A coroner’s inquest has made recommendations in the death of a woman in the Saint John Regional Hospital psychiatric unit.
In December 2020, 27-year-old Hillary Hooper died by suicide in 4D North after she had been a patient in the unit.
Hooper had made an attempt to do so weeks earlier.
The five-member jury heard from 16 witnesses this week and made the following recommendations:
- that 4D North use bedding that tears easily and will not support a person’s weight if used as a noose. This recommendation is made with consideration given to the requirement for frequent laundering in hospital settings;
- replace bathroom doors in patient rooms with doors that cannot be locked;
- fix door 62 so it closes properly;
- replace patient room doors with pocket doors, accordion doors or doors that open out into the hallway equipped with quick release hinges to prevent patients from locking doors;
- consider installing security cameras in patient rooms. This recommendation is made recognizing that there are issues pertaining to patient privacy;
- that any time a patient’s door is blocked that attention be given to that room immediately;
- that in order to prevent hospital beds from being used to block doors, that they be secured with a locking mechanism that can only be released by authorized personnel;
- consideration be given to searching patients upon admission to 4DNorth, (pat-down, searching bags and pockets in order to detect potential weapons, drugs, mobile phones, etc.) This recommendation is made with recognition of issues pertaining to patient privacy;
- that staffing be increased during night shifts beyond three registered nurses. Additional staff need not be registered nurses. Licensed practical nurses, personal support workers and security staff may be options. This recommendation is made with recognition of current staffing challenges and shortages;
- that a code blue crash cart be situated on 4DNorth;
- that a short stay unit be implemented as part of the psychiatric services available at the Saint John Regional Hospital. Said unit to include dialectical-behavior therapy as part of its treatment protocol, with linkage to community-based dialectical-behavior therapy for follow-up, post discharge.
The coroner added the following recommendations:
- that Horizon Health Network continue to explore the possibility and support the implementation of crisis stabilization units in its hospitals;
- that Horizon Health Network provide an information session on local resources available for people with borderline personality disorder to its physicians. A list of these resources should be displayed and available to physicians;
- that Horizon Health Network adopt or make a continuous assessment of suicide urgency. A form should be used in any medical clinic or emergency department where a patient presents themselves in either a mental health crisis or self-reports being suicidal. The network should also evaluate the form to see if there is merit in also using it on units;
- that the Department of Justice and Public Safety support the office of the chief coroner in establishing a suicide fatality review committee.
The chief coroner will forward these recommendations to the appropriate agencies or organizations for consideration and response.
The responses will be included in the chief coroner’s annual report for 2023.
An inquest is a formal court proceeding that allows public presentation of all evidence relating to a death.
It does not make any finding of legal responsibility, nor does it assign blame.
However, recommendations can be made aimed at preventing deaths under similar circumstances in the future.
