Report to the Minister of Justice and Attorney General Public Fatality Inquiry

Transcription

1 CANADA Province of Alberta Report to the Minister of Justice and Attorney General Public Fatality Inquiry Fatality Inquiries Act WHEREAS a Public Inquiry was held at the Calgary Courts Centre in the City of Calgary, in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 17th day of March, 2016, (and by adjournment year on the 18 th day of March, 2016 and April 29, 2016) year before Joanne Durant, a Provincial Court Judge, into the death of Lianjie Ma 49 (Name in Full) (Age) of # Oakmore Drive SW Calgary, Alberta and the following findings were made: (Residence) Date and Time of Death: Found deceased on July 12, 2014 Place: Glenmore Reservoir, Calgary, Alberta Medical Cause of Death: ( cause of death means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization The Fatality Inquiries Act, Section 1(d)). Drowning Manner of Death: ( manner of death means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable The Fatality Inquiries Act, Section 1(h)). Suicide

2 Report Page 2 of 13 Circumstances under which Death occurred: Background: At the time of his death, Lianjie Ma (Ma) was a 49 year old married man, father to an adult son, and living in the city of Calgary, Alberta. He worked as a contract analyst for AltaGas. On April 26, 2014 Ma travelled to China to assist with the care of his ailing father. Ma s father died on May 1, By May 3, 2014 Ma had begun exhibiting some very unusual behavior and appeared to have suffered a psychotic episode during which he tried to strangle the driver of a cab in which he was a passenger. Ma was admitted into a psychiatric hospital in China and diagnosed with acute psychosis. Ma remained in hospital until May 16, 2014 during which time he was treated with Zyprexa and a Chinese herbal antidepressant. Ma returned to Calgary following his discharge from hospital and immediately returned to work. Ma reported that he felt well and asked his Dr to decrease his medication. He also stopped taking the herbal antidepressant. Ma began to decompensate and despite efforts by his family physician to increase his medication, his deterioration continued. On June 12, 2014 Ma attempted to strangle both his wife and himself. Ma s wife was able to contact the Calgary Police Service (CPS) and Ma was apprehended pursuant to a Form 10 of the Mental Health Act (MHA) as Cst Veerasammy was satisfied that Ma presented both a danger to himself and to his family. Cst Veerasammy transported Ma to the Rockyview General Hospital (RGH) where he was treated by an emergency room physician and admitted pursuant to a Form 1 (MHA) since he presented as being both suicidal and homicidal. Ma specifically stated he wanted to jump in the Glenmore reservoir located immediately adjacent to RGH. On June 13, 2014 Ma was transferred into the care of Dr Jack Chu (Dr Chu) who issued a second Form 1 certifying Ma as a formal patient for a 30 day period. As a result, Ma was admitted to Unit 49 at RGH which is a secure mental health unit. Ma continued to be under the care of Dr Chu and nursing staff (details below) until he left the unit without permission on June 19, Extensive efforts to locate Ma were unsuccessful. His body was found in the Glenmore Reservoir on July 12, Prior to reviewing the evidence heard at the Inquiry, it is important to distinguish between a patient being away without leave (AWOL) from the hospital and a patient eloping from the hospital, as those terms were used frequently during the course of the evidence. It is clear that while an individual may be certified under the MHA and required to stay in the unit, a patient can earn privileges to leave the hospital for short periods of time if the attending physician believes it is safe to allow the patient to do so. These off unit privileges can involve simply permitting a patient to go outside to have a cigarette or indeed can permit a patient to go for a walk on the hospital grounds. A patient who does not return to the unit following an approved off unit break is considered AWOL. A patient-like Ma-who has no off unit privileges but escapes, is considered to have eloped from the hospital. Once a patient is noted to be missing from the unit, a Code Yellow is announced with specific duties assigned to various staff members to commence the search for the patient. Ultimately, if staff members at the hospital are unable to locate the patient, CPS is contacted to assist with the search.

