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

CANADA Province of Alberta Report to the Minister of Justice and Solicitor General Public Fatality Inquiry Fatality Inquiries Act WHEREAS a Public Inquiry was held at the Medicine Hat Provincial Court in the City of Medicine Hat, in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 3 rd day of May, 2017, (and by adjournment year on the 4 th and 5 th day of May, 2017 ), year before His Honour Judge F.C. Fisher, a Provincial Court Judge, into the death of Glenn Paul Piche 49 (Name in Full) (Age) of 157 Northlands Crescent N.E., Medicine Hat, AB and the following findings were made: (Residence) Date and Time of Death: #1 - June 20, 2013 between 22:30 23:00. Patient revived and moved to Intensive Care Unit. Final: June 21, 2013 at 17:34 Place: Medicine Hat Regional Hospital, Medicine Hat, Alberta Medical Cause of Death: 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 Inquires Act, Section 1(d)). Hanging 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

Report Page 2 of 12 Introduction: Glenn Paul Piche, a 49 year old male, was transported to the Medicine Hat Regional Hospital, located in the City of Medicine Hat, Alberta, on June 19, 2013, by Constable Scott McWhinnie, a member of the Redcliff Detachment of the Royal Canadian Mounted Police (RCMP). Constable McWhinnie presented Glenn Paul Piche to the hospital under a Form 10, under Section 12, Mental Health Act, RSA 2000 C. M-13. Dr. Geoffrey Harris, emergency physician at the Medicine Hat Regional Hospital, examined Glenn Paul Piche on June 19, 2013. Following his examination, he admitted Glenn Paul Piche to 5 th North under a Form 1. Glenn Paul Piche remained in 5 th North on a second Form 1, issued by Dr. Aditi Patel. He remained in 5 th North until his death on June 20, 2013. He was revived after his suicide attempt but died June 21, 2013. Prior to the Inquiry evidence being called, Exhibit 1, being 2 binders, were entered into evidence. Circumstances Under Which Death Occurred: Glenn Paul Piche, a 49 year old male, had a long history of mental illness and had been admitted to the Medicine Hat Regional Hospital on a number occasions: 1. June 19, 2013 - Form 10, Mental Health Act; 2. June 6, 2013 - Form 10, Mental Health Act; 3. March 20, 2013 - severely intoxicated, head injury; 4. March 17, 2013 - police transport, agitation and depressed, admitted to 5 th North; 5. July 7, 2012 - right hand injury; 6. May 9, 2011 - emergency department; 7. August 11, 2008 - emergency department; 8. October 9, 2006 - emergency department; 9. March 8, 2006-5 th North, certificate cancelled by Review Board March 17, 2006; 10. March 11, 2005 emergency department, overdose; 11. March 11, 2005 referral to Claresholm Care Centre; 12. February 6, 2003 5 th North, overdose. History provided, schizoaffective disorder for a number of years. Glenn Paul Piche s wife had reported to the Medicine Hat Police Service that her husband told her he wanted to cut his own head off this morning. This complaint was on June 20, 2013. Cst. McWhinnie of the Redcliff RCMP, received a message from the Medicine Hat Police Service that they had been informed by Glenn Paul Piche s wife that he was suicidal and was presently at a storage locker located in Redcliff, Alberta. Cst. McWhinnie received a request from the Medicine Hat Police Service to have the RCMP investigate a report that Glenn Paul Piche was suicidal. The information provided was that Glenn Paul Piche wanted to cut his head off that morning. Cst. McWhinnie located Glenn Paul Piche at the storage locker and found him to be notably calm and placid. Glenn Paul Piche denied being suicidal. Cst. McWhinnie had reviewed the RCMP database and he had found a file that contained a 911 call that led to Glenn Paul Piche being transported to the Medicine Hat Regional Hospital under

