lack of communication, collaboration, and coordination of care between service providers. For instance, a mother shared her frustration, noting, “The professionals that were involved didn’t communicate with each other…This whole idea of circle of care is idealistic, but it doesn’t really happen…If there was really clear communication between all the different supports…it would really help” (P14). Another mother highlighted the gaps in care:

In terms of the services, they’re like little islands. And there’s no connection or communication between those islands. It’s like you went on a boat and then the boat sunk, and you’re stuck on this island. It’s isolating. There are psychiatrists, psychologists, social workers…but no one comes together. Everyone is just on their individual island…no one’s coming together and collaborating and saying, “OK, this is what we have in front of us…This is what I’m doing.” That’s a huge gap…And they put it down to the family doctors. The family doctors don’t have time for that. So, they’re saying “Go back to your family doctor, or go to emerg.” (P11)

Echoing these concerns, many parents discussed the assumption from hospitals and psychiatrists that family doctors would follow up with patients, despite there being no discharge planning or communication about medication.

She was treated with ECT 12 times and never followed up in between…The family doctor was trying her best …I can’t say enough about the family doctor. They didn’t communicate what the plans were. They didn’t communicate what was going on. One time our [daughter] was discharged, and we looked at the medications and we were like, this doesn’t make sense and called, and it was wrong. The medication that she was given was wrong…They have to have a discharge plan…Where’s the warm handoff to the next program that will keep her safe or give her the skill set to do it? There was none of that. (P7)

Absence of guidelines for assessments, treatment, and safety planning

Parents described inadequate assessments of mental health and suicide risk, perceiving that risk factors were not fully considered, and that the level of risk was minimized. One mother highlighted, “I really don’t think they took into consideration, you know, the age, gender, and self-harm. It was just attention seeking to them” (P16). Another mother expressed her exasperation that her son had multiple emergency visits without being admitted because he was not deemed to be in crisis:

You’re going to the people who you think are supposed to know. But it was always the same story…He would do all this crazy stuff and you know, there’d be like so much evidence…He’s abusing drugs…he can’t keep a job…he’s saying he’s gonna kill himself…They would interview him and they were like, “Well, he seems fine.” How can anyone be fine that’s doing the things that he’s doing? All the times that he went to emerg., he never got admitted. We had multiple emergency room visits and that was the one thing I remember the most is someone saying to me , “Well, he’s not in crisis”…I was begging them to keep him…It was like, “You’re not at my house, you don’t know what we’re going through.” That was really frustrating…You’re just trying to help your kid and there’s nothing you can do. (P12)

Another mother shared that even though her son had disclosed his suicidal plan to hospital staff, he was discharged, and he died by suicide shortly after: “He told them he was going to go kill himself, and they still let him out” (P15). Parents underlined the importance of having a “consistent mental health assessment…not just a subjective assessment” (P7), emphasizing the need for more “standardized testing” (P8). A mother explained that her son completed a questionnaire during a visit to his family doctor just 10 days before his death. She later gained access to her son’s personal health information and discovered that his scores showed significant red flags, but there was no follow up by the family health team:

Because he was on medication, they had him fill out a form just to check in how he’s doing…And I was able to see that of course, after he died, because I requested all of those pieces of information. So, this was probably 10 days before he died that he indicated on this form at our family doctor’s office that he was not functioning daily, like huge red flags that he was struggling, that he felt that he could hurt himself. And that was never even looked at…They just continued on with this appointment…You fill out the form to cover your butt cause it needs to be filled out…If they would have read that form they could have followed up with him and said, “Come back here like we need to talk. What’s happening?” And it could have just been that moment that made a difference. “Let’s review what medication you’re on. What’s going on? Maybe we need to think about putting you in the hospital. Maybe we need to think about calling your mom.” I took it to her and I said, “I cannot believe that this information was laid out for you within two weeks of his death and there was no follow up.” (P14)

Some parents described their youth’s diagnoses as unclear, with inconsistent information from different healthcare professionals and noted that “the treatments didn’t always match the diagnosis” (P8). This mother added,

There needs to be much better focus on assessments. The treatment plan was always the same despite her not getting better. She was always in the severe range, but she was getting these mild recommendations for CBT and to call the crisis line. That’s a mild recommendation. That’s not something you do for somebody with severe symptoms. (P8)