3 Report Page 3 of 13 Inquiry Evidence: 5 witnesses were called to provide evidence during the course of the Inquiry. Ma s family did not seek standing at the Inquiry nor did they attend. Dr Jack Chu: Dr Chu was Ma s attending psychiatrist following Ma s admission pursuant to the Form 1 to RGH. He took over Ma s care as of June 13, After meeting with Ma on that date, as indicated above Dr Chu issued a second admission certificate (Form 1) which authorized the detention of Ma on Unit 49 (the secure mental health unit) at RGH for assessment and treatment for an additional 30 days. That certificate was set to expire July 13, Dr Chu testified that after meeting with Ma and his family and being apprised of the background detailed above, he was satisfied that Ma had suffered a psychotic episode coupled with major depression. He also noted some mixed features of manic episodes accompanied by anger and irritability. After having reviewed the risk assessment completed upon Ma s admission, Dr Chu considered Ma to be a high risk of elopement and self- harm, and as such he ordered that Ma be checked every 15 mins (Q 15) by nursing staff, and that he remain dressed in hospital clothing. Dr Chu testified that requiring a patient to wear hospital clothing minimizes the risk of self- harm for patients since there are no pockets where items can be hidden. Dr Chu testified that only when a Dr determines it is safe is a patient permitted to wear his/her own clothes. Further, Dr Chu testified that Ma was not permitted to leave the unit unaccompanied for any reason. Dr Chu continued to treat Ma over the following 6 days with anti-psychotic medication, noting there seemed to be some small improvement in Ma s condition. Ma appeared to be sleeping better, his affect was not quite as flat and he did not appear to be as consumed by hopelessness or have as many feelings of self- harm. However, at times Ma still became very agitated and anxiety ridden. For example, on the morning of June 18, 2014 Ma became very agitated and was banging his head on the nursing station. Dr Chu prescribed Ativan and Seroquel as needed when Ma was in this kind of agitated state-often in the mornings. These two drugs seemed to provide considerable relief for Ma once they were administered. Dr Chu testified that Ma s antipsychotic medication had to be changed due to an increase in cholesterol as a result of the initial medication prescribed, and that he slowly began to introduce an antidepressant medication as well. Dr Chu reassured Ma and his family that his condition was treatable and testified that Ma seemed happier after his family had visited. Dr Chu changed the orders such that Ma could be checked every 30 mins during the night and as of June 17, 2014 permitted him to wear his own clothing. He was however still to be checked every 15 mins during the day and he was still not permitted any off unit privileges. On the morning of June 19, 2014, Dr Chu saw Ma briefly prior to a weekly conference. Ma indicated that he was feeling really good and that he was cured. Dr Chu testified that when he saw Ma he did not have any concerns and that Ma s subsequent elopement from the unit was totally unexpected. Dr Chu testified that everyone knew that he was not to leave and surmised that perhaps Ma escaped with a group of other patients. Dr Chu testified that there is a whiteboard at the nursing station with the names listed of all patients in the unit. The names of the patients are colour coded which indicates whether a patient has off unit privileges or not. When asked if Dr Chu could offer any recommendations for the Inquiry, Dr Chu testified that it was not possible to make a psychiatric unit into a maximum security facility. He testified that it was difficult to balance the dignity and freedom of the patients with the need for security. Dr Chu also testified that photos were not taken of the patients due to what he believed to be a privacy issue.

