A fatality inquiry report into the death of a Calgary psychiatric patient who drowned in the Glenmore Reservoir three years ago concludes her death was not the result of any breach of procedures or policy by hospital staff.  

The body of 52-year-old Trinh My Tran, who was being treated for schizophrenia at the Rockyview General Hospital, was discovered in the water next to a steep embankment near the hospital grounds.

On the day she died, Tran had been given a pass to leave her unit but had promised to stay on hospital property. She had hour-long, off-unit privileges and was exercising them at the time of her disappearance.

In his final reportprovincial court Judge Karim Jivraj said “the circumstances and events leading to Ms. Tran’s death do not disclose any limitations or problems with the hospital’s policies and procedures, or with the type of care that was provided to Ms. Tran.”​

It was never determined whether her drowning was an accident or suicide.

Six staff members from the hospital — including doctors and nurses — testified at the fatality inquiry that wrapped up last year.

Tran’s psychiatrist Dr. Roy Turner testified at the inquiry that she had responded well to her treatment, earning the right to leave the facility unescorted. And she showed no signs of being suicidal, he told the inquiry.

Since Tran’s death, a fence has been put up to prevent accidental falls down the embankment, the judge noted.

While Jivraj said he had no recommendations for preventing similar deaths, he suggested more signage be installed near the mental health units marking where hospital property begins and ends.