Many parents reported adverse effects associated with their youth’s psychotropic medications, noting that they were not closely monitored. One mother stated, “One hospital used the medications just to sedate the person when they’re not doing well and didn’t deal with the underlying issues. I don’t think the patient fully knew, you know what they’re taking, when they’re taking it, why they’re taking it? Our [daughter] was on a variety of medications. She had a variety of side effects from the medications, so they kept switching” (P11). A father expressed concern about the lack of individualized treatment:

With the final treating psychiatrist or some of the other people we encountered, they had their tools, they just kind of apply to everybody they see. They don’t necessarily tailor it to the specific patient…But with the psychiatrist, it was kind of like the chemistry experiment. “Oh, this calm drug doesn’t work, oh, we’ll switch it for this one.” “Oh, then we’ll add another.” Just kind of going through drugs, but I have a feeling that there was more needed than that. I think some of it has to do with the very difficult skill of being able to use your judgment to tailor it. The final treating psychiatrist also erred in prescribing a highly toxic antidepressant to a person who three times tried to kill themselves with pills…It doesn’t have a big margin for safety. (P5)

A mother added that her son had some changes in behaviour before his death which she attributed to his medications:

I found out after, the dosage that he got for the anxiety pill was way too much for his weight and that was kind of making him go crazier…they were for someone who weighs 250 pounds and my son only weighed 100 pounds, maybe 90 pounds. They should at least let the parents know exactly what’s going on, you know, and if he’s taking other medication, I still need to know. (P10)

Another mother highlighted, “My [son] did the meditation, he did the work, he did the journaling, he did the ‘every day I’m grateful for this’…but after that medication…that’s when it all changed” (P2).

Most parents were unaware of any safety plans developed for their youth, although a few mentioned that their youth was given unrealistic recommendations that did not align with their diagnosis and suicide risk severity. For example, one father described how his son, who had been involuntarily hospitalized for 72 h with symptoms of psychosis, substance use, and a detailed suicide plan, was discharged early with no safety plan. The recommendation was to call a helpline if he is not well: “There was nothing in the plan. Call someone for help. That doesn’t make any sense. He’s not able” (P3). A mother echoed the lack of safety plan for her son: “Instead of a safety plan, I picked him up at the hospital. We came out with prescriptions” (P15).

Inconsistent quality of care

Most participants described the quality of care their youth received as poor, particularly regarding service provider interactions, facilities, and programming. These experiences primarily referred to services at hospitals and community mental health centres, with school services also frequently mentioned. While a few parents highlighted some exceptional service providers, these were rare exceptions rather than the norm . Parents noted that numerous service providers demonstrated a lack of “compassion and understanding” (P3) and were described as “dismissive” (P16), “impatient” (P14), “rude” (P3), and “indifferent” (P2). A mother described feeling dismissed by healthcare providers:

The care that you get when you take your child to hospital…the dismissiveness that they had for us. We hear what’s going on. “We’re gonna take them into this room. You’re gonna go out there. No, we don’t find this is an issue right now. They’re not a harm to themselves.” You don't know what’s going on and then we were escorted out. Just the very dismissive behaviour of the healthcare worker, that wasn’t helpful at all cause where else are you supposed to go if they’re dismissing you? (P16)

Many parents expressed understanding of the difficult work conditions for service providers but emphasized the inadequacy of standards of care for youth who are suicidal. This point was highlighted by a father: “It was just the lack, I don’t know if it’s just they’re too busy, they’re overworked. But you still have to give good care and you can’t get complacent. And that’s what I felt. There’s a lot of complacency” (P7). Another father described the services and treatment for his son:

There was no service, there was nothing. They just said “Bring him back if he’s not well.” And what the hell? He’s not a dog. It’s not like I can just put him in the car, here’s a bone, and take him to the hospital. There was no investment in my [son] to see where he was at. You treat them with dignity. They’re people for God’s sake. (P3)

For many parents, there were experiences with service providers who did not communicate a sense of hope to the youth or family, as explained by this mother:

