SOMBA K'E/YELLOWKNIFE - Stanton Territorial Hospital won't review a coroner's report on the death of a 20-year-old Yellowknife man who overdosed on antidepressant medication prescribed by a doctor at the hospital unless the hospital receives recommendations from the territorial government first, says the hospital's CEO.

Kay Lewis, CEO of Stanton Territorial Hospital, said she hasn't seen the report signed by NWT deputy chief coroner Cathy Menard, which was released to the public March 11. The report found that the man died Feb. 1, 2009 from an overdose of Venlafaxine, a popularly prescribed antidepressant commonly known as Effexor.

Lewis said she won't look at the report unless she is given direct recommendations from the Department of Health and Social Services.

"We may eventually get them; it would be dependent upon if it was policy or it impacts operational care," said Lewis.

The Inuvialuit man, who was living in Yellowknife before his death, had a history of alcohol abuse and previous suicide attempts. He had gone to Stanton Hospital that day with an empty bottle of Venlafaxine, an antidepressant he had been prescribed less than a month prior to his death. During a medevac flight to Calgary for further treatment, he suffered cardiac arrest, which forced the flight to divert to Edmonton, where he died shortly after.

A toxicology report revealed the man had a fatal dose – 59 times the therapeutic level - of Venlafaxine in his blood stream.

Garth Eggenberger, chief coroner for the NWT, said the man shouldn't have been given such a large amount of medication, and said his office is troubled over the use of the drug for patient care.

Phil McNeil, the Yellowknife man who's skeletal remains were found near Con Mine seven months after his disappearance in October 2008, was prescribed Effexor by his psychiatrist two days before he went missing.

Eggenberger has recommended changes to the territory's Mental Health Act to help improve the capacity of the health care system to assist patients struggling with mental illness and suicidal tendencies.

Lewis said the problems are not just with how the hospital deals with mentally ill patients, but with the entire system itself.

"You get into capacity issues that are there," she said of the hospital's limited ability to handle mental health issues.

"We do have concerns about the full continuum of care and the follow-up in the community so that people don't fall through the cracks. We're looking at how we can strengthen that as we admit people and discharge them. It's not one thing overall."

In the month leading up to his death, the man had attempted suicide three times, all while intoxicated – once by cutting himself, the other two by drug overdose. He was given a three-month prescription, 90 tablets, for Venlafaxine after he was released from the hospital on Jan. 4, 2009, the first of three admittances that month.

While the company which makes the medication, Wyeth, states on its website the drug needs to be closely monitored when first prescribed, Lewis said it's not uncommon for a physician to give a three-month prescription to a patient.

"In some circumstances it's quite normal," she said. "I don't prescribe medication. It all depends on where you live. In the communities you may not have as good of access."

Three recommendations were made to the GNWT; the first was for prescriptions be given in smaller amounts. The report also recommended plain-language warnings for the side-effects of using antidepressants, and for the establishment of a detox centre.

Officials with the Department of Health and Social Services told News/North last Friday it would be ready to comment on the report by sometime this week, but when contacted on Tuesday, Damian Healy, spokesperson for the department, said health officials won't comment until next week.

"A couple of the recommendations are clinical so we need to review those with clinical professionals," said Healy, adding the department has no plans to open a detox centre in the NWT.

"A detox centre is not necessarily the answer," he said.

Sandy Lee, minister of Health and Social Services, would not comment on the report.

Lewis did say recommendations have been made for changes to how long people can be kept at the hospital for a mental health assessment – currently a maximum of 24 years – but said it's not going to be easy to change.

"They're fairly complex situations and people do have their