Hospital has already made changes after suicide, inquest told

A 2010 internal review looking at a suicide at Hillsborough Hospital resulted in 20 recommendations, all of which have now been implemented, an inquest jury heard Monday.

The inquest is being held eight years after 69-year-old Catherine Shirley Gillis took her own life in February2010, while a patient at the hospital. Because Gilliswas an involuntary patient, the inquest looking into the circumstances of her death has all along been required under provincial legislation.

Testimony began and ended Monday, and the jury asked to be able to deliberate Tuesday morning.

Much of the questioning and testimony at the inquest revolved around why it's taken so long for the mandatory hearing to be scheduled.

Dr. Charles Trainor was P.E.I.'s chief coroner when the death occurred in 2010, and after a three-year hiatus, was named back to the post this month.

Under questioning from provincial Crown attorney Jeff MacDonald, Trainor said it was up to the coroner who investigated the death, Dr. Nabeel Alansari, to recommend the inquest take place. Trainor said he did not recall any conversation with Alansari around the topic.

"I didn't make a recommendation for an inquest because it was Dr. Alansari's file," Trainor told the jury.

Coroner never arrived

Trainor said the death certificate signed by Alansari included suicide as the cause of death, and under repeated questioning from MacDonald, Trainor said the duty to provide oversight of Alansari's work fell on him, as chief coroner.

Alansari is now working somewhere in the Middle East,MacDonaldsaid.

Meanwhile, staff from the facility who were working the day Gillis died said they waited for the coroner to arrive but he never did. They said instead a staff person from the coroner's office arrived to take away the body.

MacDonald said the six-person inquest jury should be free to consider the long delay in calling the inquest, given the fact another suicide took place at the facility three years later, although he was careful to point out he wasn't suggesting an earlier inquest might have prevented the death that followed.

"To not have the jury be able to consider that evidence would be an error," MacDonald responded, when questioned by the coroner presiding over the inquest, Dr. Roy Montgomery, to explain why the timeline might be relevant.

Video testimony shown

The jury was also shown recorded video testimony from four staff who were on duty at Hillsborough the day Gillis died. One nurse described how Gillis had been agitated days before her suicide, and placed under closer "one-on-one" scrutiny before being put back on checks every 15 minutes.

Other staff described Gillis as being calm, with a "flat demeanor" the day of her death. One nurse described Gillis taking her medication without fuss that morning, which he said was unusual.

Then they described finding her dead on the floor of her bathroom and efforts to resuscitate her, and how staff were "devastated" by the incident.

After the testimony, jurors were given copies of a 2010 internal review conducted by the Department of Health with 20 recommendations.

A lawyer at the inquest representing Health PEI said all the recommendations have since been implemented, the last of the 20 involving the installation of video surveillance cameras in the hospital over the past two years.

Other recommendations included:

• Reviewing observation levels of patients during weekly rounds.
• Conducting audits of electronic health records.
• Reviewing protocols for contacting EMS and responding to an unexpected death.

A nurse supervisor who was called in the day Gillis died said one recommendation removing vinyl gloves from areas where patients can access them was carried out that very day. Staff described how Gillis used the gloves in her suicide.

The jury said it would meet to consider recommendations of its own.

No third-party review

One thing the jury did not receive was a third-party review of the circumstances surrounding Gillis' death.

The 2016 inquest looking into the 2013 suicide death of Sherry Ball who was also a patient at Hillsboroughincluded a report from a forensic expert from Nova Scotia, whose 10 recommendations for change were adopted by the inquest jury.

The only outside opinion offered in this inquest came from Nova Scotia's chief medical examiner, Dr. Matthew Bowes.

Bowes did not examine the particular circumstances around Gillis'death, but offered general advice on how P.E.I.'s coroner system might benefit from the inclusion of peer reviews of contentious cases such as suicides.

Bowes also suggested a standard form for coroners with a series of "tick boxes" to check, including one to specify whether the death in question requires a mandatory inquest.

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