4 Report Page 4 of 13 Cst Josef Chudy: Cst Chudy (Chudy) is a member of the CPS and has been so employed since He is assigned to District 6 and as such was dispatched to the missing person call involving Ma. Chudy testified that he attended to Unit 49 and was given a Form 3 pursuant to the MHA filled in by hospital staff which provides police the authorization to return a patient certified under the MHA to the hospital. In accordance with hospital protocol, Chudy was provided with Ma s personal description, family contact information and medical status. This information assists police in determining what level of urgency or danger a missing person could present either to him/herself, to police, or to a member of the community. Chudy searched Ma s personal items in his room looking for any information which might assist him in determining where Ma may have gone. He testified that there was nothing located in Ma s personal items that could assist. Chudy contacted the CPS Real Time Operation Centre (RTOC) to access additional information. Homeless shelters and the LRT transit security were contacted so that surveillance could begin through cameras on transit platforms. Since Chudy had information from the hospital that Ma was suicidal and homicidal, he immediately went to Ma s home address to advise Ma s wife and son that he had left the hospital. Chudy testified that he was told Ma had no wallet or credit cards with him but asked that Ma s wife monitor their bank account and advise if any transactions occurred that she had not made. Chudy also notified HAWC (the CPS helicopter) and requested that a search be conducted of the reservoir given the information that he had been provided from Ma s risk assessment that he wanted to commit suicide by jumping into the reservoir. Chudy also asked the hospital security staff to conduct a search of their CCTV cameras to determine if Ma had been seen leaving the hospital. Chudy testified that Ma was not seen leaving the hospital on CCTV surveillance and as such he surmised that Ma had left via an emergency exit and the downstairs maintenance bay which is not covered by CCTV cameras. Chudy testified that he advised the security personnel at nearby Heritage Park about Ma s disappearance and also involved the CPS Mountain Bike unit to ensure nothing had been missed in attempts to locate Ma. Chudy testified that he had a bad feeling about Ma s disappearance. After some time had passed without locating Ma, Chudy testified that DNA samples were obtained and forwarded to Detectives in case a body was ultimately recovered. Chudy testified that since the file remained open, HAWC was again dispatched to search the reservoir and other investigative steps were repeated, but to no avail. Chudy was advised when Ma s body was located July 12, 2014 in the reservoir. Chudy testified that Ma s disappearance was far from the first situation of its kind in which he had been involved regarding a certified patient leaving Unit 49 at RGH. Chudy testified this was also the second incident in which he had been involved where a patient was subsequently located deceased in the reservoir but that he was aware of at least one additional patient with the same outcome. Further he testified that although these are the extreme cases he is aware that there are on average 3-4 certified patients reported missing by RGH per week. Chudy testified that although he appreciates that the hospital is not a jail, these patients have been certified for a reason-specifically because the patient has been assessed by a Dr as being a risk to either him/herself or others- and therefore expressed significant concern about possible unpredictable behavior by these patients placing officers and members of the public at significant risk. Chudy testified that he has spoken many times to hospital staff and managers in attempts to try and stem the tide of this exodus from Unit 49 but for a variety of reasons his efforts have not been successful. Chudy testified that trying to locate these missing persons from RGH is a huge issue for CPS and results in a significant drain on resources. Chudy testified that in the last 5 years a form has been developed which provides CPS with a description of the patient as well as information as to

5 Report Page 5 of 13 why the patient was certified. Chudy testified this latter information is essential since knowing what medication the patient has been prescribed will also help CPS predict a patient s behavior and the risk to the safety of the patient and members of the community can be better assessed. Chudy testified that despite this form being created, there are times the hospital will still refuse to provide this information due to privacy concerns. When asked what recommendations he would make to assist the Inquiry, Cst Chudy suggested the following: 1. A photograph be taken of a certified patient upon admission which could be provided to CPS in the event that a Form 3 is completed. The photograph could be destroyed once the patient was located. 