I could tell along the way, the staff who cared, it’s having compassion and hope. Our family doctor was fantastic. She consistently said to my daughter, we are gonna get you back to school. We’re gonna figure this out. I believe in you. That was amazing. My daughter knew it. Even though she wasn’t doing well, she knew when staff cared, she knew they believed in her. They spent time with her. They talked to her. What was not helpful was this arrogant medical model - I know best - this is what we’re gonna do - this is the way it is. Refusing to make referrals and spending all their time behind the desk and not spending time with my daughter. They had five minutes a day with her. That’s it and not really caring. When you get that sense that staff don’t care, you lose hope, and it was detrimental to her health. (P8)

A father described the risks and harms that losing hope had on his daughter:

They never had a sense of hope. They never gave hope. They never even talked about hope. You just need to be, you know, “we don’t know what’s going on right now, but we’re gonna figure it out. I’ve seen people in your situation before. It’s gonna work out. Just take some time.” But no…they took away the hope. And when you lose hope, that’s a dangerous thing to do. (P7)

Parents explained that the quality of care was affected by facilities and settings, noting that most hospital settings were unwelcoming and offered subpar care. One father described his perceptions: “It was like prison. The harmful part was the stripping away of any sort of rights combined with actually no services or treatment…Just kind of holding her there” (P5). A mother added, “If you’re in the hospital, you don’t get better, you actually get worse. My [daughter] went 10 days without fresh air…She would have had better care in a prison. It was that awful” (P8).

This mother acknowledged the outstanding care from nurses but noted that the hospital protocols and settings were inhumane:

Least helpful was the hospital…The nurses, oh God, they were just fabulous. But you just look at the state of our healthcare where I’ve gotta sit outside a padded room and listen to my son scream. And it’s dirty in there, and it’s dingy. They lock everybody in their rooms, and it’s inhumane and it had to have been so humiliating for him. (P15)

Numerous youth, as described by their parents, tried to get help and support but felt “defeated” (P11) due to negative experiences with the mental health treatment system:

A mother described her son’s experience:

Nothing was provided. He was put into this stainless-steel room. I don’t even think they gave him a juice…he drank water out of the tap. They left him alone for five hours and then gave him the name, a referral to the psychologist. “Someone will be in touch with you for an appointment.” That’s all. He probably would have gone back to somewhere that he felt comfortable when he was in distress, as opposed to going to somewhere that put him more into stress. There was no going back to the hospital for him for getting help cause he knew he wouldn’t get any help there. (P2)

A father explained that the approach used with youth who have acute mental health concerns is “punitive” rather than focused on “wellness” (P7). A mother reported that her son and another young girl who had attempted suicide spent the entire night in the hallway of the emergency department:

He slept in the hallway, but and then I didn’t know this till the next day, but there was another young girl there…She was there for the same reason. She had attempted suicide and they were just in a hallway, not even across from the nurses’ station. So, two kids in there because they called the suicide hotline. Not even in front of the nurses’ station…that was just very bizarre to me like that they would let that happen…Shouldn’t they be somewhere or in a psychiatric waiting room specifically with someone really paying attention? If that’s why they’re there…A terrible lack of service. (P6)

The quality of care was also affected by stigmatizing attitudes from service providers regarding mental illness and suicidality, which further undermined trust and access to necessary support, as this mother noted:

There was stigma with mental illness, and you were treated deplorably like, not even like a second-class citizen when you went into emerg. If you were saying, you know, “I think he’s suicidal” or “I think, you know, we need to have something addressed,” and there was no compassion. It was all behaviour and bad parenting…A lot of them are not treated as individuals. They’re treated as mental illness. (P11)

Parents also perceived that some diagnoses were stigmatized more than others. Another mother stated:

There is a stigma around borderline…they believe it’s more behavioural…A week before she died, we were calling in saying she’s not doing very well. She’s having a hard time getting out of her bed. She’s suicidal. But they believed she had borderline, so they just ignored. (P8)

Substance use faced similar stigma, as this mother described:

The social worker that intervened, didn’t intervene but she talked to my [son] at one point…She was very rude…She said “Well your [son] is just gonna go back and smoke drugs anyway.” Her tone was very bad. She was supposed to set up a meeting, but never did. (P3)

Inadequate training and education for service providers

Parents highlighted that while hospitals and community agencies are treating youth with complex mental health concerns and elevated suicide risk, some clinicians had inadequate training to appropriately and effectively respond to the needs of youth. One father stated:

A lot of the healthcare providers didn’t have basic mental health training. They don’t have a nurse trained in mental health for triage in ER. That was shocking to me. My daughter would say, “I’m having suicidal thoughts,” and they would say “Well, just ignore your thoughts.” (P7)

A mother shared her son’s story, hoping it would help better equip school professionals:

Even after three years, I still could not understand why it happened and how it happened. So, I wanted to share this information. Maybe I’m not the expert, right? Maybe at least the experts, if they get all the information, they might understand the signs, they might educate the parents, teachers, social workers, whoever it is so that another child does not lose his life like this. That’s all I want. (P1)

Insufficient involvement of parents and caregivers

Despite all parents being the primary source of support for their youth, the mental health care system continuously excluded them from the treatment and services provided to their youth. One mother highlighted that consent and confidentiality policies were barriers:

I was never involved. I didn’t even know what was going on…I just think the policies needs to change whether they go to rehab or whether they go see their family doctor or psychiatrist…Parents need to be able to have information…to help their kids, cause who else is going to help them, cause nobody is helping them. We’re the ones that are here to help them. (P10)

Other parents reported that, although their youth had provided consent to share information with them, they were still inconsistently and inadequately involved in their youth’s care:

I’m very thankful our [daughter] always signed consents. There was still this inconsistency… We had very little involvement with the doctor…Very much a strong medical model. “We’re not going to listen to the voice of the family.” It really depended on the personality of the healthcare provider and their willingness to work with the family. There was not a consistent treatment or service delivery. (P8)

As highlighted by this mother, “A parent has no say…And that is just bull. We know our kids better than anybody” (P15). Parents described feeling hopeless as they tried to support their youth and advocate for them, feeling that their voices were not being heard, as one mother described:

I would really like them to honour family-centred care and listen to the caregivers, listen to the parents. I didn’t feel supported by the system. Again, it was that whole feeling of hopelessness., and I said, “I have to keep it together because if I don’t keep it together then my [son] will see that and he’ll think that it’s hopeless”… It wasn’t welcoming…I said, “I would love a family meeting.” And the social worker he had says, “I don’t deal with families. I deal with the individual.” And that was the end of the story. (P11)

Parents not only felt unheard, but also felt blamed by service providers for the mental health challenges their youth faced. This father described taking his daughter to the hospital following a suicide attempt: “She’s overdosed. She’s throwing up. I took her to the hospital. And they said, ‘You’re doting on your daughter too much. You’re giving her too much attention’” (P7). A mother added, “Most of it was blaming the parent. It was bad parenting. You know you weren’t being strong enough or you’re letting him do too much on his own or not doing enough on his own” (P11).

Parents explained that being involved in care would have given them more information and tools to be able to support their youth and better cope in the extremely high stress situations: “How we could work together with whoever is providing the advice to her…What we could do to reinforce it, or just for us like how to cope?” (P5).

Limited psychoeducation for youth and families

Another important theme that emerged from parents’ stories was the lack of psychoeducation or information for youth and parents on mental disorders, including substance use disorders, evidence-based treatments, suicide risk factors, individualized treatment plans, safety plans, and medications. A father stated, “No professionals shared any information with us. And I wish they did, so we’d actually have a better understanding” (P17). A mother explained that she needed to do her own research: “There was no communication and no education…Any of the information I received is what I picked up by getting books or searching the Internet” (P11). Another parent underlined the importance of providing psychoeducation to parents who are advocating for their youth:

It just felt like a lot of fragmented information, bits and pieces that were coming from him or what I could see, but without ever really knowing everything. And as his primary advocate, outside of himself, it’s a tough place to be, not knowing everything…What do you do next? I think my doctor even expressed that to me cause as I sat and cried in her office and explained to her how I felt about what happened and saying that my [son] kind of like got into a spinning tornado and at first he was able to express it, but then eventually he lost himself in it and he didn’t have control anymore of what his actions were going to be. And he needed somebody that was going to be able to speak for him and care for him and advocate for him and pull him out of that tornado. My [doctor] said, “Pull him out to what?” And I thought to myself, “Well, you should know. You need to know the answer because I’m coming to you asking for help. You’re the expert.” (P14)

Experiences of bullying, racism, and discrimination with lack of accountability

Parents described their youth as not being physically, psychologically, or emotionally safe in various systems of care, including hospitals, community mental health agencies, and schools, due to experiences of bullying, discrimination, and racism. Most parents reported that bullying at elementary and secondary schools was prevalent and poorly addressed, with one mother stating, “Even though the schools now have a bullying policy, a lot of the time bullying is not addressed. Kids are still not feeling safe” (P11). Many parents added that “kids are afraid to speak up” (P11) and one mentioned, “He begged us not to report it” (P14). Another mother highlighted that racism influenced her son’s experiences of bullying and the school’s inadequate response: “There is racism. I feel that as a coloured immigrant…From the school’s point of view, they did not want to understand what such children face, how my son will be treated and how that plays a role” (P1).