Report Page 3 of 12 the Mental Health Act on June 6, 2013. Cst. McWhinnie formed his reasonable and probable grounds to arrest Glenn Paul Piche under the Mental Health Act based upon the information received from the Medicine Hat Police Service and his review of the RCMP database. Cst. McWhinnie transported Glenn Paul Piche to the Medicine Hat Regional Hospital following Mr. Piche s arrest. He presented his Form 10 (Mental Health Act), and Glenn Paul Piche to the peace officer at the hospital. Dr. Solomon Van Der Westhuizen testified he was a family physician in the City of Medicine Hat and often took care of patients admitted to the Medicine Hat Regional Hospital when those patients did not either have a family physician, or had a family physician who did not have hospital privileges. Glenn Paul Piche had a family physician who did not have hospital privileges. Dr. Van Der Westhuizen was assigned Glenn Paul Piche when Dr. Geoffrey Harris, the emergency room physician that examined Glenn Paul Piche, certified him under a Form 1 (Mental Health Act). He was admitted to 5 th North involuntarily. Dr. Van Der Westhuizen then spoke with Glenn Paul Piche and was told by Glenn Paul Piche that all the allegations on the emergency documents were false. Dr. Van Der Westhuizen stated he was told that Glenn Paul Piche had gone to the storage locker in order to keep the peace as his wife was drinking. Dr. Van Der Westhuizen indicated that Glenn Paul Piche was well-spoken, calm, and had a grasp of his mental history. Dr. Van Der Westhuizen indicated he formed a diagnosis of possible bipolar and possible schizophrenia. Dr. Van Der Westhuizen indicated that Glenn Paul Piche denied any suicide ideations and told him he should not be held in the unit and he should be released. Dr. Van Der Westhuizen then referred Glenn Paul Piche to the psychiatrist, Dr. Aditi Patel. Dr. Aditi Patel examined Glenn Paul Piche and found him to be pleasant, cooperative, with no distress. Dr. Patel examined the notes regarding the Form 10, and the Form 1 from the emergency room, along with the facts that there was a distinct difference between what the family stated about his mental stability and what Glenn Paul Piche stated. She determined she would hold Glenn Paul Piche on a second Form 1. Dr. Patel was aware that Glenn Paul Piche had been on 5 th North previously and she ordered the historic files pertaining to of Glenn Paul Piche and that they were to be delivered for her review. Dr. Patel testified she also had a plan to speak with family members. Dr. Patel also testified that Glenn Paul Piche told her that he should not be in 5 th North as the allegations were false and there was nothing wrong, and he did not have any suicidal ideations and he did not want to harm himself.

Report Page 4 of 12 Dr. Patel was aware that Glenn Paul Piche had a history of being bipolar, had a major depressive disorder, and had attended the Claresholm Care Centre. Dr. Patel was also told by Glenn Paul Piche that he recently got married and there were stresses in his life because of his wife s excessive drinking. Dr. Patel reported that Glenn Paul Piche s mood was good. He was confident, up front, showed good judgment, but was somewhat vague at times and jumped from topic to topic. He denied any visual or auditory hallucinations and displayed no psychosis. Glenn Paul Piche s impulse control was good; he was not angry or irritable. Dr. Patel certified him under a Form 1, so that she would have the opportunity to review his old charts. Dr. Patel, at the time, wanted Glenn Paul Piche observed every 15 minutes, but changed that observation time to 30 minutes because Glenn Paul Piche wanted some freedom as he believed he should not be in the psychiatric unit. Dr. Patel did the observation change based upon Glenn Paul Piche s request and based on her observations of him not being in distress, as she stated, he was very convincing. There was no thought in her mind of a risk. The second Form 1 would secure Glenn Paul Piche in the unit for 30 days. The Form 1 was put in place because the nurses told Dr. Patel they had concerns about his health, and because of the discrepancy with respect to Glen Paul Piche s history. Also, there was some concern about his appearance that he appeared more guarded. Dr. Patel did not consider a change of the observation period from 30 minutes to 15 minutes because of the denial of suicide and because Dr. Patel did not believe there had been a change in the risk. Dr. Patel did not have a further consultation with Glenn Paul Piche after the morning of June 20, 2013. Dr. Patel had two meetings with family members of Glenn Paul Piche after his suicide. Dr. Patel indicated to the family that: 1. There had been no suicidal ideations; 2. No concern about Glenn Paul Piche s safety; 3. There was no discussion about a change of the observation of 30 minutes being changed to 15 minutes; 4. The nurses did not have any concerns about Glenn Paul Piche s safety; 5. No impression that Glenn Paul Piche had said anything to give rise to a change in the observation period. Janice Norrie, a psychiatric nurse employed at the Medicine Hat Regional Hospital, testified that Glenn Paul Piche was in Room 190 which was located approximately six to seven steps from the nurses station in 5 th North. Ms. Norrie indicated to the Inquiry that each time she comes on shift she reviews the interdisciplinary notes, nurses notes from the prior shift, and the written records of the patients.