2. Security staff be required to escort patients outside when they are permitted to leave the hospital for cigarette breaks; 3. GPS bracelets (or similar tracking devices) be used when a patient is admitted to Unit 49 to allow them to be quickly located if they leave the hospital without permission Eric Sampson Mr Sampson (Sampson) is the program manager for all mental health services for RGH. While he was not working at RGH at the time of Ma s disappearance, it was clear that he has extensive experience working in adult inpatient mental health facilities and indeed had worked either as a psychiatric nurse or the unit manager on Unit 49 for some 11 years prior to working for a short period of time at the South Health Campus (SHC). This particular time frame at SHC coincided with the time in which Ma was an inpatient at RGH and so as such, Sampson was not present at RGH when Ma eloped. Sampson was able to detail both the staffing levels of Unit 49 as well as the physical layout of the unit -a diagram of which was marked as Exhibit 5 in the Inquiry. Addressing first the physical layout of the unit, there are two sets of locked doors which access Unit 49. One set of doors leads directly into a different unit (ie not directly to exit doors or public elevators) and therefore was not the main focus of this Inquiry as it was not believed to have been the route Ma took to leave the unit. The second set of locked doors-and really the main entrance to the unit-has camera surveillance which is to be monitored by the Unit Clerk (or an RN in the absence of the Unit Clerk) who is located at the nursing station some significant distance away from the actual doors. There is no direct line of site from the nursing station to this door. Access to the locked unit is by either a swipe pass which unlocks the door or by pushing a buzzer which notifies the Unit Clerk that someone wants in or out of the unit. The Unit Clerk then presumably identifies the person at the door as being one of a multitude of individuals who is permitted to either enter or exit the unit and pushes a button which releases the lock on the doors. The doors open and close automatically but do so quite slowly. Sampson testified that staff are supposed to watch to make sure that no one enters or exits the unit with them without authorization, and that the Unit Clerk-in addition to numerous other duties-is to also watch the camera to ensure the same. Sampson testified that the unit is staffed during the day by 7 Registered Nurses (RN) or Registered Psychiatric Nurses (RPN), 1 Licensed Practical Nurse (LPN) and a Unit Clerk. These are the front line staff responsible for the direct care of the patients. In addition to these front line workers, at various other times of any given day, other staff may be on the unit including-but not limited to-doctors, social workers, occupational therapists, physio therapists, lab technicians, Code teams, porters, food staff, delivery people, family members/visitors of the patients and janitorial/cleaning staff. The nurses are required to monitor their assigned patients, provide medication, carry out any orders given by the Doctors and document their observations in the online system-sunrise Clinical Manager- for each of their assigned patients. Nurses are also

6 Report Page 6 of 13 required to cover off one another when a nurse is on a break. Sampson testified that Unit 49 is usually functioning at 110% capacity with 33 patients being the norm. Each RN is assigned between 4-5 patients of his/her own which doubles when the buddy nurse is on a break. The number of front line staff is reduced to 3 during the overnight hours (2 RNs and 1 LPN). Sampson testified that while nurses are required to take their breaks during a day shift, he asks that no more than 2-3 nurses be off at a time. During the total of 3 hours during any 8 hour day shift while various nurses are on break, the remaining nurses effectively go into custodial mode. Once the unit is fully staffed again, nurses can return to their required duties. In addition to the duties described above, nurses are also required to perform suicide risk assessments, notify patients as to their rights pursuant to the MHA, and attend conferencing with other professionals every Tuesday and Thursday morning to discuss patient needs/care. When a patient is Q 15, the assigned nurse is to check on the patient as per the Dr s orders every 15 minutes. In addition to this, nurses sign up at the beginning of shift on a Q 15 log sheet so that for 1 hour of the shift, all that specific nurse does is check to ensure all of the patients on the list are accounted for and checked accordingly. Sampson was unable to locate the specific Q 15 log sheet for June 19, These log sheets were created as a result of a recommendation made by an earlier Fatality Inquiry. Sampson testified that a directive was given as a result of the Inquiry that this Q 15 log sheet was to be created but it is not in any legal form nor are there instructions or directions as to whether the log sheet is to be kept and if so, where it should be kept or for how long. Sampson testified that when a shift change occurs, all incoming staff are advised what has happened with each patient on the unit in the last 24 hours. Sampson confirmed Dr Chu s testimony regarding the white board that is by the nursing station which contains information as to whether the patient is an elopement risk or not. If the patient is a high risk to leave the unit and has no off unit privileges, the name of the patient is written in red marker. If the patient has off unit privileges, the name is written in green marker. This information is also contained in the electronic health record of the patient accessible to all front line staff. Sampson confirmed that the Unit Clerk is to be the key point of contact for this information and has to learn to put a face to a name pretty quick. When asked about education