Inquest begins into Hillsborough Hospital 2010 patient suicide
Catherine Shirley Gillis, 69, died from suffocation after ingesting two rubber gloves
A inquest into the 2010 suicide of Catherine Shirley Gillis, 69, would have taken place much sooner if the investigating coroner submitted a form indicating that the death occurred in an institutional setting.
Instead, the inquest into Gillis’ Feb. 14, 2010, death at the Hillsborough Hospital in Charlottetown got underway more than eight years later on Monday in the Supreme Court of Prince Edward Island.
Testifying at the inquest was Dr. Charles Trainor, chief coroner with the province.
He said he received a report from the investigating coroner, Dr. Nabeel Alansari, the day after Gillis’ suicide. The report indicated the cause of death was suicide and that an autopsy had been ordered.
Trainor received the autopsy report around June 10, 2010.
He said he contacted the Hillsborough Hospital because Gillis apparently had a medical genetic issue that other family members should be tested for.
But Trainor said that Alansari didn’t request an inquest into Gillis’ death and didn’t submit a form that indicated the suicide occurred in an institutional setting, in this case, a hospital. Crown prosecutor
Jeff MacDonald pressed Trainor on why, as chief coroner, he didn’t request the inquest. Trainor replied that it wasn’t his file.
Trainor did admit that, according to the legislation, since the death was not from natural causes and since it was in an institutional setting, an inquest was mandatory.
He was asked by MacDonald what happens if an investigating coroner doesn’t do what he was supposed to do, in this case, submit the form indicating the suicide occurred in an institutional setting. And, who is responsible for providing the oversight if something is missed.
“It falls under the chief coroner,” said Trainor.
In 2016, Trainor said he got a call from a doctor indicating that he was getting legal information about calling an inquest, especially in light of another suicide at Hillsborough Hospital in 2013.
The inquest into the 2013 suicide of Sherry Jean Ball happened in 2016.
He couldn’t consult Alansari, who left Canada several years prior to 2016, according to Trainor.
In terms of the 2013 suicide, MacDonald said he wasn’t suggesting that it could have been prevented if an inquest into the 2010 incident was held sooner.
Trainor was chief coroner since 1995. He retired but returned on a one-year basis earlier this month. He said the continuing education for coroners would be an improvement.
The six-person jury (and one alternate) also heard video testimony from three hospital nursing staff members and one supervisor who worked the day Gillis died.
The jury heard that at 3:43 p.m., a nurse found Gillis on the floor of the bathroom unconscious. As staff tried to revive Gillis, another nurse noticed she wasn’t getting air, so he reached into her throat and pulled out two blue plastic (nitrile) gloves rolled up. The autopsy report later determined her death was a suicide and the cause of death was suffocation from ingesting the plastic gloves.
Gillis was an involuntary patient on the fifth ward, also known as the psychogeriatric ward. Gillis was checked on by a nurse every 15 minutes.
Other lawyers involved with the inquest were Mary Lynn Kane representing Health P.E.I and Chris Montigny representing the province’s department of justice and public safety.
Kane told the jury that the matter was reviewed internally and 20 recommendations have been implemented, including a policy of no gloves in patient’s rooms, which was first put in place immediately after Gillis’ death.
The inquest also heard submissions from Matthew Bowes, the chief medical officer with the province of Nova Scotia. He offered comparisons between Nova Scotia and P.E.I. in terms of handling similar cases. However, Bowes said he didn’t have specific knowledge of Gillis’ death.
MacDonald submitted to the jury a Feb. 14, 2010, hospital incident report on Gillis’ death, the autopsy report, a risk management report from Health P.E.I. and a portion of Gillis’ medical chart. He then addressed the jury, saying that Gillis’ had a long history of mental illness and that the suicide was a sad and unfortunate end to her life.
Dr. Roy Montgomery presided over the inquest.
The inquest is scheduled to resume today at 9:30 a.m.