That’s an easy one.

A gamut of systems— health, school and society—failed Prashant Tiwari.

Trapped in an abyss of darkness and hopelessness, Prashant probably felt he had no choice, but to finish the task he had set in motion a few days earlier when he grabbed a knife and stabbed himself repeatedly on the torso, neck and other parts of his body.

At that time, he could have harmed himself fatally; but instead he reached out in despair and asked his father for help. In the ER, Prashant clung on to a weak thread of hope and placed his trust— and life — on a team of professional all sworn on the Hippocratic oath.

On June 26, at approximately 2 a.m., the 20-year-old — who was supposedly on a suicide watch at Brampton Civic Hospital (BCH) — removed his clothes and fashioned a noose around his neck. He then climbed on to a chair and proceeded to hang himself from a vent in the washroom. His body was discovered three hours later.

A retired nurse that I spoke to recently expressed surprise at the circumstances surrounding Prashant’s death. Apparently, patients placed on suicide watch cannot wander into the washroom, unsupervised. How’s it that, she wondered, for three hours no one bothered to check on a high-risk patient who had few days earlier slashed himself and needed multiple stitches?

I’m certain, it must not have been easy for Prashant’s still-grieving family to revisit and share details of his life and death. Yet they did.

The raw grief on their faces as they talked about him was heartbreaking. Both Rakesh (dad) and Gautam (brother) talked candidly without sugarcoating the truth because they want Prashant’s story to be a lesson and a wake-up call for families nursing a relative with mental health issues.

“No child or a human being wants to die,” said a distraught Rakesh. “It’s only when you experience total hopelessness or have a mental illness where you have no control over your own actions that the idea of death and dying will come to your mind. Prashant was a disturbed child who reached out to authorities in his school, his guidance counsellor and in the last few days of his life to the healthcare professionals. No one helped him…”

Prashant, a child of divorce, for some odd reason blamed himself for the fracturing of his parents’ marriage. He carried guilt, truckloads of it.

As the drama of life unfolded in the Tiwari household with custody battles and divorce proceedings, a young bewildered child unwittingly became the collateral damage in the saga of life. He was four-years-old or even less when the world stopped making sense.

Following the divorce, Prashant went to live with his mother, but somehow a few years later, he ended up in the foster care system.

Try and imagine the confusion of a young innocent child trying to come to terms with abandonment and rejection. The effect of his turbulent childhood soon began to manifest.

Prashant was troubled and exhibited behavioural problems typical of a child that had seen more than its share of upheavals. Labeled a troublemaker, he was suspended numerous times for his difficult behavior and later for smoking pot.

In Grade 10, Prashant turned into a new leaf. He became a peer leader at school and was active in sports. The insidious demon that was depression surfaced every now and then, but the resilient young man fought bravely.

He told Rakesh that he had sought help from his guidance counsellor and his principal. He criticized the school for not doing enough to help students like himself exhibiting signs of mental health issues.

If we are looking for irony, how’s this? Prashant graduated from Mississauga Secondary School in 2012. A year before that, the school made headlines when a gruesome incident of murder-suicide involving a student occurred.

Akash Wadhwa, 16, jumped to his death (from the Hwy. 401 overpass near Mavis Road), after murdering fellow student, Kiranjit Nijjar.

Much like Prashant, Akash suffered from depression. As news of Akash’s and Kiranjit’s deaths rocked the school and the community, Prashant felt the school had let Akash down.

Prashant’s death has unearthed a can of crawling worms.

He was on a suicide watch, so why was he left unsupervised? What was a chair doing in the washroom? Why was the hospital initially reluctant to conduct an internal autopsy? And more importantly, why are the circumstances surrounding his death still cloaked in secrecy?

In my next blog entry, I will reveal details of Prashant’s life leading up to his death including chatting with his friends. Stay tuned.