Inquest: Fraser Todd Jeffrey | Systemic Advocacy | Psychiatric Patient Advocate Office

Inquest: Fraser Todd Jeffrey

Background:

On September 6, 2001 the PPAO wrote to the Regional Supervising Coroner to support the patients of the Mental Health Centre Penetanguishene (MHCP) in their quest to be involved in the upcoming inquest into the death of Mr. Jeffery. The patients wished to seek standing and to be involved in all aspects of the process. The patients were successful in being granted standing and were represented by the law firm of Hiltz Szigeti LLP. The inquest was held at the Oak Ridge Division of the MHCP which allowed co-patients of the deceased to attend the proceedings.

On January 4, 2002 the PPAO attended a pre-inquest meeting with the other parties seeking standing at which time the office was given a copy of the brief that was to be used for the purposes of the inquest. Following that initial meeting, the Psychiatric Patient Advocate Office (PPAO) wrote to Mr. Michael Flosman, Crown Counsel and Dr. Peter Savage, Coroner on January 17, 2002 pursuant to subsection 41(1) of the Coroners Act, R.S.O. 1990, c.C.37 to ask for standing at the inquest into the death of Mr. Fraser Jeffrey, which was scheduled to commence on Monday, January 21, 2002.

The PPAO in their letter stated that "although the PPAO has not officially been apprised of the specific issues that will be raised at the inquest, discussions at the preliminary meeting and document review raised issues of appropriate monitoring during evening shifts; early identification and treatment for depression with a comprehensive suicide prevention program, and; environmental, operational and institutional issues relating to maximum secure forensic facilities. The PPAO's interest in these issues is direct and substantial from the perspective of a public interest group with substantial expertise in working with provincial psychiatric patients and a provincial perspective which can be brought to bear on the issues to be examined at this inquest".

The inquest was held at MHCP from January 21-24, 2002.

Regrettably, the Coroner denied the PPAO standing at the inquest as he was of the opinion that the PPAO did not have a "direct and substantial" interest in this particular case. However, the PPAO remained at the inquest to monitor the issues raised and provided informal feedback and support to the parties involved. Following are the recommendations from the jury:

We wish to make the following recommendations:

That the hospital immediately enrols in the PRACTICE SETTING CONSULTATION PROGRAM developed and implemented through The Ontario College of Nurses. This program is a nurse driven and management-sponsored consultation service designed to assist nurses and their employers to identify, create and maintain characteristics in their workplace that support quality professional practice.
This program offers nurses and employers a chance to work together. In addition it provides a unique leadership opportunity for nurses within their organization.
Within the next two months, we recommend that all nurses (RN, RPN) on ward 04 complete a morbidity round reviewing the issues leading up to and surrounding Fraser Jeffrey's death. This process allows the nurses to self analyze their own practice in an environment restricted to themselves, the results of which are not subject to any outside scrutiny. The purpose of this is to allow the nursing staff to share ideas and learn from this tragedy. A morbidity round is a medical process with well established guidelines. This should be done on hospital time to ensure inclusively.
That the hospital shall pay and sponsor, the membership of all registered nurses working facility wide who desire to join the Registered Nursing Association of Ontario. This will ensure that a link is developed between the nurses at Oakridge and a professional body that is continually striving to promote excellence in nursing.
Mandate a Nursing Council, made up of front line nurses, one of whom shall act as a meeting facilitator and have facilitation skills, be created with representation from each ward to meet monthly in order to discuss:
1. Problems that are impediments to their ability to provide quality nursing care,
2. Concerns or issues brought up by the patients,
3. Suggestions brought forward to improve quality care. The minutes of this meeting are distributed to institution's administration. Responses to any recommendations would be expected in writing.
The Chief Nursing Officer and the Nursing Practice Committee shall review this recommendation to determine how it will be implemented.
Re-install the dimmer switches. In an effort to accommodate the needs of the patients' comfort and the needs of the nursing staff to verify patients' wellness, re-installing the dimmer switches to balance the requirements of both parties.
The level of competence pertaining to the specialty of Psychiatric Mental Health could be dramatically improved if the Registered Nurses were encouraged to pass the Canadian Nurses Association certification or any other courses that would pertain in this specialty. We recommend that Oak Ridge should fund this initiative.
That the hospital have a procedure to ensure that part time employees be made aware of the policies and policy changes.
That all nursing staff be given night-time orientation post lock up HS.
That there be a greater emphasis at performance review time of the educational needs of the staff.
That a protocol be developed for "critical incident" investigation and review including the bringing of an external resource.
Privacy curtains should offer patients dignity, but should not be used between the hours of 11:00 p.m. to 6:00 a.m. for better visualization of the patient.
The clinical team should be made aware of suicidal patients and have the doctor assess them as such, so special attention can be applied if needed.
All staff on every shift should record all pertinent information (depressed or problematic etc.) Information to be discussed and passed on to the oncoming shift.
When a day/night shift changes, both nurses should be required to do a ward walk around taking a headcount.
A staff patient committee needs to be developed with all patients to work with staff re: patient daily needs and living conditions. Staff and patients need to work together to resolve problems to bring down the mistrust barriers that presently exist.
There should be counselling for patients and staff to help with such a great loss. Situations such as this should tend to draw people together, not push them further apart.
The general theme in the hospital now is Security versus Compassionate Patient Care - which reduces staff patient intimate communication and sets up security issues verses patient treatment, rehabilitation, living conditions and privileges. It may be more useful to develop a theme of - Compassion Patient Care with enhanced security by staff and patients through knowing and working with each other. This shall be an agenda item for the patient staff council.
That all new Nursing staff be paired with a mentor for the first year.
That a review of the present security orientation education occur with an emphasis on duties and role of staff observing patients on night shifts. That consideration be given to annual or biannual refresher programs to reinforce and support staff duties; to support consistency in carrying out said duties; and to provide contemporary information and instruction regarding relevant policies and practices. This would also provide a forum to address and suggest approaches with difficult patients.
That general orientation programs for new staff address the importance of risk assessment (e.g. aggression, self injury, suicidal ideation), and mental status examination. Additionally, these programs should reflect the importance of regular, standardized, documentation and communication of the results of risk assessment and mental status examination. Mandatory in-service training be provided to all staff to assist them the identification and management of patient stress indicators, suicidal indicators, symptoms of relapse, and identification of potentially dangerous patient situations.
That uniform assessment instruments be utilized across the facility to ensure quality care, accurate assessment and timely intervention and patients in need. Uniform, valid and reliable assessments will promote continuity of care and communication, and support evaluation of care and initiation of Best Practice Care Models.
That the facility review patient-focused Crisis-Debriefing, and intervention strategies, and develop strategies and interventions to address patient responses to tragic/unforeseen events.
That the facility continues to support Crisis Debriefing activities for staff members, and that Crisis Debriefing activities be uniformly applied across the facility. This should include a review of how the Crisis Debriefing is activated, and examples of events that would trigger activation of the Crisis Debriefing Team.
That the appropriate balance between patient protection, safety and security; and patient privacy, freedom and dignity be a topic for discussion by clinical teams and the Forensic Division Operating Team on a semi-annual basis.
That procedures be identified to safely and discreetly provide privacy for the body of a deceased person which allows for containment of the scene, while being sensitive to the needs of other patients and staff.
Patient files should have pertinent facts highlighted for easy viewing.
Non-regular staff should take second walk about in order to read patient information.
All night staff should be required to carry non-intrusive flashlights and be used with courtesy.

Download Verdict of Coroner's Jury with Coroner's Explanation: PDF

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