Report Page 5 of 12 Ms. Norrie testified she tries to talk to each patient on each of her shifts and she indicated that she did talk to Glenn Paul Piche on her shift on June 20, 2013. Also, Ms. Norrie testified that Glenn Paul Piche was on the phone at about 21:50 on June 20, 2013, and after the phone call, Glenn Paul Piche appeared to be upset. She did touch base with him to make sure he was doing okay. Glenn Paul Piche did not indicate to Ms. Norrie at any time that he had any suicidal thoughts on June 20, 2013. Ms. Norrie was still on duty when Glenn Paul Piche was found hanging from this bathroom door by a bed sheet. Ms. Norrie testified she ran to the room upon the code blue call and she did chest compressions. She indicated that the code blue team was able to stabilize Glenn Paul Piche and that he was breathing and had a heartbeat when he was moved to the intensive care unit (ICU). Ms. Norrie testified she did not have any safety concerns about Glenn Paul Piche when he was in 5 th North. Ms. Norrie testified there is not a video camera in Room 190, but that there are video cameras in five seclusion rooms in 5 th North. The cameras are located in rooms where the patients are high risk patients. Ms. Norrie testified that cell phones are not allowed in the patient s room, but the patients have access to a phone located near the nursing station. She believed that the no cell phone policy was in effect on June 20, 2013. Lana Jacob testified that on June 20 and 21, 2013, she was employed by Paladin Security. That corporation provided security services to the Medicine Hat Regional Hospital. These services included observations of the patients in 5 th North according to the doctor s order. Ms. Jacob testified there were observation sheets (Exhibit #1, page 217), that were filled out for each patient. The sheet included columns for: 1. Time of observation; 2. Location of observation of the patient; 3. Initials of person observing the patient. It was Ms. Jacob s evidence that Glenn Paul Piche was observed every 30 minutes. Ms. Jacob testified the conversation with a patient was limited. Ms. Jacob testified that if there was something that seemed out of the ordinary, such as physical or emotional distress, change in behavior, she would inform the nurse in charge of that patient. Ms. Jacob testified she did not notice anything unusual about Glenn Paul Piche during her observations of him on June 19 and 20, 2013. Ms. Jacob told the Inquiry she was familiar with Glenn Paul Piche from her association with him in the community and she believed he was not as happy (in 5 th North) as she remembered him in the community.

