Several recommendations from the coroner’s inquest that examined the death of Kaytlyn Hemsworth in Moncton.
A five-member jury found that Hemsworth’s death at the Dr. Georges-L.-Dumont University Hospital Centre psychiatric facility on April 11, 2023, was the result of suicide.
Nine witnesses appeared during the inquest.
The five-member jury made the following recommendations:
- Staff should be assigned solely to conduct required patient checks to eliminate lapses caused by multi-tasking or staff shortages and to reduce the burden on nursing staff, allowing them to focus on patient care.
- Continuous monitoring with wearable devices that track vital signs, such as heart rate, oxygen saturation, and movement, should be introduced. This would ensure the early detection of physiological distress and allow for timely intervention and harm prevention.
- The patient-to-nurse ratio should be reduced.
- Doors and windows should be kept clear of obstructions, and the possibility of removing curtains to improve visual access should be evaluated.
It also recommended that all new guidelines and changes be implemented across all psychiatric units in the province.
Deputy Chief Coroner Emily Caissie presided over the inquest and also made additional recommendations to Vitalité Health Network.
- Equip all nursing stations on psychiatric units with a “J-knife” to facilitate rescue in the event of a hanging situation.
- Vitalité Health Network should put in place a policy to accompany its “documentation of surveillance” form (RC-357B (2024)) to ensure proper implementation, compliance and quality assurance in its use.
Recommendations will be forwarded for consideration and response.
Inquests are held to allow for the public presentation of all evidence relating to a death.
Recommendations can be made, aimed at preventing deaths under similar circumstances in the future.