for those working on the unit, Sampson confirmed that when hired Unit Clerks attend an in-house orientation for 5 days. Although there is no formal process in place, Sampson confirmed that he does discuss the security aspect of Unit 49 with other managers and asks them to remind their specific staff to be mindful when entering and exiting the secure unit to ensure patients do not follow them out. Sampson testified that since his return to RGH he has identified a need for education for staff and as such 4 educational sessions have been created for staff working on Unit 49 related to mental health issues. Educational sessions are not mandatory for staff but remain a professional choice. Sampson testified that a Mental Health Elopement Committee has been established to attempt to address the issues facing this Inquiry since the problem of patients leaving secure mental health facilities is not unique to the RGH. Sampson testified that it is a challenge to balance stigmatizing the patients and building a trusting therapeutic relationship with them. As such, Sampson did not agree that having patients wear a coloured hospital bracelet or a Wanderguard bracelet would be useful considerations for this Inquiry as it would negatively identify the patients as being those suffering from mental health issues and would decrease trust between the patients and the primary care givers if they believed they were being monitored. Sampson also did not believe that Wanderguard technology would be useful for Unit 49 since it was already a locked unit. When asked about what recommendations Sampson would make to assist this Inquiry, he

7 Report Page 7 of 13 testified that the implementation of double containment doors at the entrance to the unit as well as limiting those with card access to the unit would be very beneficial. Sampson also testified that having a completely separate unit where those who are at a particularly high risk for elopement or self- harm could be held until they have improved to the point of being able to move to a less secure environment may be helpful, although he was concerned that any therapeutic advances made over the course of the time in the high risk security environment may be lost once the transfer to a less secure environment occurred. Justine Mitchell Ms Mitchell (Mitchell) is an RN working at RGH and assigned to Unit 49. She has been so employed for approximately 6 years and was Ma s nurse for 3 shifts while he was a patient at RGH. Mitchell provided information as to the multitude of duties performed by the nurses on Unit 49 on any given day shift as well as the staffing levels. Mitchell also testified to the plethora of other professionals who would have access to the unit at any given time. Mitchell testified that all patient records are required to be kept online and that legally a nurse is to chart twice per shift although depending on the day and the patient, a nurse may chart matters of significance many more times than that. Mitchell testified that patients are assigned by the charge nurse and that ideally they would work with the same patients on subsequent shifts but that did not always happen. Mitchell testified that there can be a high patient turnover in the unit but she did recall working with Ma at least twice. Mitchell confirmed information regarding Ma s history and status provided by Dr Chu. She testified that Ma presented with depressive psychotic features and concerns that he would not get better. She testified that at times he became overwhelmed with bouts of anxiety and would hurt himself. These episodes of anxiety usually happened in the mornings and as such Ativan would be provided to Ma as needed. Once he had taken the medication, Mitchell testified that Ma was easy to talk to, engaging, hopeful and very much wanting to get better. She testified that when Ma was settled he was very forthcoming with information; that he had a lovely family, and was very happy with them. Mitchell testified that Ma would take his medication when required and was always thankful once he had taken it-particularly after a bout of severe anxiety. Mitchell testified that on June 19, 2014 she saw Ma briefly prior to going into her patient conferencing meeting. She testified that Ma stated he was cured and that he wanted to go home that day. Mitchell also saw Ma following the conference, prior to going on break at 10:15 am. Upon returning from her break Mitchell testified that she checked with her buddy nurse and asked if she had checked on Ma while Mitchell was on break since this would typically be the time of day when Ma became anxious and unsettled. Mitchell testified that her buddy nurse advised her that she had not seen Ma. Mitchell testified that she looked for Ma and paged him but could not find him. She also testified that she checked the Q 15 list and Ma had not been noted as being seen on the unit since 10:15. Specifically there was no indication that Ma had been checked at 10:30 or 10:45 as required. Mitchell properly followed the missing person protocol (Code Yellow) and attempted to assist CPS as best she could. Mitchell testified that given the timing of Ma s disappearance and the challenges Ma often faced in the mornings, she told CPS to check the reservoir. Mitchell testified that typically the nurses who work on Unit 49 do not hold the door open and allow people to go in and out of the unit, but that other staff members do not always appreciate the need for security on the unit.