Several parents stated that their youth identified as lesbian, gay, bisexual, or trans (LGBT), or were questioning their sexual orientation or gender identity. Discrimination by peers and service providers was reported by parents, with one mother describing a traumatic experience at a gender identity clinic. She highlighted that there was a “specialist who had his own narrow-minded agenda, even though he was the kind of guru on gender identity,” and she received messages that said, “You better get over it. Get used to it now. Your kid’s never gonna function” (P9). A father discussed the lack of inclusivity in schools, and how this affected his son: “Culturally in the high schools, it’s still a kind of a macho environment. My [son] was not macho in any sense…It’s a guy’s hockey jock, guy’s environment and it doesn’t accommodate different maleness there” (P4). One mother emphasized that the unjust treatment of youth with mental health concerns is discrimination: “It is unfair treatment because they didn’t meet the standard of care at all. I believe it was discriminatory ” (P8).

Many parents explained that they are using their own experiences to advocate for changes in policies, service design, and quality of care. They underscored that there “should be some accountability” and “there should not be fear of repercussion” (P1) to effect changes in the different systems of care. One mother explained how she has been advocating to make her son’s experience heard: “If you do not pull through, nobody will get to know what your son went through. You have to be his voice. He left you with so much pain, so since that day I have been working for my son’s case to make his voice heard as much as I understood him” (P1).

Discussion

This study offered key insights into the gaps within the systems of care that engaged with youth and young adults who died by suicide, as viewed through the perspectives of bereaved parents. Parents shared their stories with the hope of preventing similar tragedies among other youth and families. Through these stories, we identified eight themes concerning the systems of care their youth engaged with, focusing on the nature, quality, and type of care received. Each theme highlighted significant gaps in the systems of care, especially within the mental health care system. These eight themes were: (1) barriers to accessing services, (2) gaps in continuity and coordination of care, (3) absence of guidelines for assessments and safety planning, (4) inconsistent quality of care, (5) inadequate training for service providers, (6) insufficient involvement of parents, (7) limited psychoeducation, and (8) experiences of bullying, racism, and discrimination.

Most of the youth who died by suicide had mental health and addiction-related concerns, previous suicide attempts, suicidal ideation, or self-harming behaviours. Most of the youth had received services, their needs were complex, and the services were unable to address these needs. In an audit of suicides in New Brunswick, Lesage [18, p.673] noted that “comorbidity was the rule rather than the exception” and recommended integrated services that address both mental health and addiction concerns. A recent policy brief by Sansone [28, p.11] examined the inadequacy of Ontario systems to support children and youth with complex needs, defined as “characterized by the presence of multiple diagnoses or behavioural problems, which are anticipated to have long-term consequences and necessitate engagement with multiple service sectors.” The report also notes that these complex needs may be further complicated by systemic barriers that are associated with the exclusion of specific populations. Levesque et al. [46] developed a framework to conceptualize access to healthcare across five dimensions, which include: (1) approachability, which concerns how reachable and visible services are for service users; (2) availability, which refers to geographical accessibility, hours of operation, and whether services are virtual or in person; (3) affordability, which considers the direct cost of private services and indirect costs, such as taking time off to attend an appointment; (4) appropriateness, which examines the alignment between the services and the needs of service users; and (5) acceptability, which focuses on how inclusive and culturally responsive the services are to the needs of diverse populations. Parents in our study noted challenges across all five dimensions. Access to mental health services has been identified as a critical issue in several studies [19, 21, 26, 47]. Suicide audits have highlighted the need for improved access to primary care, as well as specialized services for psychosis, depression, and substance use disorders [21], especially in rural communities [20, 21]. Additionally, Renaud et al. [19] examined unmet needs for youth who died by suicide and recommended shortening waitlists and increasing access to school counselors and psychologists.

