‘We begged for help’
Lisa Jodway was one of 11 psychiatric patients at St. Joseph’s Healthcare who died by suicide in 18 months. But assessing suicide risk is not an easy task, reports The Spectator’s Susan Clairmont
Sixteen hours before killing herself, Lisa Jodway was discharged from the ER at St. Joseph’s Healthcare.
It was the fourth time she had been there in six days.
One time it was because she tried to jump from her mother’s balcony. Another, her mom brought her in, begging staff to admit her because she was suicidal.
For emergency room doctors and nurses — even those specializing in psychiatry — assessing a patient’s suicide risk is one of the most challenging aspects of their job. It is an imperfect science with sometimes tragic consequences.
Still, for many families in crisis, the ER is their best hope.
Lisa was born and raised in Hamilton and her 34 years of life were troubled. She had a history of mental illness, and there were long periods when she was estranged from family members. At 32, she spent two months in St. Joe’s, with a failing liver due to her alcohol abuse. She had a history of using IV drugs and cocaine. She had several interactions with COAST (Crisis Outreach and Support Team), and had treatment at Womankind Addiction Service. She had three children who were not living with her.
She tried to kill herself several times. One of the last occasions was May 8, 2016. She climbed a highway overpass, poised to jump. Passersby alerted police and Lisa told them “I don’t want to live.” Officers talked her down and got her to the St. Joe’s ER. A psychiatric assessment was done and she was released, despite a request from her family doctor for her to be admitted.
That night, Lisa’s sister, Laura Rodrigues, reached out to the family’s beloved physician, Dr. Lino Lagrotteria, who had been Lisa’s doctor since she was six years old.
“It’s tough,” he says about watching Lisa’s steady decline. “It’s hard to see something like that.”
Lagrotteria believes that as much as medicine needs to get better at treating patients with mental illness, society must get better at dealing with the underlying issues that often accompany it: addiction, stigma and a shortage of psychiatrists.
He calls Lisa’s history up on his computer screen. It shows dozens of missed appointment days. But when she did make it in — usually dragged by her sister — “she would make all these promises.”
The last time he saw Lisa was by chance at St. Joe’s. He almost walked by her. She had aged so much and her belly was so distended from her cirrhosis that he didn’t recognize her.
The night Lisa was on the overpass, Lagrotteria called the ER and instructed staff not to release his patient because she was suicidal.
But St. Joe’s did its own assessment and then released her.
Lagrotteria was told by the hospital that Lisa regretted climbing the overpass.
“I don’t know what I was thinking and it would hurt so many people if I did something stupid like that,” she said.
“She tries to convince everyone that she’s fine,” says Lagrotteria. “There is no blood test we can do to predict suicide,” he adds.
Lisa’s family has shared her hospital records with The Spectator, allowing us (with the help of notes from Lagrotteria) to piece together her last few contacts with St. Joe’s.
On June 11, 2016, Lisa wound up at St. Joe’s, though it is unclear why from the available records.
Two days later, she was brought in by police and EMS after she drank, wrote a suicide note and tried to jump off her mom’s seventh-floor balcony. Her mother pulled her back to safety.
Two days after that, her mom brought her in and begged the hospital to admit her to the psychiatric unit because she was suicidal.
“She was begging, pleading with them,” says Rodrigues. “My mom did what she could to help my sister.”
Lisa mostly talked about — or tried — suicide when she was drunk.
On this particular morning, June 15, she was sober. The hospital triaged her in the ER, then moved her to the psychiatric emergency services area for a second assessment. Several thousand patients a year are assessed in the psychiatric ER and about 50 per cent of those have thoughts of suicide, according to the hospital.
Dr. Peter Cook, St. Joe’s interim chief of psychiatry, says suicide ideation is “relatively common,” yet is “one of the most complex and challenging assessments that we do.”
It is even more difficult when it is complicated by “the concurrent effects” of drugs and alcohol.
“Substances can really change a person’s presentation, change the way they think about things, change their judgment,” he says.
Sometimes patients are kept for hours in the ER until they sober up or detox, so doctors can better assess their suicide risk. However, Lisa presented in the opposite way. She was sober and not talking about suicide. She was sent home that day with a referral to a concurrent disorders clinic.
“If any member of the team actually feels there’s a significant safety risk, we would keep the patient and admit them,” says Cook.
The team considers the concerns of the family, the input of the family doctor, the wishes of the patient, but ultimately the call is up to the hospital whether to admit or not. Cook says sometimes families feel the only acceptable treatment is to have their loved one admitted.
“Frankly, with the resources we have, with the in-patient beds we have, we have to do an assessment of those we can admit and those that we think we can safely support in the community,” he explains. “It’s a judgment.”
Most patients with mental health issues are treated in the community, says Dr. Ian Preyra, chief of emergency medicine and deputy chief of staff at St. Joe’s.
Whenever possible, “the community is where we want patients to be.”
But deciding if that is the best option is difficult.
“Assessing suicide risk is one of the most complex tasks for a clinician,” Preyra concurs. “One, because there’s so many layers to it. We need to develop that understanding. You have to listen to the patient, you have to get information from a variety of sources to make an informed assessment. Two, because internationally, the literature doesn’t tell us how to do this. There is no best way. We’re following best practices and we’re leaders in best practices, but still, no one does this perfectly.”
“We begged for help,” Rodrigues says. “I wanted her to be admitted to the hospital. I wanted her to get help for the depression.”
For 60 days prior to her death, Lisa stayed with Rodrigues while trying to get clean.
The sisters made a deal — if Lisa could stay sober for 30 days, Rodrigues would take her out dancing. In anticipation of that, Lisa bought a sparkly pair of pink pumps and set them aside for that night out.
In one 18-month span, 11 St. Joe’s psychiatric patients — including Lisa — died by suicide, either at the hospital or after walking out its doors. The first nine suicides were the subject of an external review done by a psychiatry professor and a former regional coroner. The result was a list of recommendations and a pledge by St. Joe’s to work toward making suicide a “never event” for its patients.
Doctors Preyra and Cook agreed to talk to us about their ER care for patients with suicidal ideations, but declined to talk specifically about Lisa, out of concern for her privacy.
Later that day, June 15, after being discharged with a referral, Lisa returned by ambulance, complaining of severe abdominal pain due to complications from cirrhosis.
She spent the night in the ER, was given medication and, at 7:55 the next morning, was discharged.
At 11 p.m. that same day, June 16, 2016, she showed up at her mom’s downtown apartment, drunk on vodka and agitated.
“My mom was just trying to calm her down, make a tea,” says Rodrigues.
Lisa went out to the balcony to smoke. And then ….
“She was trying to climb over and my mom had a hold of her.”
At about 11:30 p.m., Lisa climbed over the railing on the balcony and — this time — wriggled out of her mom’s grasp.
“She then apparently leaned backwards, released her grip and then fell approximately seven floors to her death,” according to the coroner’s report.
Lisa was pronounced dead just after midnight — at St. Joe’s.
Rodrigues kept those dancing shoes her sister bought, but never wore.
The last word goes to Dr. Preyra. He is concerned for those who may be discouraged by this story. He wants you to know St. Joe’s is committed to providing help.
“For every tragedy, there are hundreds of stories of people who go on and live happy lives in the community, with their families. And they get better.”