A judge has recommended that Edmonton's Alberta Hospital improve its search plan after 68-year-old Lorraine Adolph froze to death three years ago.
Adolph walked out of the hospital on Dec. 4, 2008, to smoke a cigarette, but failed to return.
Her frozen body was found seven days later beside an abandoned building on the hospital grounds.
Adolph, who had schizophrenia, had wandered away from a hospital in Stony Plain, Alta., and was sent to Alberta Hospital because of its onsite security.
In a fatality inquiry report, provincial court Judge Ferne LeReverend suggested the hospital appoint one person per shift to be a search leader in charge of all aspects of search and return.
The leader would also be in charge of appointing and training a search team, ensuring the proper equipment, including snowmobiles or ATVs, is available.
The inquiry had heard that security guards sent to find Adolph didn't have winter boots and were unwilling to walk through five centimetres of snow to search around buildings.
The leader would be tasked with calling police or other agencies if the patient is not returned to the unit within a reasonable period of time, keeping in mind weather conditions and the patient's mental health, LeReverend wrote.
Sister angry with 17-minute search
The search leader would also conduct sufficient drills to ensure a timely and thorough search of the grounds.
Lorraine's sister Esther Gehlert told CBC News Tuesday her sister had a history of walking away from hospitals.
Gehlert said she would recommend staff accompany patients on a smoke break.
"Somebody should have gone out there with her to have a cigarette," she said. "It only takes what? Two minutes?"
Gehlert was especially angry staff only spent 17 minutes searching for Adolph before giving up.
"That's ridiculous," said Gehlert who looked after her sister for 25 years. "I mean if my dog was missing, I would look for longer than that."
Hospital improving search process
Alberta Health Services said it has made changes to the way it searches for missing patients at the hospital since Adolph's death.
"We certainly identified ways that the system could be improved," said Mark Snaterse, the executive director of addictions and mental health.
"Sometimes it has to do with processes, internal processes and policies and training and orientation," he said. "And certainly we've made steps to enhance that significantly."
Snaterse also says they are in the process of leasing ATVs and snowmobiles for searches during winter.
LeReverend also recommended a secure outdoor area be made available for patients who wish to smoke.