Our findings highlighted inadequate communication between service providers, lack of coordination of services or follow-up even when youth had high-acuity needs, and poor transitions between services, particularly from hospital to community. Suicide research has underlined the critical role of continuity of care [19, 48]. The lack of coordination at a systems level means that some children or youth fall through the cracks, are referred to child protection, are diverted to the justice system, or they seek help through emergency or crisis services [28]. Lesage et al. [21] recommended the implementation of mobile crisis intervention teams to check in and monitor patients leaving emergency departments. A policy report on the complex needs of children and youth in Ontario highlighted the lack of coordination across systems, which requires youth and families to navigate the system with inconsistent plans of care in each service, rather than one integrated plan [28]. Arnon et al. [48] identified four key elements for continuity of care in suicide prevention. These elements include (1) continuity of care across multiple levels, including inpatient and outpatient services; (2) the important role of primary care providers and case managers; (3) the importance of follow-up and monitoring after hospital discharge, ED visits, or during transitions in care, which should include a mood and suicide risk assessment along with a review of the safety plan; and (4) the establishment and maintenance of national and institutional guidelines, standards, and best practices for patient engagement, suicide risk assessment, treatment planning, and the involvement of families.

The lack of consistent guidelines for assessing suicide risk was one of our findings, as parents highlighted how that affected service providers’ ability to take their youth’s symptoms seriously, often minimizing their severity. Additionally, most parents were unaware of any safety plans, except for a few whose youth were merely advised to call a helpline. A comprehensive suicide risk assessment, which includes an analysis of risk and protective factors, has been documented as a best-practice standard [49–51]. The Safety Planning Intervention (SPI), developed by Stanley and Brown [51], is listed as one of the brief interventions for managing suicidal crises by the American Foundation for Suicide Prevention [52]. Safety plans are widely used and recommended for individuals at higher risk for suicide. These plans include warning signs and triggers, coping skills, distractions, social and emotional informal supports, professional support, methods to restrict access to lethal means, and reasons for living [49–51, 53]. Erbacher and Singer [49] developed the Suicide Risk Monitoring Tool (SMT), which can be used by any service provider, including school mental health professionals. The SMT helps track changes in youth already identified as at-risk for suicide. Abbott-Smith et al. [54] conducted a systematic scoping review on safety planning for young people and noted that safety plans for children and youth need to be adapted for their age and developmental stage. They also emphasized the importance of involving parents and caregivers in the safety planning process and identified seven elements to consider: (1) sharing the safety plan and encouraging its use; (2) means safety; (3) promoting connections; (4) psychoeducation around warning signs and triggers; (5) listening and validating; (6) developing their own support network and emergency contacts; and (7) supervising and monitoring their youth.

Another theme in our study highlighted the inconsistent quality of care received by youth and parents, emphasizing the need for greater compassion and hope. This included stigmatization by service providers, particularly toward youth with specific mental health diagnoses and those using substances. Compassion is defined as a response that “seeks to address the suffering and needs of a person through relational understanding and action” [55, 56]. Studies have shown that it is an important part of the quality-of-care ratings in EDs [56, 57] and have also highlighted the need for individuals experiencing suicidality to have positive interactions with service providers who listen with compassion and foster a sense of hope [58, 59]. A systematic review by Vandewalle and colleagues [59] found that adults with suicidal ideation and behaviour need to feel cared for, accepted, and understood through meaningful connections with service providers. Another study conducted in Québec examined the experiences of individuals with suicidal ideation and behaviour who had received care in emergency departments. Like the parents in our study, participants in this study emphasized the need for more compassionate attitudes, behaviours, and approaches from service providers. This study also found that hospitals presented an uncomfortable physical environment and inadequate organization of care, leaving many individuals in distress, alone, and unattended for lengthy periods of time [58]. A recent paper focused on “mattering” and its impact on youth suicidality, highlighting how this contributes to strength and a sense of hope [60]. Mattering fundamentally means feeling valued by parents and friends, at school, and in the community. Not mattering, or experiencing anti-mattering, is associated with heightened vulnerability and risk, especially for youth recovering from a previous suicide attempt. Flett [60, p.10041] emphasizes that “mattering occurs in the moments,” and service providers can build connection and show that youth are cared for through responsive listening, encouragement, and giving the youth a sense of voice.

