Coro­ner’s in­quest would an­swer many ques­tions

Pub­lic ex­am­i­na­tion of sui­cides could ben­e­fit St. Joe’s, other hos­pi­tals

The Hamilton Spectator - - LOCAL - SU­SAN CLAIRMONT

There should be a coro­ner’s in­quest into the sui­cides of five St. Joseph’s Hos­pi­tal psy­chi­atric in-pa­tients — in­clud­ing Ni­cole Pate­naude.

A full pub­lic ex­am­i­na­tion of the cir­cum­stances sur­round­ing their deaths and a jury’s rec­om­men­da­tions on how St. Joe’s — and all other On­tario hos­pi­tals — can avoid sim­i­lar deaths would be tax­payer money well spent.

Hos­pi­tal sui­cides hap­pen more of­ten than you might guess. An in­ves­ti­ga­tion by the TV show “W5” in 2014 showed in the 10 years be­fore that at least 300 hos­pi­tal pa­tients died by sui­cide across Canada. Of those, 98 were in On­tario.

There have been at least six in­quests in On­tario looking into the is­sue. One of those probed into three deaths at the same hos­pi­tal. Sev­eral of those sui­cides were hang­ings. One in­volved a pa­tient jump­ing out of a win­dow. An­other hap­pened when a pa­tient left the hos­pi­tal, took a num­ber of pills and froze in a park­ing lot. Dozens of rec­om­men­da­tions have flowed from those in­quests. And yet … In the past 18 months, five in-pa­tients at the West 5th cam­pus of St. Joe’s have died by sui­cide. Four of those took place within the hos­pi­tal it­self.

Ni­cole, 20, was on a day pass on May 16 when she jumped from a bridge onto Hwy. 403 and died. I re­cently pub­lished a long story about her life, her men­tal ill­ness and her sui­cide.

Her mom, Carol Pate­naude, is left with many ques­tions about Ni­cole’s care and the last day of her life. At 10:30 a.m. that day, Ni­cole met with a mem­ber of her care team. At 11:30, Ni­cole wrote a sui­cide note and made a good­bye video. At 4 p.m. she jumped.

Carol be­lieves an in­quest may help her un­der­stand her daugh­ter’s death, help four other fam­i­lies un­der­stand their tragedies and bring about life-sav­ing changes across On­tario.

But it will take the will of the Of­fice of the Chief Coro­ner to make that hap­pen. Ni­cole’s death and the oth­ers do not meet the cri­te­ria for a manda­tory in­quest un­der the On­tario Coro­ner’s Act.

A spokesper­son for the pro­vin­cial coro­ner’s of­fice says at this time there is no plan for an in­quest into Ni­cole’s sui­cide or any of the oth­ers at St. Joe’s.

The act says there must be an in­quest in cases where there is a death of a per­son in a psy­chi­atric fa­cil­ity where the use of me­chan­i­cal re­straints were a fac­tor in the death. But that was not the sit­u­a­tion in the St. Joe’s cases.

The act also says there must be an in­quest in cases where some­one dies in po­lice cus­tody or in the cus­tody of a cor­rec­tional fa­cil­ity. And yet it does not man­date an in­quest for psy­chi­atric pa­tients who are on a Form 1 — which forces them to re­main in the cus­tody of a hos­pi­tal.

In On­tario there are Death Review Com­mit­tees that ex­am­ine spe­cific cat­e­gories of deaths in the prov­ince and make rec­om­men­da­tions to avoid sim­i­lar deaths. It in­cludes a Pa­tient Safety Review Com­mit­tee (PSRC). Though the lat­est an­nual re­port is not yet com­plete, The Spec­ta­tor was able to ob­tain redacted case re­ports re­viewed by the PSRC. They in­clude the sui­cides of two pa­tients. One was a man who was given a ra­zor to shave and he used it to cut his throat. The other was a woman who over­dosed while on a day pass.

St. Joe’s is cur­rently wait­ing for re­sults of an ex­ter­nal review it re­quested into the “clus­ter” of three sui­cides that took place at the West 5th Cam­pus in 2016. The review is be­ing con­ducted by a for­mer chief coro­ner of On­tario and a for­mer chief psy­chi­a­trist at a ma­jor On­tario hos­pi­tal. The re­sults were ex­pected in Fe­bru­ary, but were not ready. Since Fe­bru­ary, Ni­cole died as did an­other pa­tient af­ter her.

The re­sults of the review, which will in­clude rec­om­men­da­tions, are now ex­pected to be re­leased on Fri­day at noon on the St. Joe’s web­site.

The re­sults will be shared first with the coro­ner, the fam­i­lies and the hos­pi­tal staff, says Dr. Ian Preyra, deputy chief of staff at St. Joe’s, who is chief of emer­gency medicine and also a coro­ner. Then with the pub­lic and psy­chi­atric hos­pi­tals across On­tario. The im­ple­men­ta­tion of rec­om­men­da­tions will be over­seen by a se­nior group of St. Joe’s staff.

“We’re go­ing to con­tinue to be ex­tremely open,” he says.

Preyra says the review may make a coro­ner’s in­quest un­nec­es­sary be­cause it could cover the same ground. He says the coro­ner’s of­fice will be asked to ex­am­ine the re­sults “crit­i­cally” to “de­ter­mine if it sat­is­fies all the rea­sons why we do an in­quest.”

While the review is cer­tainly a good step, it is not the same as an in­quest. At an in­quest, wit­nesses are called to tes­tify, the fam­i­lies of the de­ceased can have stand­ing, the scope can in­clude all five deaths, a jury is able to ask ques­tions and form rec­om­men­da­tions and — most im­por­tantly — all of it is done in pub­lic.

Of course, there is one mas­sive flaw in the in­quest process. And that is that rec­om­men­da­tions made by the jury are non-bind­ing.

So no matter if there is an in­quest or not, any po­ten­tially life-sav­ing changes to pre­vent more sui­cides at St. Joe’s are left up to the dis­cre­tion of the hos­pi­tal to im­ple­ment.

Let’s hope it does.

Su­san Clairmont’s com­men­tary ap­pears reg­u­larly in The Spec­ta­tor. sclair­mont@thes­pec.com 905-526-3539 | @su­san­clair­mont

PHOTO SUP­PLIED BY FAM­ILY

Mom Carolyn Pate­naude with daugh­ters Ni­cole, Emily, Re­bekah and Jean­nette.

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