Full Breakdown
Coroner's Inquest into Brandi Clarke's Death Yields Key Recommendations
11/28/2025, 10:55:55 AM
Overview of the Inquest
The coroner's inquest into the death of Brandi Clarke, a 25-year-old woman who died from diabetic ketoacidosis while living in a transitional housing program run by the Canadian Mental Health Association (CMHA), concluded after three days of testimony. The inquest, which took place in March 2023, resulted in eight recommendations aimed at preventing similar tragedies in the future.
Circumstances Surrounding Clarke's Death
Brandi Clarke was living at CMHA's Notre Dame Place in Summerside, Prince Edward Island, when she passed away on March 19, 2023. Staff discovered her unresponsive in her room after she failed to appear for her usual afternoon smoke break. Paramedics pronounced her dead at the scene, with the cause of death identified as diabetic ketoacidosis, a condition resulting from insufficient insulin. The inquest revealed that Clarke's blood-sugar levels had only been monitored twice in the four months leading up to her death.
Recommendations from the Jury
The jury's recommendations, directed at the CMHA, include the following measures:
1. Develop policies for clients with severe medical conditions unrelated to mental health.
2. Provide training for staff on managing such medical conditions or restrict admissions for clients with these illnesses.
3. Conduct team meetings when clients transition between facilities.
4. Ensure comprehensive sharing of client information among all staff.
5. Implement formal training and onboarding for new staff members.
6. Assess the skills of clients before they move to independent living.
7. Place clients in independent living on a probationary period.
8. Maintain ongoing supervision for clients deemed to require additional support.
Perspectives from Inquest Participants
During the inquest, staff from both the Summerside and Charlottetown facilities provided differing accounts of Clarke's capabilities. While Summerside staff described her as a complex client requiring more oversight, Charlottetown staff noted her claims of independence. The inquest also highlighted the informal training received by frontline workers, raising concerns about their preparedness to handle complex cases like Clarke's.
Heidi Clarke, Brandi's mother, expressed her desire for systemic changes to prevent future incidents, stating, “I'm just calling for some change in the future so that it doesn’t happen to someone else.”
Official Responses
The CMHA's legal representative emphasized that the organization does not operate healthcare facilities and asserted that Clarke was an autonomous resident receiving care from external providers. Health P.E.I.’s lawyer noted the collaborative care team surrounding Clarke, which included her psychiatrist and diabetic nurse educator, all of whom had her consent to communicate.
Next Steps
Chief Coroner Dr. Brandon Webber will present the jury's recommendations to the provincial justice minister and other relevant parties. He is expected to follow up on the implementation of these recommendations in one year, aiming to enhance the safety and care of clients in similar transitional housing programs.
