Jurors deliberated at the final day of the inquest into the death of Hillary Hooper, who died in December 2020.
Hooper was found hanging by hospital staff nearly a month after she first checked herself in after consuming 50 pills an hour before. When she arrived at the Saint John Regional Hospital doors, she had a history of depression and attempted suicide.
Jurors were asked to make recommendations based on the evidence that was presented over the three-day span.
The selected jury heard from a range of doctors, police and nurses who spoke on the night that Hooper arrived at the hospital through to the night she died in December.
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In total, 11 recommendations were set by the jury, including:
- Recommend that 4DNort utilize bedding that tears easily and will not support a person’s weight if used as a noose. This recommendation is made with consideration given to frequent laundering requirements in hospital setting.
- Replace bathroom doors in patient rooms with doors that can be locked.
- Fix door 62 so it closes properly.
- Replace patient room doors with pocket doors or accordion doors or doors that open out into the hallway equipped with quick release hinges to prevent patients from looking doors.
- Consider installing security cameras in patient rooms. This recommendation made recognizing that there are issues pertaining to patient privacy that requires consideration in this regard.
- Recommend that any time a patient door is blocked that attention be given to that room immediately.
- Recommend that in order to prevent hospital beds from being used to block doors, that they be secured with a locking mechanism that can only be released by authorized personnel.
- Consideration be given to searching patients upon admission to 4DNorth, (pat-down, searched of bags pockets ect.) in order to detect potential weapons, drugs, mobile phone etc.) This recommendation is made with recognition of issues pertaining to patient privacy in this regard.
- Recommendation that staffing components be increase during night shift beyond 3 RNS (registered nurse). Additional staff need not to be RN’s. LPN’s (licensed practical nurses), PSWs (personal support workers), security staff may be options. This recommendation is made with recognition of current staffing challenges and shortages.
- Recommend that a code blue crash cart be situated on 4DN.
- Recommendation that a short stay unit be implemented as part of the psychiatric services available at the Saint John Regional Hospital. Said unit to include DBT (dialectical-behaviour therapy) as part of its treatment protocol, with linkage to community based DBT for follow-up, post discharge.
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Coroner Emily Caissy made additional recommendations, including:
- That Horizon continue to explore the possibility and supports the implementation of crisis stabilization unit in its hospitals.
- That Horizon provides information session on local resources available for people with borderline personality disorder. A list of resources should be displayed aA list of these resources should be displayed and available to physicians
- That Horizon adopts, or makes, a continuous assessment of suicide urgency. The form should be used in any medical clinic, or emergency department where a patient presents themselves in either a mental health crisis or self reports being suicidal. Horizon should also evaluate this form to see if there is merit in also using it on units.
- That the department of justice and public safety support the office of the chief coroner in establishing a suicide fatality review committee.
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In a statement to Global News, Horizon Health Network said they’ve already put in place some of the recommendations and will look to continue to add to them.
“Horizon embraces opportunities for ongoing quality improvement and any recommendations that will result in improved safety and quality of care for our patients and staff,” said Renée Fournier, director of Addiction and Mental Health Services.
“These changes, and any others resulting from these recommendations, will help mitigate the risk of similar incidents from taking place in the future.”
For Hooper’s mother Patti Borthwick, it meant the end to a 27-month soul search. Following the inquest, she rose in the courtroom, thanking the jurors.
She said, “Finally my girl can rest in peace.”
She told Global News that the jurors hit all the recommendations that she was looking for, adding that the recommendations will prevent further suicides.
“She’s going to save lives, I honestly believe that,” she said while speaking inside the Saint John Courthouse.
“They got everything we wanted to get: the doors, the bedding, all the things that make it impossible for someone to do what she did again.”
She explained that the process was emotional for the mother, who hadn’t known some of the things that happened in the days leading up to her death.
The coroner will take the finding to the chief coroner for presentation at a later date.
If you or someone you know is in crisis and needs help, resources are available. In case of an emergency, please call 911 for immediate help.
For a directory of support services in your area, visit the Canadian Association for Suicide Prevention at suicideprevention.ca.
Learn more about preventing suicide with these warning signs and tips on how to help.
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