The B.C. Coroners Service has confirmed 16-year-old Gwyn Kenny-Staddon died in a Port Moody Starbucks washroom from an accidental overdose of heroin and fentanyl.
Coroner Adele Lambert says toxicology tests found heroin, a lethal level of fentanyl and the anti-anxiety drug alprazolam, also known as Xanax.
The syringe located near her body was found to contain heroin, fentanyl, caffeine and trace amounts of cocaine.
In her report, Lambert outlines how school staff first became concerned about Kenny-Staddon in 2012 and contacted the Ministry of Children and Family Development about the girl's behaviour.
It was around the same time the then-12-year-old had started experimenting with drugs according to the report. By 2015, she was a regular user of heroin and fentanyl.
Kenny-Staddon was "referred to a variety of treatment options, including an in-patient detox program and the use of opioid substitution therapies" but "was frequently reluctant to participate in any of the programs."
The MCFD also offered Kenny-Staddon alternative living options, however she elected to stay with her family.
"The representative for children and family development had also been requested to be involved as an advocate, but it is not known what services were provided," wrote Lambert.
The report makes a single recommendation that the MCFD "consider conducting a comprehensive review of the services provided to Gwynevere Joan Kenny-Staddon with a view to improving services and outcomes for children in the province of British Columbia."
Veronica Staddon, Gwyn's mother, told CBC News that her daughter needed rehab, but the public wait-lists were too long and the family couldn't afford $50,000 for a private clinic.