Our study identified the need for enhanced training and education for mental health professionals to more effectively respond to youth at risk of suicide. Studies have shown that graduate education programs offer very little in suicide prevention and intervention [61–63]. For example, Mitchell et al. [61] reported that only 50% of psychology interns and 25% of social workers have received suicide training in their programs. Although most psychiatry residency programs include suicide training, the majority of residents consider it inadequate. Furthermore, many mental health professionals lack the necessary knowledge, attitudes, skills, and confidence to screen, assess, and address suicide risk with patients [64–66]. Research indicates that service providers who complete suicide-related training gain more knowledge about risk and protective factors, are better able to conduct suicide risk assessments, and have increased confidence [61]. This training also helps change attitudes, reduce biases, and decrease stigma among service providers [65]. The need for improved training is a recurring recommendation in suicide audits conducted in Canada [17–19, 21, 22], which specifically call for training professionals in both primary and specialized mental health care settings, due to a pervasive lack of understanding about how substance use heightens suicide [21]. Enhanced training, ongoing professional development, and support will enable service providers to better address complex mental health care needs among youth and develop more effective systems of care for delivering safe and effective treatment [28].

The need for family involvement in services for their youth emerged as a salient finding in this study. For some parents, involvement was restricted by confidentiality and consent policies and laws. However, even in families where youth had provided consent, parents were still not informed about their youth’s diagnoses, treatments, and safety plans. Parents also reported a lack of psychoeducation regarding medication changes and potential serious side effects, including an increased risk of suicide. Parents supporting children with complex mental health needs face significant burdens, which intensify when the child has attempted suicide [67]. The challenges are linked to fragmented services, difficulties navigating disjointed and unavailable services or those with long waitlists, and high levels of emotion and distress [28]. Grant et al. [68] explain that service providers should work in partnership with families, encouraging an empowerment approach that harnesses family strengths. They also underline the importance of providing psychoeducation to increase understanding of suicide, normalize the experience, renew a sense of hope, and help develop coping skills. An article examining evidence-based interventions for youth suicide risk highlights the need for clinicians to provide tailored psychoeducation to both youth and caregivers [69]. The authors emphasize the importance of addressing symptoms and specific risk factors for suicidal and self-injurious behaviours that are relevant to the youth’s individual needs, explaining that targeted psychoeducation can foster a more nuanced understanding of suicide risk among both youth and caregivers.

A final important finding to highlight is the experiences of bullying, racism, and discrimination among many of the youth who died by suicide, coupled with a perceived lack of accountability, as reported by the parents. Most parents described their youth experiencing bullying at some point before the suicide, with one case occurring immediately beforehand. A study conducted in Ontario found that 77% of youth presented to emergency with suicidal ideation had experienced bullying, and children who were bullied were 19 times more likely to have suicidal ideation than youth who had not experienced bullying [70].

Sexual and gender minority youth (SGMY) experience higher levels of childhood adversity [71, 72], victimization, rejection, and discrimination, and are also at increased risk of suicide [6, 73, 74]. Researchers and community organizers have identified several key priorities for suicide prevention for SGMY. Specifically, creating and leveraging safer, affirming spaces [6, 75, 76], reducing barriers to mental health services, supporting community-based interventions, and delivering evidence-based interventions tailored to SGMY identities, experiences, and mental health needs [77], can reduce the risks of suicide [8]. Kelleher et al. [78] found that healthcare professionals in emergency departments lacked confidence in their basic knowledge of SGMY health disparities and in their preparedness to provide care for this population.

In our study, experiences of racism also emerged, reflecting broader disparities affecting youth from underrepresented ethnoracial groups. Alvarez et al. [79] explain that addressing structural racism is essential to preventing suicide among ethnoracially minoritized youth. They developed a framework showing how structural racism shapes inequities in service access, school discipline, and crisis response (including law enforcement), and call for strategies at the macro, meso, and micro levels. In Canada, suicide disproportionately impacts Indigenous populations and is increasingly understood as a social response to systemic racism, marginalization, and ongoing trauma [80]. Indigenous community members and scholars advocate for suicide prevention and life promotion grounded in Indigenous ways of knowing and being, culture-based interventions, a focus on strengths, and a wholistic approach to wellness that fosters a sense of hope, belonging, and purpose [80, 81].