8 Report Page 8 of 13 Dr Lisa Gagnon Dr Lisa Gagnon (Dr Gagnon) is a psychiatrist currently employed at the Foothills Medical Centre (FMC) focusing on care for adults with a sub-specialty in peri-natal mental health. In October 2015 she accepted the position of being in charge of quality assurance in the Department of Psychiatry for the City of Calgary. Recently Gagnon had been asked to create and chair the AWOL Committee (Committee) given concerns about the number of mental health patients leaving (AWOL) or eloping from the city hospitals, as well as the serious outcomes in some of those situations-including the matter which is the subject of this Inquiry. The Committee is in its infancy having only met 3 times prior to Gagnon s testimony at this Inquiry. To date, the Committee has discussed membership and implemented further tracking measures to gather information around the factors involved in elopements or AWOLs from hospital so that they can be properly understood. The Committee has also recently learned of the work already done by The Elopement Committee chaired by Kathy Schultz. The Elopement Committee focused on patients who were AWOL or who had eloped from hospital from non-mental health care units (ie dementia patients or those with other cognitive difficulties). This work included the implementation of a yellow wristband policy for patients who are at risk of wandering, as well as signage throughout the hospital and additional education for staff regarding the purpose of the yellow wrist band and what to do if a patient wearing a yellow wristband is located wandering alone in the hospital or on its grounds. By all accounts this project has been successful in reducing the number of Code Yellow alerts for this particular demographic of patients in hospital. Gagnon testified that all mental health wards in the city hospitals have the capacity to be locked. All but those located at the SHC have a single set of doors where anyone wanting to enter or leave the unit needs to press a buzzer to have the door unlocked. Gagnon testified that on all of those units across all hospitals, there are many people coming and going and that if a mental health patient wants to elope from the unit he/she can simply watch for people to leave or enter the unit and escape. Gagnon testified that unlike other units where a patient may accidentally wander off a unit due to cognitive difficulties, the patients on the secure mental health units are quite purposeful in their leaving. Gagnon confirmed that the hospital with the lowest number of Code Yellows from secure units is the SHC. She confirmed that this is the only hospital which currently has double containment doors, although a renovation is in place for the Peter Lougheed Hospital. Requests for funding for double containment doors have been made for other hospitals including RGH but there is currently no funding in place for those projects. Gagnon testified that there may also be other factors resulting in the low number of Code Yellows from the SHC including the fact that while those units are always at capacity (as they are in all other hospitals in the city), the SHC provides single rooms with a bathroom for each patient whereas there can be up to 5 patients per room at the FMC with 1 bathroom for 2 rooms (10 patients), Gagnon testified that the Committee has discussed a variety of other possible solutions to the AWOL patient problem from mental health units including: a) increased education on and about the units; b) having high risk patients who do not have off unit privileges wear a coloured wristband or a different coloured housecoat; c) increased signage on the units alerting staff and visitors to the need to keep the units secure; d) becoming more effective at identifying patients who are at high risk to leave the unit; e) photographing patients for easier identification and; f) improving methods to identify certain physician practices that may result in an increased

9 Report Page 9 of 13 likelihood that a patient will leave a mental health unit without permission. Similar to the concerns expressed by Sampson earlier in this Inquiry, Dr Gagnon also testified that some of the measures that have been effective in non-mental health units such as the coloured wristbands or the use of Wanderguard or GPS technology are more difficult to successfully implement for mental health patients due to the concern surrounding stigmatization as well as the cost involved in repairing or replacing a purposeful destruction of more technologically advanced bracelets. Gagnon testified that the Committee will continue to gather information to determine how best to address this serious problem over the next few years. She testified that very likely the implementation of the double containment doors as well as increased education surrounding the issues involving mental health patients would be most helpful. Recommendations for the prevention of similar deaths: Section 53(1) of the Fatality Inquiries Act, RSA 2000, c. F-9 directs a written report be provided to the Minister at the conclusion of the Inquiry. Section 53(3) directs that the report shall not contain any findings of legal responsibility or any conclusions of law. However, section 53(2) provides authority for the report to include recommendations as to the prevention of similar deaths in the future. There is a clear distinction to be made between those patients who are hospitalized due to cognitive impairment (ie a brain injury or dementia) and those who are hospitalized because they are in crisis and are therefore formal patients pursuant to the MHA. While this Court is aware of other Fatality Inquiries that have been held, or are currently before the Court, involving patients who-like Ma-left the RGH and were found to have drowned in the Glenmore Reservoir, the focus of this Inquiry has been directed specifically towards providing recommendations for preventing formal patients in crisis from eloping from a secure ward and committing suicide. The evidence heard at this Inquiry made it clear that those who provided care to Ma did so in a very compassionate, capable and respectful fashion. Health care providers for those in crisis such as Ma clearly try to strike a balance between respectfully maintaining the patient s dignity, and keeping that same patient safe. Complicating this is the very fact that the patient is in crisis and consequently may make decisions which are intentionally designed to thwart all efforts made by staff to prevent self-harm. Additionally, these health care providers are trying to provide this service in an overburdened system which routinely functions well above capacity. Counsel for Alberta Health Services (AHS) has urged the Court to make no formal recommendations following this Inquiry. Her reasons for doing so include the fact that AHS is taking this issue seriously and has established the AWOL Committee to specifically make informed decisions designed to address the concerns raised by the evidence in this Inquiry. Further, counsel for AHS has cautioned the Court about making recommendations essentially in a vacuum which may-if accepted-impact on the allocation of very limited and valuable health care dollars. Being mindful of both of these factors, this Court is still tasked with making principled recommendations towards preventing similar deaths in the future. The evidence heard at this Inquiry detailing the extent of the problems faced by health care professionals in this environment and the consequent impact on the patients in crisis, was very concerning.

