Mental-health advocates say past death reviews like Abbotsford inquest haven't prevented tragedies

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      The B.C. Schizophrenia Society (BCSS) has said it has low expectations for a coroner’s inquest that will examine three deaths linked to mental-health issues that occurred over a four-month period beginning in December 2014.

      According to the B.C. Coroners Service, all three individuals died shortly after leaving Abbotsford Regional Hospital, which is run by the Fraser Health Authority. The inquest is scheduled for May 16, 2016.

      BCSS program and development coordinator Ana Novakovic called attention to a number of previous government reviews of similar deaths. She emphasized those were followed by recommendations that failed to prevent the three being examined next year.

      “Since 2008, there have been three other coroner’s inquests into deaths involving improper monitoring and discharge of mentally ill patients in hospitals under Fraser Health Authority’s jurisdiction,” Novakovic told the Straight. “A number of improvements were recommended as a result of these inquests, but it seems that they are either inadequate or have not been implemented.”

      According to a BCSS analysis, those earlier cases concerned Ross Allan, who died in April 2008, Jasdeep Sandhu, who died in October 2008, and Patricia Reed, who died in February 2011. According to their respective inquest verdicts, all three were admitted to Fraser Health hospitals for mental-health reasons and died while in the care of those facilities or shortly after discharge.

      BCSS executive director Deborah Conner said she’s worried the review scheduled for May 2016 will find the three people who are the subjects of that inquest—Brian Geisheimer, Sebastien Abdi, and Sarah Charles—died under similar circumstances.

      “My question would be: was there a treatment plan when these people were released?” Conner said.

      In a phone interview, Stan Kuperis, director of mental health and substance use for Fraser Health, listed a number of mental-health-care reforms implemented in recent years. These include improved patient-transfer protocols, for example, and revised policies for discharging patients. In addition, Kuperis emphasized that Fraser Health pays close attention to coroners’ investigations.

      “We have responded to all those recommendations within previous coroner’s inquests and have put changes into place in response,” he said.

      According to Conner, the most troubling aspect of this series of events is that when it comes to mental health, Fraser Health is actually among the best B.C. service providers.

      “There are similar problems everywhere,” she said. “It could very easily be happening in all the other regions.”

      According to Fraser Health, during the 2013–14 fiscal year, its 12 hospitals throughout the Lower Mainland saw 30,305 emergency mental-health visits.

      On August 19, the Straight reported that the number of emergency mental-health visits Vancouver General Hospital and St. Paul’s Hospital see together in one year is projected to surpass 10,000 before the end of 2015. That’s up from 6,520 in 2009.

      Those hospitals—operated by Vancouver Coastal Health and Providence Health Care, respectively—have also dealt with high-profile incidents that followed patients leaving a facility after they were admitted for a mental-health issue.

      In December 2012, for example, Nicholas Osuteye attacked three women two days after he was discharged from St. Paul’s Hospital. In February 2012, Mohamed Amer stabbed an elderly man the same day he was released from St. Paul’s. And in January 2012, Jerome Bonneric was charged with assault shortly after St. Paul’s let him go. (An external review of the Amer case resulted in 22 recommendations for service improvements.)

      In a telephone interview, Dr. Bill MacEwan, head of psychiatry at St. Paul’s Hospital, explained how staff work to try to ensure nobody admitted for mental-health reasons leaves on their own or without a support system in place.

      “The three key things for any individual that we always try for is a place to live, follow-up care, and support, where support can be a variety of things, from family to a mental-health team,” he said. “To get those three variables covered, that’s the general approach that we take.”

      MacEwan stressed that’s not always easy, especially when an individual has no fixed address.

      “It’s harder to track somebody and find somebody and follow up with care if you don’t know where they live,” he said. “For those individuals, to have them go into care, that becomes more difficult. Sometimes it’s a shelter.”

      Conner said the problem is not insurmountable and primarily persists on account of a lack of political will.

      “It’s not like we don’t know what has to happen,” she said. “Programs have been around for a long time. They have proven to be effective, and they have academic rigour. They just needed funding and consistency.”

      In 2010 (the last year for which statistics are available), hospitals only fully implemented 26.3 percent of coroners’ recommendations, according to a department annual report.

      The B.C. Ministry of Health did not make a representative available for an interview.

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      Comments

      10 Comments

      MarkFornataro

      Aug 26, 2015 at 2:09pm

      a question I have is- does Abbotsford Regional Hospital have a policy of force -medicating their patients with drugs that cause suicidal tendencies-such as Prozac? if they had an orthomolecular approach- based on optimum nutrition- as practised by the late Dr Abram Hoffer I'm sure they'd have better outcomes.

      @MarkFornataro

      Aug 26, 2015 at 4:16pm

      No, they don't. They do absolutely nothing to do with nutrition---our whole medical system is in a shambles because nutritional defects are not considered possible in our "affluent" society. I had a skin problem for years, and all the docs ever did was prescribe cortisone creams. I started eating properly, no more skin problem. Our healthcare system is a travesty---and if they won't do nutritional stuff for obvious things like skin problems, you can bet they don't when there isn't any visible sign of disease. Mental illness is all genetic, donchaknow!

      &^%$

      Aug 26, 2015 at 6:15pm

      One of the biggest travesties in our society was the dumping of patients into the community in the early 1980's.

      The large hospitals were outdated and in desperate need of being replaced, but the mainstream media fed the hysterical narrative of sadistic evil people working there in order to torture the patients. No proof ever provided.
      How much cheaper to simply cut them loose and let them founder with drugs and street life instead of replacing the aging infrastructure and looking after the patients properly?
      Presently, we have TV shows showing schizophrenics as crime solving geniuses and people eat that shit up.
      The Social Credit government, the NDP and the Liberal are all to blame for the incredibly shortened lives of misery.

      DeceitinDrugs

      Aug 26, 2015 at 8:57pm

      How is it they cannot act based on the past tragic deaths..clearly need to address the
      problem..staff shortages is one of the biggest contributors to patient deaths.

      more swears

      Aug 26, 2015 at 10:06pm

      30 years later and we're still desperately trying to piece together some semblance of haphazard community care for the mentally ill that doesn't in any way address their real needs. It provides a shit ton of jobs for social service workers though and costs us all a lot more than inpatient treatment would. It costs the patients more though.
      If we keep addressing it the way we have been it isn't going to get any better and people will continue to needlessly die.

      Barry William Teske

      Aug 26, 2015 at 11:40pm

      Question please?
      Are these reviews meant to prevent tragedies or are they necessary to keep everybody on the same page, above board and provide a review the paper trail?

      @Barry etc

      Aug 27, 2015 at 12:51pm

      Neither.
      According to past history they're simply a way to say "Look at us looking into this issue. Now back to business as usual"

      Barry William Teske

      Aug 27, 2015 at 2:47pm

      @Barry etc

      I was hoping on a response from the writer or at the very least an official response...
      I am not looking to place blame.
      It is apparent though getting to the truth about this is going to be harder than climbing Everest during a snowstorm just before an earthquake...

      Hey Barry

      Aug 27, 2015 at 3:57pm

      Blame is part of the forensic procedure. It's how you figure out what went wrong. Don't let a word scare you.

      Lori b

      Sep 1, 2015 at 1:18pm

      I know of one more patient released from Abbotsford Regional for months in 2014 and took her life 2 days later. How many more r there that have not been mentioned or made known in the greater VCR Fraser Valley and surrounding areas? There is always more to the story.