St. Joe's releases action plan to make patient suicide a 'never event'

St. Joseph's Healthcare Hamilton says it will expand its list of items that psychiatric inpatients are restricted from having, and more frequently assess patients for risk of suicide, as part of a renewed goal to make suicide a "never event".

Hospital released external review recommendations and action plan on Friday

The hospital led a study that examined 700 patients globally to identify what treatment options are for ANCA-vasculitis. (Dave Beatty/CBC)

St. Joseph's Healthcare Hamilton says it will expand its list of items that psychiatric inpatients are restricted from having, and more frequently assess patients for risk of suicide, as part of a renewed goal to make suicide a "never event".

The move comes as the hospital grapples with a succession of suicide deaths at Hamilton's psychiatric specialty hospital, St. Joe's West 5th campus, last year and this year.

A revelation from its reports released Friday was that the St. Joe's hospital system experienced nine suicide deaths of patients in 2016, not just the three it had previously acknowledged.

In addition to the three inpatient suicides, the review also examined:

  • Two other inpatient suicides where the patients were out on a day pass
  • Four outpatient deaths where the patients had accessed some care from St. Joe's (either its West 5th or downtown campus) during the year
Joel Verge died by suicide while a patient at St. Joe's West 5th campus on Nov. 9. (LifeNews.ca)
After those nine deaths, the hospital commissioned an external review by a former coroner and a suicide expert psychiatrist. 

The hospital released the recommendations and action plan from that review Friday.

Justin Bryant's mother, Eva, killed herself while an inpatient at St. Joe's last August. He hadn't had a chance yet Friday afternoon to read the review, but said he hoped it would be helpful for families like his.

"I do hope that tragedies like this will be prevented however or some changes will be made for the future so others will not have to endure such loss in a place that is supposed to be safe," he said. "The loss is quite difficult and is something I live with everyday." 

'One suicide is too many'

Winnie Doyle is executive vice president for St. Joe's, overseeing mental health and addictions at the hospital, said the hospital takes the situation "extremely seriously."

"There is lots of sadness about these tragic deaths, but there is a really deep passion and commitment to moving forward and doing all we can to prevent future suicides," she said. 

The hospital set up a task force to prevent suicide and to implement the recommendations within six months.

"For the families, loved ones and communities that have experienced the pain and anguish of mental illness, one suicide is too many," hospital president David Higgins said in a statement.

What St. Joe's plans to do

The hospital released Friday an outline of its task force, a list of the reviewers' recommendations and a timeline for the actions it commits to taking. 

"I think the commitment of St. Joe's is absolutely to be moving forward with these thoroughly, to ensure they're fully implemented, so that any opportunity we have to prevent someone from harming themselves, that we have taken that," Doyle said.

Among the hospital's action steps: 

  • updating the hospital's practices around searching and seizing contraband and means for suicide.
  • standardizing the way a patient is evaluated for suicide risk when seen in the emergency room.
  • holding focus groups with patients and families to address any perceived gaps in care.
  • reporting "lessons learned" to other hospitals in the province.

The hospital will also evaluate needs for training to make sure staff "feel confident and competent" for patients at risk.

St. Joe's also said it will move away from a long-standing mental health practice known as "contracting for safety," where a patient promises to a doctor not to harm themselves, or if they did feel like harming themselves, that they would follow a safety plan.

"There's been research looking at contracting [for safety], and did it contribute to prevention of suicide attempts, and it's been demonstrated that it doesn't," Doyle said. "The recommendation is to make sure we're not using it, because it's not helpful."

The hospital said its electronic record system, coming into effect in the coming months, will allow hospital staff to have more ready access to all of these assessments. 

'Would it have made a difference?'

Since the hospital commissioned the external review, and said it was taking steps based on an internal review, there were two more deaths. 

Two more West 5th patients have killed themselves – one who was out on a day pass, one who died in hospital.

Doyle declined to comment on the specifics of the cases. 

"Both of those are tragic events, and there is no doubt we would've liked to have prevented them," she said. 

She said the cases that West 5th health care workers encounter are complex and demanding. She said she's hopeful that these new action steps will prevent suicides in the future, but the illness is difficult to predict.

"I don't think we know whether if these were fully implemented, would it have made a difference in either of these cases? I don't know for sure. I hope it would've. But I don't know."

Review: Staff 'deeply committed to providing the safest care possible'

The external review was conducted by Paul Links, a psychiatrist specializing in suicide studies, and Craig Muir, a former regional supervising coroner.

The reviewers noted that there's no reliable data to compare the number of suicide deaths at St. Joe's to other similar programs.

Brandon Taylor was 29 when he died at St. Joe's West 5th campus last August. (Jenn Smyth)

"The events were nonetheless sufficiently disconcerting to the organization and their healthcare providers that they requested and facilitated a critical examination of their practices," they wrote.

They reviewed hospital policies and procedures, health records, the hospital's own internal review documents and death investigation reports of the individuals who died. They visited the hospital and interviewed leaders, doctors and front-line healthcare workers.

The reviewers also note that they came away with a "clear impression that all those responsible for providing care to this very challenging population are, at every level, exceptionally engaged and deeply committed to providing the safest care possible."