10 Report Page 10 of 13 As such, this Court makes the following respectful recommendations: 1. Double containment doors be installed at the entry/exit point on all secure mental health units. It is very clear from the evidence of this Inquiry that despite the fact that the mental health units for patients such as Ma are to be locked and therefore secure, they are not. Patients can-and do-leave the unit with other patients, staff or visitors. Statistics from the SHC suggest that-among other factors-the double containment doors seem to have a significant impact on lowering the numbers of patients eloping from the unit. The installation of these doors will delay the patient from leaving the unit and provide staff a further opportunity to ensure that those individuals leaving the unit are permitted to do so. The subsequent reduction in staff time spent looking for missing patients will permit staff to have more time to spend on other very important tasks directed towards patient care. 2. Unit clerks who are responsible for monitoring those entering and exiting the secure mental health units be located at the point of entry/exit such that there is a clear line of site to the double containment door. It is clear from the evidence in this Inquiry that the Unit Clerk for Unit 49 at RGH does not have a clear line of site to the secure doors. The Unit Clerk is required to look at a monitor, determine that the person requesting to either access or exit the unit is permitted to do so then push a button to open the door. The Clerk is then supposed to watch the monitor to ensure that the doors close without anyone leaving the unit without permission. These doors open and close slowly. Even if the Unit Clerk is not distracted by any number of other duties and is able to watch the monitor closely and appreciate that a patient without off unit privileges has left the unit, the Clerk is still a considerable distance away from the doors. Valuable time is lost. Having the Unit Clerk sit at the door and making the gate-keeper function a priority for this position will assist in preventing patients from eloping. If the role of the Unit Clerk is such that the gate-keeper role cannot be a priority for this position, then AHS should give consideration to creating a new position in which this would be the key component, thereby relieving nurses and Unit Clerks of this responsibility, allowing them to focus more on primary patient care. 3. A security alarm be installed for the Unit Clerk to activate immediately if a patient with no off unit privileges is seen leaving the unit. It was clear from the evidence of this Inquiry that time is of the essence when a patient such as Ma elopes from a secure unit. Having an alarm in place would immediately notify other staff members and security staff that assistance is needed to have the patient returned safely to the unit. 4. Mental health patients at high risk of elopement with no off unit privileges must be immediately identifiable as such. It is here where the difficulty in maintaining the balance between respecting the dignity of the patient and ensuring the safety of the patient is the most challenging. However, as was clear from the evidence of this Inquiry where there is no safety, dignity sadly becomes moot. While efforts have been made to attempt to identify these patients for nurses and unit clerks (the board by the nursing station with names in red if the patient

11 Report Page 11 of 13 has no off unit privileges; the entries on Sunrise Clinical Manager) these efforts are clearly not sufficient. Unit clerks and nurses coming on shift cannot be expected to know every patient by site immediately. Consideration should therefore be given to the following: a) Having patients identified as high risk to elope- particularly if they are formal patients because of homicidal and suicidal ideations (as was Ma)-remain wearing hospital attire for longer periods of time. If the concern is comfort and dignity, then hospital clothing can be provided that is both comfortable and appropriate but still identifiable immediately by staff as hospital attire; b) Having patients identified as high risk to elope wear a low cost, secure, coloured wristband. While I appreciate that these patients may ultimately be successful in damaging or removing such a wristband, while in place it would provide yet another way for staff and visitors to quickly identify these patients. 5. Patients admitted to a secure mental health unit be photographed upon admission. These photographs will be available at all times to the Unit Clerk and nursing staff and will be provided to police along with a completed Form 3 by hospital staff. The photograph will be returned to hospital staff upon location of the patient and destroyed upon discharge of the patient. Evidence was heard about the concern shared by staff that photographing a patient upon admission could well be viewed as a violation of the privacy of that patient. The photograph however would provide an invaluable tool both for Unit Clerks and nurses still determining the identity of new patients on the unit, as well as for police should a Code Yellow occur and a Form 3 be necessary. It was clear from Chudy that the description provided by the hospital of Ma was not sufficient information for police and that a photograph would have been far more helpful. Restrictions on the use of these photographs as suggested above would be such that the important patient privacy element would be respected, with the likelihood of a successful elopement with tragic outcomes lessened. 