Notice to Our Community: Coroner’s Inquest Recommendations
Today marks the conclusion of the Coroner’s Inquest into the death of Mr. Steve Mesic, a former patient cared for in our Mental Health and Addiction Program. We continue to express our sincere condolences to Ms. Dorr, her son Dominic, and to the family of Mr. Mesic on their loss.
Mr. Mesic’s death was a tragedy that has had a significant impact on our organization, and on our community as a whole. The purpose of a Coroner’s Inquest is not to assign fault or blame, but to investigate the death of an individual, and seek recommendations that could prevent similar deaths.
As a regional leader in mental health and addiction care, it is my great hope that in addition to internal improvements within our organization, the inquest will provide insight into how we can systemically work together we can work to improve the lives, health, and experiences of those who live with mental illness and addiction.
An internal review of Mr. Mesic’s clinical assessment in the days and hours leading up to June 7, 2013 showed no evidence he intended to take his own life after leaving hospital. With the wider and more inclusive review afforded by this inquest, we have had the opportunity to evaluate our policies and processes for further improvements.
As a means of enhancing care, St. Joseph’s Healthcare Hamilton submitted its own recommendations to the Crown and Counsel for its consideration, including the following:
A. The Hospital should review its patient observation process, and monitor staff adherence to this process including the use of the electronic documentation device (Tough Book), in the Mental Health and Addiction Program.
B. The Hospital should review its policy and procedures for management of Off Ward Passes and how that Policy is applied in the Mental Health and Addiction Program.
The jury considered these recommendations, as well as recommendations put forward by Hamilton Police Services and the family of Mr. Mesic. After careful consideration of all evidence, recommendations and testimony, the returned with the following:
Ontario Police College:
1. We recommend that the Ontario Police College include training by consumers/survivors of mental health services when providing EDP (Emotionally Disturbed Persons) training.
2. We suggest that the events surrounding Mr. Mesic’s death be included in scenario training at the Ontario Police College
The Hamilton Police Service:
1. We recommend that the Hamilton Police Service receive additional EDP training (annually) by consumers/survivors of mental health services, due to the statistics supporting the amount of police calls dealing with EDP within Hamilton.
2. We recommend that Hamilton Police Service consider the feasibility of radio prompts in addition to MDT messages to alert officers of persons displaying self-harm and harm to others.
3. We recommend that the Hamilton Police Service study the results of the current project being piloted by Toronto Police Services with respect to lapel cameras. If the results warrant, then we recommend the program be introduced to Hamilton Police Service.
All Police Services within Ontario:
1. We recommend that all Police Services in Ontario provide Subject Officers mandatory “Re-certification” of “use of force” training and mandatory consultations with psychologists prior to returning to work after lethal use of force scenarios.
St. Joseph’s Healthcare Hamilton (the Hospital):
1. We recommend that St. Joseph’s Hospital review its client observation process, and monitor staff adherence to this process including the use of electronic documentation device (Tough Book), in the Mental Health and Addiction Program. We suggest that the hospital consider enhanced identification measures such as the possibility of using arm band bar-code scanning system or including patient photos in client profiles to facilitate accurate observations, increase meaningful interactions between staff and clients and provide precise documentation of client locations.
2. We recommend that St. Joseph’s Hospital develop a specific policy for the Mental Health and Addiction Program in order to provide direction to staff in the management of “Off Ward Passes” and for voluntary clients who do not return, and that this program be reviewed by staff and doctors annually.
3. We recommend that St. Joseph’s Hospital standardize the transfer of primary responsibility between physicians and that this information be included as part of the permanent client record.
4. We recommend that where family involvement is accepted by the client, that St. Joseph’s Mental Health and Addiction Program increase communication with the family as to the plan of care prior to the expiration or change of a “Form 1” and/or “Form 3”.
The jury’s recommendations for St. Joseph’s Healthcare Hamilton are thoughtful. The men and women of the jury did a remarkable job in understanding both the complexity of this case, and the complexity of the systems under review in this case. We are committed to carefully reviewing these recommendations, and considering how to address them within our vision of delivering transformational mental health and addiction care to our patients, and for our community.
Dr. David Higgins,
President
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