Editor’s note: This story discusses suicide. If you or people you know are at risk of self-harm, the National Suicide Prevention Lifeline provides 24-hour support at 1-800-273-8255.

A Utah youth residential treatment center will not be disciplined by state regulators after a teen girl from Bermuda died by suicide there last November.

West Ridge Academy was under investigation with the state’s licensing agency for about four months before the Department of Human Services’ Office of Licensing closed its case in March.

It found that the treatment center did violate one rule — that a staff member who was watching the girl should not have been outside the bathroom when she attempted to end her life. But no disciplinary action was listed in documents released recently in response to a records request.

The investigation was a disappointing result for the girl’s mother, who asked not to be identified to protect the privacy of her younger children. Her daughter, Kirsta, was supposed to get help at West Ridge Academy. But they failed her, her mother said.

“To know that my baby girl died in such a horrific manner is heartbreaking,” she said. “To know there was no one held responsible is a slap in the face. Her death may have been self-inflicted, however, she was supposed to be monitored to prevent this outcome.”

The 17-year-old girl had been sent to the facility by Bermuda’s child welfare system. She struggled there, according to police reports. She told staff members that she felt like no one loved her, and she had been harming herself.

Kirsta had been on suicide watch in the days before her death, according to a police report, but she was allowed to have 10 minutes of privacy to shower.

When a staffer told her that her shower time was up one Thursday afternoon, Kirsta reportedly asked to go to the bathroom. She was given an extra two minutes. That’s when she hanged herself.

State regulators found that the male staff member who was watching her was conducting “verbal check-ins” that day, but was outside the bathroom — which violated the facility’s policies.

The facility’s handbook for suicide watch states: “You will always be within arm’s length of staff, except while toileting or showering. Staff will be in the bathroom during these times and you will maintain frequent verbal check-ins with staff.”

Investigative documents say the handbook has been updated, and the state licensing worker expressed no other concerns in documents released to The Salt Lake Tribune. The West Jordan detective didn’t seem worried about foul play, the report reads, and the medical examiner ruled Kirsta’s death a suicide.

“No further action required,” the report states.

Janet Farnsworth, the executive director of West Ridge Academy, said she couldn’t speak specifically about Kirsta’s death, but said the facility sends “heartfelt concern” to her grieving family.

“At West Ridge Academy, safety for our students is a top priority and we regularly engage in continuous improvement exercises assessing and reassessing our protocols to ensure that we are attending to the very specialized and acute needs of our clients,” she said. “We appreciate the thorough review that was conducted by the DHS staff, and continue to work closely with our licensor.”

(Rick Egan | The Salt Lake Tribune) West Ridge Academy in West Jordan, Wednesday, Jan. 22, 2020.
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Farnsworth has said previously that her facility has spent “a significant amount of time” reviewing policies after Kirsta’s death, and trained and debriefed their staff. She said the girl’s death did not prompt changes in their treatment methods, but they did make changes to how they respond during crisis events. They’ve changed the way they decide which students require more supervision for their safety, she said, and also added more lighting and signage across the campus to better assist emergency workers when they are called.

Kirsta’s mother said she hasn’t received any communication or condolences from West Ridge after her daughter’s death, calling that lack of communication a “disgrace.”

“Where is the accountability?” she said. “I am deeply appalled by how this matter is being handled.”

Utah’s licensing agency oversees 3,000 facilities, everything from treatment centers for both kids and adults and foster care agencies.

The last time it publicly took action against a youth facility was a year ago, when it threatened to yank the license for Red Rock Canyon School in the aftermath of a riot, child abuse allegations and sex abuse charges.

Sequel Youth and Family Services, which owns the St. George facility, ultimately opted to close Red Rock Canyon School last summer.

Bermuda, a British island territory deep in the North Atlantic Ocean, has spent more than $8 million in the past five years sending 40 children in its foster care system to Utah “troubled teen” facilities. West Ridge Academy received nearly $850,000 of that money, according to data from Bermuda officials.

The Bermuda government wrote in a public statement in December that sending a youth overseas is not a decision taken lightly and is only done “after all other resources locally are exhausted.” Local resources, they say, include family, counselors, psychologists, psychiatrists and other family intervention programs. They further stated that removing a child from their home and placing them in DCFS care, like Kirsta was, is only done as a “last resort.”