By James Wood and Ashley Wiebe

Piche fatality inquiry report recommendations released

Aug 21, 2017 | 10:34 AM

MEDICINE HAT, AB — The results of an inquiry into a suicide at the Medicine Hat Regional Hospital have been released.

The inquiry took place in May of 2017, and dealt with the matter of Glen Piche, a Medicine Hat resident who took his own life while being held in the psychiatric unit at the local hospital back in 2013.

Piche had been brought to the hospital by police, after they were told by family he was threatening to take his own life.

At the time of the inquiry in May, his family expressed both happiness for the inquiry taking place, and anger at how long it took to happen.

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The lawyer for Piche’s family also brought forward more than 20 recommendations to the judge overseeing the inquiry, which included the installation of cameras in all patient rooms and hallways of the psychiatric ward.

Three other files were brought before the judge, outlining similar cases of suicide. The family’s lawyer pointed out that previous judges had made recommendations of having cameras and video, but the system never changed.

Judge Fred Fisher agreed with the recommendation that cameras should be in all of the patient rooms and was clear that it would be included in his recommendations. He went on to say that he can simply make the recommendations to Alberta Health Services, but there’s no mechanism to have them put in place.

“Hopefully they’ll do what we ask them to do,” he told the court in May.

The recommendations released in the inquiry report address the installation of cameras, as well as the timing of inquiries and the removal of dangerous items in the psychiatric ward. They were listed as follows;

1. When fatality inquires are to be held, they must be held within two years of the date of the death of the person who is the reason for the inquiry.

2. All units within 5 North, the psychiatric ward at the Medicine Hat Hospital, should be monitored by video cameras, regardless of whether they are seclusion rooms or not. Patient safety was said to be important than the privacy issues that may arise.

3. All records at the Medicine Hat Regional Hospital should be put into electronic form as “quickly as reasonably possible”, as well as past records pertaining to a patient newly admitted to the psychiatric unit be provided to the attending psychiatrist within four hours of the patient arriving.

4. All records stored off site are to be provided as soon as reasonably possible to the attending psychiatrist in order for them to have all pertinent information to make a proper assessment of the patient.

5. All police agencies making arrests under mental health warrants should check their databases prior to the arrest to determine if there are prior mental health issues, suicide attempts, or harming behaviours in a person’s background. This should be done to provide as much information as possible to hospital staff who might be evaluating the person.

6. All mechanisms attached to bathroom doors in the psychiatric units at the Medicine Hat hospital should be removed, as Piche had been found to have tied his bed sheet to a hanger on the inside of the bathroom door.

7. Due to evidence that Piche used the patient phone continually during his stay and became upset after the call, it is recommended that nurses in charge of patients monitor their use of the phone on a case by case basis. This would be to determine whether or not to limit their phone usage.

8. It was recommended that security staff working in the hospital do observations of patients while nurses are on their breaks, and any observation sheets used by the guards that record patient issues become part of the patients record. This was also extended to observation sheets used by nurses.

9. Nursing and security staff who carry out patient observations were recommended to not use the same routine for checking patients while on rounds, while keeping the required levels of checks in mind.

Marc Piche was excited to see what the judge had to say and said it helped answer a lot of questions, but the family still wants to know why Glenn died in the first place.

“It helps answers a lot of questions, from what the judge has said, how he implemented or suggested that things should change,” he said. “But the question is why did it happen still? They knew there was a problem but yet [Alberta Health Services] chose not to do anything about it.”

Katherine Chubbs with AHS said they’re working on putting together a team to review the recommendations and determine what changes, if any, need to be made.

“There’s a lot of things that we have to consider when putting in any recommendations,” she said over the phone from Lethbridge. “We look at safety as one part of it, but we also have to look at the quality of care and the experience for the individual so we would understand the impact on the diagnosis they would have.”

Recommendations from the Piche family lawyer touching on the standard of care and post-suicide incidents involving Alberta Health Services were found to be out of the scope of the inquiry, as well as recommendations about the training of medical and security staff.

A recommendation touching on the preservation of live-circuit monitoring video within 5 North was also mentioned. While the report states that it may be beneficial, it was found to be beyond the scope of the inquiry.

-with files from Ashley Wiebe