Biruk Silvers, a 17-year-old boy, died Nov. 5, 2024, at Discovery Ranch. Court documents filed by Kathryn and Joshua Silvers allege in the days leading up to his death, Biruk disclosed plans of self-harm to his medical caretakers and participated in a dangerous asphyxiation game, but was never placed on suicide watch, was permitted to keep a belt in his possession and was left alone for extended periods of time despite experiencing a mental health crisis.

The lawsuit is being filed against Discovery Ranch, the University of Utah, Redcliff Ascent Inc., Pilcrow Advisors, individual therapists and nurses at Discovery Ranch and a University of Utah psychiatrist.

According to court documents, the Silverses complied with the Utah Medical Malpractice Act prelitigation requirements and received a meritorious finding against all the defendants. The family is demanding a trial by jury.

“This is one of the most egregious cases of negligence we’ve seen in a youth treatment setting,” said Alan Mortensen, attorney for the Silvers family. “The system utterly failed Biruk. He asked for help. He described his plan to die. And those responsible for protecting him did nothing.”

Randy Spencer, the attorney representing Discovery Ranch in the case, provided a response to the suit being filed to the Daily Herald on Friday:

“Discovery Ranch would like to express its deepest sympathies to the Silvers family for the loss of their son and sibling, Biruk,” Spencer said. “Discovery Ranch received a copy of the Silverses’ complaint yesterday and is in the process of reviewing it with its legal counsel. Discovery Ranch disagrees with many allegations made against it by the Silvers. However, it’s unable to comment more specifically due to the ongoing litigation which the Silvers have now initiated. Discovery Ranch looks forward to addressing these allegations as part of the litigation process. It will also continue to support its current residents and dedicated team as it navigates this unfortunate event.”

Court documents filed by the Silverses state Biruk was admitted to Discovery Ranch for therapeutic treatment to address struggles with depression, suicidal ideation and trauma on April 17, 2024. The Silverses said Discovery Ranch was recommended to them by Pilcrow Advisors, a consulting practice that specializes in helping parents find educational and therapeutic placements for their children.

In September and October of 2024, the Silverses claim Biruk’s mental health was worsening, and on Oct. 14, a staff member allegedly told the family he was “very depressed.”

Biruk was started on a new medication Oct. 18, Lexapro, that may heighten a person’s risk of suicide, court documents said.

The suit claims reports from a University of Utah psychiatrist show Biruk shared a self-harm plan during a remote appointments on Oct. 23, but that the doctor did not share the information with the Silverses or initiate one-on-one supervision.

The Silverses also said they expressed concerns to Biruk’s Discovery Ranch therapist about his mental state and his participation in a dangerous asphyxiation activity, but the concerns were “minimized.”

The therapist did not review the initial psychiatric reports, the suit claims, and was unaware of Biruk’s suicide plan until Nov. 4, when he signed off on the psychiatrist’s report.

The court documents allege Biruk met with the University of Utah psychiatrist again Nov. 1 and disclosed self-harm plans and plans to possibly harm others, but no immediate measures were taken such as alerting law enforcement or immediate intervention.

Kathryn Silvers scheduled a follow-up appointment with the psychiatrist, but it was canceled because he reportedly stated that there was “no acute concern requiring a meeting,” the suit said.

On Nov. 4, court documents state the Discovery Ranch therapist reviewed Oct. 23 and Nov. 1 notes from Biruk’s psychiatrist, and had Biruk complete a suicide severity risk assessment and his score was classified as “moderate severe” risk of self-harm.

The Silverses allege the therapist did not notify the family, call law enforcement, place Biruk in one-on-one supervision or ensure his belt was taken away.

On Nov. 5, Biruk died by strangulation from a belt that the Silverses said was “either provided by or allowed by (Discovery Ranch) for Biruk to possess, while Biruk was left alone with no staff present,” the documents said.

The suit added: “Biruk died either by the plan of self-harm that he had explicitly disclosed to his psychiatrist, therapists and registered nurses just days earlier, or by playing a self-harm game that is known to be extremely dangerous and harmful and which (Discovery Ranch) and the other defendants had been aware of for almost two weeks.”

A Nov. 6 inspection by the Utah Department of Health and Human Services found Discovery Ranch was noncompliant of the following rules: “Services and supervision to meet each clients needs;” “provider shall protect clients from abuse, prevent abuse;” “suicide prevention policy;” and “critical incidents reporting requirements.”

Discovery Ranch was placed on a conditional license by the Utah Department of Health and Human Services but has since been reinstated, and has been found in compliance by the Utah Department of Health and Human Licensing and Background Checks, and licensing rules, a department spokesperson confirmed.