Families want independent review of hospital suicides
The Spectator has learned another St. Joe’s patient died while on a temporary pass
One recommendation from the coroner’s report is to have a better risk assessment system for in-patients being considered for temporary passes into the community
Two months after family members released recommendations to prevent patient suicides at St. Joseph’s Healthcare, yet another patient took their own life. The Spectator has learned the patient died while on a temporary pass from the West 5th Campus psychiatric unit in October. St. Joe’s confirmed one patient died by suicide during 2021. A spokesperson declined to provide more detail, citing patient and family privacy. The hospital has a history of psychiatric in-patients dying by suicide within the hospital or while on passes. Since 2016, 10 people have died. That is what led the Office of the Chief Coroner to take extraordinary measures to try to address the systemic problems connected to the tragedies. Though there were calls from families, Ontario NDP Leader Andrea Horwath and The Hamilton Spectator for a coroner’s inquest into the deaths — in the hope of preventing other, similar deaths — a unique alternative was struck. Family members of some of the deceased St. Joe’s patients were asked to work with coroner Dr. Reuven Jhirad to review the suicides and draft recommendations to prevent more from happening. The group issued 17 recommendations in August and asked St. Joe’s to respond by February. Meanwhile, another suicide occurred. In 2020, no patients died by suicide, according to St. Joe’s, which counts in-patient deaths within the hospital and in-patients out on temporary passes. In 2019 there was one suicide; in
2018 there were two; in 2017, two: in 2016 there were four.
In September 2017, after interviewing numerous families who lost a loved one to suicide w
St. Joe’s, The Spec reported 11 deaths in less than two years. One of those families was featured in an award-winning Spectator investigation into the suicide of Nicole Patenaude. Nicole, 20, was out on a pass from St. Joe’s when she jumped off a bridge onto a highway and died.
It is that spike in 2016 and 2017 that led to a call to action.
In 2016, the hospital conducted an internal review into that year’s suicides. The results were not made public.
The hospital then commissioned an external review of nine suicides and a July 2017 report released publicly said better understanding of the patients’ stories, closer collaboration with families and better safety planning were needed. Those recommendations closely echo the latest calls for change from the families and Jhirad.
To throw more weight behind those recommendations, relatt
ves of all St. Joseph’s Healthcare psychiatric patients are endorsing them and specifically highlighting one, which is the creation of an independent group to review hospital suigc
des and ensure the implementation of all recommendations from the most recent report.
“The strength, courage and commitment of the families who assisted the coroner in this challenging and difficult work must be applauded,” the Family Advisory Council of the Mental Health and Addiction Program said in a letter addressed to the coroner. “Those we have lost to suicide who no longer sit at any table, only have their family to speak for them. These families and the loved ones they lost deserve our respect and our support of their request.”
The council is urging the province to establish a standing committee to see that the coroner’s report recommendations are acted on, since there is no legislation that makes implementation mandatory. It hopes an oversight committee “will help forge a path for improved patient care, renewed respect and increased communication with patients and families who are in the care of St Joseph’s Healthcare Hamilton.”
“The oversight committee must be completely at arm’s length from St. Joe’s,” says Judy Fabris, who helped draft the recommendations. “I have no trust in St. Joe’s implementing these policies and procedures because they haven’t followed through in the past.”
Fabris may not have trust, but she does have hope.
“I truly am hoping. Because I have lived experience with suicide and St. Joe’s,” she says. “I’m hoping this time will be different.”
Fabris’ daughter Michelle, 46, died by suicide while on a pass from the hospital. She had been living with mental illness for 15 years.
“She was a beautiful human being. She was a wonderful person,” her mom says.
“I’m still looking for answers. It is a very personal thing for me. I am angry. I am angry at the system. It let my daughter down.”
Fabris alleges St. Joe’s ignored some of its own care policies in her daughter’s case. She says other families have had the same experience.
One recommendation from the coroner’s report is to have a better risk assessment system for in-patients being considered for temporary passes into the community. That issue also showed up in earlier reviews, reports and recommendations.
The families who worked with the coroner have given St. Joe’s until February to respond to the recommendations. St. Joe’s provided a statement to The Spectator on its progress, saying it “supports the recommendations in the coroner’s report” — including the independent review committee — “and has committed to bringing in an objective third party to support our review where there has been a death by suicide by an in-patient or in-patient on a pass.”
The hospital says it is not uncommon for an objective expert to be used in incident reviews by hospitals when they have critical incidents but these are not standing review panels.