6. Increased education for all staff within hospitals (mandatory) as well as for visitors accessing the secure mental health units regarding the unique aspects of these units and the danger to patients if the security of the unit is compromised. While efforts to address education for all hospital staff have begun, these educational seminars addressing the unique security concerns of the mental health units should be mandatory. Visitor education is currently in place and should be continued. 7. Increased signage in the hospital and in particular signage in or posted outside of- the secure mental health units, regarding the need to protect the safety of the patients. Increased signage could be implemented at relatively low cost and would serve as an important reminder to all staff and visitors to be mindful of the unique security concerns of the mental health units.

12 Report Page 12 of A standardized format for the Q-15 sheet should be created and clear standards of retention developed. Although the practice of keeping a Q-15 sheet appears to have been implemented pursuant to recommendations made following an earlier Fatality Inquiry, a policy regarding accessibility and retention of this information still needs to be developed. Equally important, the reason for creating this sheet in the first place needs to be further stressed with frontline staff. While I appreciate how many duties the primary care givers are trying to balance, the evidence in this Inquiry was that although Ma was to have been checked pursuant to the Q 15 order, he was not. It is clear that if patients elope from the unit, time is of the essence- particularly if the patient is suicidal given the close proximity and easy accessibility of the Glenmore Reservoir. Ensuring that a patient with a Q 15 order is checked as directed must be a priority. It is hoped that implementation of double containment doors will result in a significant reduction in the challenge created by the elopement of high risk patients. Should that not be the case however, the following recommendations are made: 9. Alberta Health Services (AHS) should consider the feasibility of Wanderguard technology for mental health patients with no off unit privileges identified as being at high risk of elopement. Should patients continue to elope from secure units once the double containment doors are implemented, consideration should be given to having high risk patients wear a Wanderguard bracelet that would sound an alarm at the Unit Clerk s desk if the patient left the unit. 10. AHS should consider the feasibility of reducing the maximum number of mental health patients per nurse. The evidence heard in this Inquiry was that there were times during the day while nurses were on break, that the buddy nurse remaining on the unit would be responsible for as many as 8-10 patients. At this point the nurses are in custodial mode. The Inquiry was told that the unit is regularly functioning at 110% capacity. Ma was to have been checked every 15 mins during the day. The evidence has shown that he was not checked at 10:30am nor was he checked at 10:45am. Clearly staffing levels were such that this order from Dr Chu implemented for Ma s wellbeing and safety could not be carried out. As such, Ma was missing from the unit for a minimum of 15 minutes (possibly longer than 30 mins) before his absence was noticed. These patients are by definition high needs and high maintenance. Many are at risk of self-harm or aggression towards health care providers or others. During a Code Yellow, staffing levels are reduced further while resources are spent trying to locate a missing patient. If safety of the patients- and the staff who care for them- cannot be guaranteed at current staffing levels, consideration should be given to changing the nurse to patient ratio such that safety for all staff and patients is increased.

13 Report Page 13 of AHS should consider the feasibility of having CCTV cameras on all entry/exit/emergency doors to secure mental health care units with footage being retained for a minimum 48 hours. Having this information readily available will provide important information- should the elopement problem continue- as to how patients are leaving the unit. This will allow AHS to respond quickly and appropriately to prevent further elopements, and as a result, further tragedies in the future. DATED May 22, 2016, at Calgary, Alberta. Original signed by The Honourable Joanne Durant A Judge of the Provincial Court of Alberta