JURY OFFERS RECOMMENDATIONS TO PREVENT FUTURE DEATHS
Inquest into suicide of Catherine Shirley Gillis in 2010 at Hillsborough Hospital wraps up
After deliberating for about an hour Tuesday morning, a Charlottetown jury at the Catherine Shirley Gillis inquest into her 2010 suicide came back with recommendations on how to prevent similar deaths in the future.
Gillis, 69, was an involuntary patient at the Hillsborough Hospital in the psychogeriatric ward when, on Feb. 14, 2010, at 3:43 p.m., hospital staff found her unconscious in her room on the bathroom floor.
Attempts to revive her were unsuccessful.
One nurse pulled out blue (nitrile) gloves rolled up and lodged in her throat.
The jury heard that Gillis suffered from a mental illness.
An autopsy report later determined her death was a suicide, and the cause of death was smothering (suffocation) from the plastic gloves in her throat.
At around 11:25 a.m. on Tuesday, the six-person jury presented the following recommendations from the two-day inquest.
— A risk-management report, similar to the one produced by the Hillsborough Hospital following Gillis’ death, should be done following any institutional deaths deemed unnatural.
— A review of the Nova Scotia medical examiner’s protocols with the intent to adopt any of the protocols and to have a checklist to account for all data and the completion of all forms that need to be included.
— That incident reports, autopsies and investigations be completed in a timely manner involving institutional deaths that are deemed unnatural (such as suicides or violent deaths).
— That a computerized, electronic health record be implemented in P.E.I. institutions to ensure the proper monitoring of patients. This would involve chronologically recording relevant patient information with a time stamp and providing a verifiable record of patient’s health and well-being.
— Deaths in institutions should be listed separately on the (coroner’s) annual report to the attorney general’s office.
The jury also confirmed the basic facts of the case — such as the identity of Gillis, how she died as well as when and where she died and by what means.
The jury’s recommendations are based on evidence, testimony and submissions heard on Monday.
To help with the determination of basic facts and recommendations, the jury was provided with copies of the Feb. 14, 2010, hospital incident report on Gillis’ death, the autopsy report, a risk management report from the Hillsborough Hospital and a portion of Gillis’ medical chart.
The jury heard testimony from Dr. Matthew Bowes, chief medical examiner for the province of Nova Scotia, who outlined the protocols for conducting unnatural death investigations in that province, as well as a comparison with practices on the Island.
The jury also heard testimony from Dr. Charles Trainor, chief coroner.
He explained that the coroner investigating Gillis’ death indicated that an inquest wasn’t required and didn’t file the proper form to indicate that the suicide occurred in an institutional setting, which would have made an inquest mandatory.
As well, the coroner’s annual report to the attorney general contained statistics of the year’s incidents but not whether they occurred in an institutional setting.
Trainor added that the autopsy report, which was ordered immediately following Gillis’ death, wasn’t received until June of that year.
Mary Lynn Kane, a lawyer representing Health P.E.I., also told the jury that the hospital immediately removed plastic gloves from the patient’s rooms, a practice that remains in place today.
Other lawyers involved with the inquest were Crown prosecutor Jeff MacDonald and Chris Montigny, who represented the province’s Department of Justice and Public Safety.
Dr. Roy Montgomery presided over the inquest. Prior to deliberations, Montgomery summarized the evidence for the members of the jury and them reminded them that the inquest was not a trial and that their role was not to find legal responsibility for the death.
Instead, their role was a “fact-finding mission” that may involve offering recommendations.
The recommendations the jury provided will be sent to the minister of justice and public safety and to Trainor for further review.