Suicide review 'too late' for some families of those who died at psych hospital

Some family members who thought their loved ones would be safe from suicide as inpatients at St. Joe's West 5th campus said they're surprised by the hospital's action plan released last week and at how long it took to complete an external review.

'I would have thought that St. Joe's was already doing all the things that were recommended': Father

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

Some family members who thought their loved ones would be safe from suicide as inpatients at St. Joe's West 5th campus have mixed reactions to a recently-released hospital action plan to combat suicides.

Some speak of how is has come too late for them and the person they lost along with frustration at how it took for an internal review to be done, while others say they hope the plan will help prevent future incidents.

Meanwhile, hospital administrators said preventing suicide is a complex task but that it is committed to preventing the tragedies from happening within its walls.

Its action plan includes expanding the list of prohibited items, evaluating risks in the physical hospital design and more frequently assessing patients for suicidal thoughts.

In general, I would have thought that St. Joe's was already doing all the things that were recommended. -  Stuart Taylor

Stuart Taylor's 29-year-old son Brandon was in the hospital — the region's specialized mental institution — for just a few days before he took his own life last August.

"The review comes too late for Brandon," Taylor said. "In general, I would have thought that St. Joe's was already doing all the things that were recommended."

St. Joseph's Healthcare Hamilton released the series of recommendations last Friday stemming from an external review commissioned after several suicides by patients at the hospital's West 5th campus in 2016 — three by inpatients in the hospital, two others by inpatients out on a day pass. 

This year, there have been two more inpatient suicides after the review was commissioned, both by inpatients at West 5th, one while out on a day pass.

The hospital said Friday it plans to make suicide a "never event" for patients of the hospital.

'This is unacceptable and one death is too many'

Taylor's family said he was supposed to be checked on every 15 minutes, but his fiancée found signs he'd been searching for ways to end his life for days.

"We have a lot of 'whys,'" Taylor said earlier this year. "Why was he able to use a cell phone? Why was he able to do this when he was on suicide watch?"

His lawyer, Michael Smitiuch, said the review makes "several good recommendations" but questions why the things identified in the plan weren't already implemented.

He said in cases around the country, two common factors stand out:

"We have cases throughout the country and there is a common theme: a lack of proper supervision and a failure to keep the environment safe," Smitiuch said. "In many cases, the hospitals allow the patients to have the very means to take their own lives. This is unacceptable and one death is too many."

'Reality that these challenges exist should not stop us'

In an interview Thursday, the hospital's deputy chief of staff, Ian Preyra, said administrators realize the goal is ambitious, given the complex nature of mental illness that often accompanies addiction.

"In medicine so many of the monumentuous achievements have started with goals that at the time of their implementation, would have been thought to be unrealistic and ambitious," he said.

"This reality that these challenges exist should not stop us from striving to prevent these tragedies from occurring within our walls."

He added: "We understand that regardless of our best effort, that suicides may occur."

Among the actions the hospital has already taken: Removing "ligature points" that have been identified by patients as aids in attempting suicide.

While the review doesn't go into specific measures to close weaknesses that led to deaths last year, Preyra said he and the hospital are careful not to publicize the specific methods used by those who died, so as to try to keep others from following in their path.

St. Joseph's West 5th Campus opened a redesigned hospital in 2014. (Dave Beatty/CBC)

That said, the hospital already doesn't have coat hooks or showerheads that don't detach, Preyra said.

"But if we find that there is something in a typical patient room that a patient might use as a ligature point, that we would not have anticipated, then we would move to close that right away," he said.

When West 5th opened in 2014, it was touted as a manifestation of best practices for patient safety and therapeutic healing for mental health. There were three patient suicides in 2013, before the redesigned West 5th opened, all of which happened while patients were out of the hospital on a day pass.

Preyra said the hospital, in making these actions public, is acknowledging that there may be ways of thinking within the hospital that could be revised in light of what others have learned – a "commitment to gain a new perspective."  

'The loss is quite difficult and is something I live with everyday'

Other families said they hoped the hospital's actions would help others not go through what they have.

Justin Bryant's mother, Eva, killed herself last August while an inpatient at West 5th.

"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, and talking about it is still very difficult and emotional for me as I am sure it is for the other families and anyone that has a family member that suffers from mental illness."

Joel Verge died on Nov. 9. (LifeNews.ca)
Jane Verge's stepson, Joel, killed himself last November.

She said St. Joe's contacted her family with a copy of the review last week. But she was especially shocked to realize that there were actually five patient deaths from suicide among inpatients at West 5th in 2016, not the three that had previously been identified.

"I have not stopped crying" since learning that, she said. "As for the review I cannot believe that it took them as long as it did to complete."

Preyra said the hospital will update its suicide prevention page on its website with its progress on its action plan, and encouraged the media, families and community to hold the hospital accountable in the coming months.