Report Page 6 of 12 Ms. Jacob did not do the 22:30 observation of Glenn Paul Piche as she was on her break, but was the person who found Glenn Paul Piche hanging by a bed sheet from his bathroom door at 23:00 hours. Ms. Jacob found that the sheet was very tight around the neck of Glenn Paul Piche and his tongue was hanging out. She screamed his name and attempted to get the sheet from around his neck. She was unsuccessful. A number of people entered the room and they were able to get the sheet from the door and Glenn Paul Piche fell to the floor. Glenn Paul Piche was revived by the code blue team and was then transported to ICU at 23:45. Ms. Jacob testified that the main room light in Room 190 was off, but the bathroom light was on. Ms. Jacob testified there are cameras in the seclusion rooms in 5 th North. There is one other camera at the nursing station. Ms. Jacob testified the video from the camera at the nursing station is overwritten every 14 days. The video for June 20, 2013 was not kept as there was no direction to preserve that video. Ms. Jacob testified that all 30 minute observations are recorded on the sheets as on the half hour and on the full hour. She testified that each patient could not be reviewed exactly on the half hour or full hour but that all observations are completed within two to three minutes. Tabitha Keen was the charge nurse on 5 th North on June 20, 2013. Ms. Keen testified that Janice Norrie was the nurse in charge of Glenn Paul Piche on June 19 and 20, 2013. Ms. Keen testified she had casually observed Glenn Paul Piche on the unit at the relevant time but she did not have any personal involvement with Glenn Paul Piche. Ms. Keen testified that Room 190 has a large window next to the door but there may be curtains. She was unsure about that fact on June 19 and 20, 2013. Ms. Keen came on duty June 20, 2013 at 15:00 hours and testified she reviewed the shift-to-shift binder that has a summary from the previous shift. This binder would include: 1. Standard observations of each patient; 2. Medications for each patient; 3. Attending doctor; 4. Significant behaviors; 5. Read out about each patient. Ms. Keen testified the observation sheets and other clinical documents for Glenn Paul Piche were in the binder and his behavior was: 1. Cooperative; 2. Polite; 3. Quiet and kept to himself; 4. Walking around the unit; 5. Talking on the phone.

Report Page 7 of 12 Ms. Keen testified there were no concerns about Glenn Paul Piche. Ms. Keen testified she was on the phone at the time of the code blue call and she did hear yelling from Room 190. She attended Room 190 within seconds to assist with the code blue call. Ms. Keen testified she did see the sheet and it was a flannel sheet, thicker than a normal bed sheet. Glenn Paul Piche was already on the floor with people attempting to revive him. Ms. Keen testified that in 5 th North now, the patient observations are carried out by nurses and not security persons except if the nurse is on a break. Ms. Keen testified there are five cameras in five rooms in 5 th North, and the cameras are in rooms that have patients who are a risk to themselves or others. They may have disruptive behaviors or those persons who are higher medical risks. Ms. Keen testified that upon a request for charts, they were usually brought to 5 th North fairly quickly. Sharon Roberts testified she is a nursing attendant and was on duty in 5 th North on June 20, 2013, and she would do observations of patients if the security person is on a break. On June 20, 2013, she observed Glenn Paul Piche at 18:00 hours and he was in the hallway. Sharon Roberts also observed Glenn Paul Piche at 22:30 hours on June 20, 2013, and he was in bed sleeping and he was breathing. She observed him from 10 feet away. Ms. Roberts testified that curtains on the window next to the door in Room 190 were closed. Ms. Roberts testified that all documents are paper on 5 th North and there are no electronic means of reviewing prior charts. Kerrie Linderman was an employee of Paladin Security and indicated she did patient observation checks according to doctor s orders. Ms. Linderman testified she had observed Glenn Paul Piche on June 20, 2013, and last saw him at 18:30. Ms. Linderman testified she did not have any concerns about Glenn Paul Piche. Ms. Linderman testified she often does her observations in different rotations so the patients do not become accustomed to a specific observation routine. Ms. Linderman also stated, as did Ms. Jacob, that if they notice anything wrong in relation to the patient, they verbally tell the nurse in charge of the patient. There is no written notation that the observation security person observed anything out of the ordinary in relation to Glenn Paul Piche. Grant Walker, Senior Operating Officer with Alberta Health Services, testified before the Inquiry in relation to a number of policies that have been implemented by Alberta Health Services. The policies are:

Report Page 8 of 12 1. Exhibit #2 Suicide Risk Assessment and Management: Acute Inpatient Psychiatric Units. AMH-02. The purpose of this policy is to facilitate patient, staff, and visitor safety. Also, this policy is for the purpose of facilitating the provision of a safe and therapeutic environment for inpatients at risk for suicide through the assessment, ongoing reassessment, and management of suicide risk. There are a number of policy elements associated with the suicide risk assessment that are to be followed by acute inpatient psychiatric units. The policy also deals with inpatient attempted suicides and sets out actions to be undertaken in such circumstances. Also, this policy establishes actions to be undertaken when there is a death by suicide. 2. Exhibit #3 Suicide Risk Assessment Procedure: Acute Inpatient Psychiatric Units. AMH-02-01. The objective of this procedure is to facilitate safe and quality care, to assess the potential for self-harm, and to identify and evaluate protective and risk factors. The procedure sets out the points to be considered in relation to suicide risk assessments. The procedure also establishes the documentation of patient suicide risk assessment that is to be in the patient s health record. 3. Exhibit #4 Mental Health Observation Policy: Acute Inpatient Psychiatric Units. AMH-01. The purpose of this policy is to facilitate patient, staff, and visitor safety. Also, the policy is to promote a therapeutic environment for patients within acute psychiatric units. The policy elements include observation levels in acute inpatient units. It establishes the observation level to be assigned to each patient based upon the assessment of their emotional, physical, cognitive, behavioral, and neurological status as determined by a physician order. The observation levels are limited to: a. Constant observation; b. Every 15 minutes; c. Every 30 minutes; d. Every 60 minutes. The policy establishes that the observation levels can only be increased or decreased by a physician order or by a duly authorized nurse practitioner. The policy establishes the type of documentation that must be completed and attached to each patient s health record.

Report Page 9 of 12 Reassessment of the patient is to be carried out throughout each shift and is to be recorded. 4. Exhibit #5 Mental Health Observation Levels Procedure: Acute Inpatient Psychiatric Units. AMH-01-01. The objective of this procedure is to facilitate patient, staff, and visitor safety and to promote a therapeutic environment and care in the best restrictive manner. The procedure details that every patient admitted to an acute inpatient psychiatric unit will be assigned an observation level, and if a level is not assigned, the default level is every 15 minutes. The procedure establishes that the patient is to have a right to the least restrictive care, based on their level of functioning. Documentation verifying the observation of each patient must be completed as per the physician s order and documented on the patient s health record at least once per 8 hour shift. Patients, agents, guardians, or nearest relative must be informed of the observation level assigned to each patient and the rationale for the frequency of observation level assigned to them. All of the policies and procedures listed were to be implemented November 23, 2011, and were to be reviewed November 23, 2014. Mr. Walker testified that the review of these policies and procedures were not undertaken in 2014, but are presently being reviewed. It was evident to the Inquiry that a number of the policies and procedures established in Exhibits 2, 3, 4, and 5, were not in effect at the time of the death of Glenn Paul Piche. Date and Time of Death The evidence presented to the Inquiry established that Glenn Paul Piche was dead between 22:30 and 23:00, June 20, 2013. Evidence was that Glenn Paul Piche was revived by medical treatment, that is, he had a heartbeat and was breathing when he was moved to ICU approximately 45 minutes after being found hanging from the bathroom door in Room 190. Dr. Amir Dolatabadi attended upon Glenn Paul Piche on June 21, 2013 in ICU and his evaluation of Glenn Paul Piche was that he suffered from hypoxic brain damage and at least part of his brain stem was not working. He indicated the prognosis was poor and treatment would only be supportive. Glenn Paul Piche died at 17:34, June 21, 2013. Medical Cause of Death Hanging. Recommendations for the prevention of similar deaths: The scope of the Fatality Inquiry and the recommendations are for the express purpose of