Strengths and limitations

The study has a few limitations that should be considered. The findings reflect the perspectives of parents who participated and may not be fully representative of other caregivers or families who have experienced the suicide of a young person. For example, parents who participated may have been more comfortable sharing their experiences, which may limit the transferability of the findings to those who chose not to engage with research.

Despite these limitations, the study has several strengths. We used thick description to generate in-depth insights into the experiences of parents navigating systems of care after the suicide of their child, offering valuable knowledge to inform service improvements and prevention efforts. To enhance the trustworthiness of the findings and minimize potential researcher bias, we employed multiple strategies, including investigator triangulation, reflexive memoing, and weekly team meetings to critically discuss interview content and interpretations throughout the research process.

Conclusion

This study highlighted how the needs of youth who died by suicide, as described by bereaved parents, were not met by the systems of care in Ontario. Parents expressed deep frustration with the many gaps and barriers in services yet also maintained hope for change. The findings have important implications for policy, services, education, and training. Researchers, parents, and clinicians have called for a full redesign of the system in Ontario [28]. A provincial policy report recommends a “systems of care” approach, describing a comprehensive network of integrated, child- and family-centred services across sectors, with emphasis on early intervention, school-based programs, support during transitions, and service provider training [28]. At the national level, the 2024 release of Canada’s first suicide prevention action plan is a promising step [82]; however, its effectiveness will depend on adequate implementation, including sustained funding, clear roles, cross-sector collaboration, and strong political leadership [83, 84].

Epilogue: A message of hope for parents

Life is a process. We learn, we grow, we share burdens, we adapt, we find strength based on adjustments, and we reshape our values. Grief is a journey through our defenses, through that instant in time that changes the course of our lives forever, toward facing our new lives, our new normal. We are blessed with the phenomenon of resilience and the ability to heal. Take the hand of strength; begin the practice of giving yourself permission to choose what is positive, as this practice will take root and bloom. This is the process of moving towards healing, and moving away from the process of mourning, a prelude to discovering who you might become. Once we open the door, even a crack, this is the time to say, “How can I move forward across this threshold?” As survivors of suicide, we are capable of reshaping our lives. Every day we are given the possibility of moving mountains in honour of our loved ones who have gone too soon. We learn that we can channel our grief into a positive force. We can turn tragedy into transformation and loss into legacy. This is post-traumatic growth. May your child’s memory be a blessing.

— David and Deborah Cooper, suicide loss survivors following the loss of their son, Eli.

Abbreviations

BFO

Bereaved Families of Ontario

CASP

Canadian Association for Suicide Prevention

ED

Emergency department, emergency, emerg

LGBT

Lesbian, gay, bisexual, trans

P

Parent

PHAC

Public Health Agency of Canada

PI

Principal investigator

RA

Research assistant

SGMY

Sexual and gender minority youth

SP

Service provider

SPI

Safety planning intervention

SMT

Suicide risk monitoring tool

TRC

Truth and Reconciliation Commission

WHO

World Health Organization

Author contributions

Each author made substantial contributions to the conception and design of this work. TK and EL conceived of the study and all other authors provided feedback on the design. TK, JJ, and CKYL were involved in recruitment and data collection. TK, CKYL, and JJ conducted data analysis and all authors contributed to the interpretation of the data. TK wrote the initial draft of the paper and all authors provided substantial contributions to the revisions of the manuscript (DC, DC, SC, EL, JJ, CKLY, R-NT, JS, MJ, JZ). All authors reviewed and approved the final submitted manuscript (TK, DC, DC, SC, EL, JJ, CKLY, R-NT, JS, MJ, JZ).

Funding

This study was funded by an Insight Development Grant (IDG) from the Social Sciences and Humanities Research Council (SSHRC), with additional support from the Presses de l’Université Laval (PUL) for the dissemination and promotion of research findings.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

All procedures performed in studies involving human participants were in accordance with the ethical standards of the Research Ethics Board at the University of Toronto (protocol # 42006) and the Comités d’éthique de la recherche avec des êtres humains de l’Université Laval (protocol #2023 − 294). Informed consent was obtained from all participants included in the study.

Competing interests

The authors declare no competing interests.