Inquest: Christopher Magee
Background:
The Psychiatric Patient Advocate Office (PPAO) applied for and was granted standing in the Christopher Magee Inquest. The PPAO chose to seek standing as a way to draw attention to medical and emergency services for individuals in the current and divested provincial psychiatric hospitals.
An inquest was held from October 18-29, 2004 and the jury returned their verdict on October 29th. Following are the recommendations of the Jury:
Jury Recommendations:
We wish to make the following recommendations:
To Caregivers of Psychiatric Patients
- That all nursing staff be aware and trained on the “emergency response protocol” (with respect to whom they call, necessary information to give (no acronyms), their exact location)
Reasoning: To expedite appropriate emergency response services. - That all nursing staff be trained with respect to securing a scene where a serious or potentially serious incident may have occurred.
Reasoning: Preserve the integrity of an investigation.
St. Joseph’s Health Centre, Regional Mental Health Care – St. Thomas
- Where patients present with complex medical problems staff should be provided the necessary background and information through in-service education to appropriately assess and respond to situations as required.
Reasoning: To educate nursing staff in regards to complex medical conditions. - Each building should be clearly labelled with signs that are visible to approaching vehicles. Evaluate the adequacy of the signage giving directions to the different buildings.
Reasoning: Responding emergency teams will be able to independently find their way in the event security is unavailable to meet them. - Install hand scanner time readers outside each of the seclusion rooms.
Reasoning: To ensure that Q15 monitoring of patients in seclusion is physical rather than video observation. If for some reason a nurse is unable to make the 15 minute scan, this should be noted in the daily check records. - Have “crash carts” available to include semi-automatic defibrillators, oxygen assisted ambu-bags and powered suction equipment. Have personnel on duty at all times who are trained to use defibrillators, suction equipment and any other equipment that could be used in the treatment of patients suffering from cardiac arrest or respiratory arrest. To include timely reviews and or training.
Reasoning: To provide the best possible patient care. - Upgrade the video monitoring equipment, to modernize technology, to include video recording equipment.
Reasoning: To better view/assess patients in seclusion rooms. Video record to ensure patient empowerment. - Initiate guidelines involving the substitute decision maker with regards to alternative methods to have patients take medicine.
Reasoning: To keep patients within recommended therapeutic levels of medicine. - Medical records must be transferred with patients within a two week window.
Reasoning: Upon review of Exhibit #3, page #1026, Tab “L” it appears that there is a significant delay in forwarding patients medical/psychological Reports to the receiving institution.
To Counties/Regions Overseeing Ambulance Services
- Ensure all removable/interchangeable cables used with the defibrillators have non-removable serial numbers. Document serial numbers of cables and defibrillators prior to shift.
Reasoning: To ensure that all equipment is properly tested in the event of a malfunction. - Any equipment with signs of malfunction be quarantined (out of service) until the equipment has been tested.
Reasoning: To ensure equipment has appropriate tests completed before being put back in service. - That they consider having more “advanced care paramedics” on staff.
- View the possibility of implementing the use of portable suction equipment that is comparable to the powered suction equipment on the ambulance.
- All 911 call centres, must clarify acronyms.
Reasoning: To avoid any misunderstanding of information provided during any 911 call.
Download PPAO Press Release and Verdict of Coroner's Jury with Coroner's Explanation: PDF 
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