Report Page 10 of 12 preventing future deaths. The circumstances of this particular Inquiry and the fact that this Inquiry was not held until more than four (4) years after the death of Glenn Paul Piche, this Inquiry is obligated to make the following recommendations. 1. When a Fatality Inquiry is to be held, it must be held within two (2) years of the date of the death of the person for which the Inquiry is to be held. It has been recommended in a number of past Inquiries regarding psychiatric units, that all rooms in all psychiatric facilities be monitored by video cameras. This has not been undertaken by Alberta Health Services. 2. It is recommended that all units within 5 th North, the psychiatric unit in the Medicine Hat Regional Hospital, whether the rooms are seclusion rooms or not, should be monitored by video cameras. The safety of the patients is more important than the privacy issues that might be argued. The evidence before the Inquiry is that the attending psychiatrist may order all historical records of a patient, whether those records are stored within the hospital or elsewhere, and are to be provided to the psychiatrist in order to better evaluate the patient. The records of the Medicine Hat Regional Hospital appear to be in form of paper records rather than electronic records. 3. It is recommended that all records at the Medicine Hat Regional Hospital be put in electronic form as quickly as is reasonably possible. Also, it is recommended that all records regarding a patient that are stored within the Medicine Hat Regional Hospital and that pertain to a newly admitted patient of the psychiatric unit, be provided to the attending psychiatrist forthwith and at the latest within four (4) hours of the admittance of the patient to the psychiatric unit. 4. It is recommended that records stored off site be provided as quickly as is reasonably possible in order that the psychiatrist has available all pertinent information that might be required to make a proper mental assessment of the patient. The evidence of the Inquiry provided facts that the RCMP officer who arrested Glenn Paul Piche pursuant to a Mental Health Warrant, checked the RCMP database to determine whether there were prior mental health issues, suicide attempts, or harming behaviors, before he arrested Glenn Paul Piche. 5. It is recommended that all police agencies that arrest individuals under Mental Health Warrants, check their databases before the arrest in order to determine whether there have been prior mental health issues, suicide attempts, or harming behaviors. This should be done in order to have all mental health information available to the hospital staff that might be evaluating the individual pursuant to the Form 10 Mental Health Warrant. The evidence of the Inquiry was that Glenn Paul Piche tied his bed sheet to a hanger on the inside of the bathroom door. 6. It is recommended that all mechanisms attached to bathroom doors in the psychiatric units of 5 th North of the Medicine Hat Regional Hospital be removed. The evidence at the Inquiry was that Glenn Paul Piche utilized the patient phone continually during his stay in 5 th North and that at least once the nurse noticed he was extremely upset after

Report Page 11 of 12 his phone call was completed. It must be said that it is more important for the patient to be focused on their care and recovery, and not being focused on the use of the patient phone. 7. It is recommended that the nurse(s) in charge of the patient on 5 th North of the Medicine Hat Regional Hospital should, on a case by case basis, monitor the patient s use of the patient phone and be able to determine the limitation, if any, to be placed on a patient s use of the phone. The Inquiry heard evidence from the security staff that they had made up their own observation sheet, which was in addition to the observation sheet kept in the patient binder. Any issue(s) that arose during their observation rounds was verbally provided to the nurse in charge of the patient having the issue. The issue was not documented by the security staff. The Inquiry also heard evidence that the nursing staff carries out the patient observations on 5 th North except when they are on a break. 8. It is recommended that if the security staff do the observations of the patients when the nurses are on their breaks, and if they still utilize their own observation sheets and record any patient issue(s) that arise during their observations of the patients, then those written sheets should become part of the patient s record and should not be destroyed. Also, if nurses prepare their own observation sheets and record any issues that arise with patients, those observations sheets should also become part of the patient s record and be placed in the patient binder. The Inquiry heard from one of the security staff that patients become aware of the specific times that patient observations are carried out and that the patients should not be able to predict exactly when the patient observations will be carried out. 9. It is recommended that nursing staff and security staff, who carry out patient observations on 5 th North of the Medicine Hat Regional Hospital, not utilize exactly the same routine for checking the patients. This, of course, must be within reason because of the requirement for the checks to be: 1. Constant; 2. Q15; 3. Q30; 4. Q60. The Inquiry heard from the lawyer acting on behalf of the family that there were a number of other recommendations that the Judge should recommend. A number of the recommendations related to the standard of care or were related to post-suicide incidents involving Alberta Health Services and the family, and were therefore beyond the scope of this Inquiry. Also, a number of the recommendations proposed involved the training of medical staff and security staff and relate to the standard of care which is beyond the scope of this Inquiry. Also, a recommendation was made to the Inquiry in relation to the preservation of any video arising from live circuit monitoring within 5 th North and again although it may be beneficial, the preservation of any video is beyond the scope of this Inquiry.

Report Page 12 of 12 DATED May 29, 2017, at Medicine Hat, Alberta. Original signed by His Honour Judge F.C. Fisher A Judge of the Provincial Court of Alberta