2010 coroner's investigation raised questions over Thunder Bay hospital's discharge practices

A coroner's investigation raised questions about the Thunder Bay hospital's discharge practices for vulnerable patients almost 10 years before a 19-year-old First Nations man was found dead hours after he was discharged, CBC News has learned. 

Managers had told coroner that hospital would develop strategy for discharge of at-risk patients

Richard Berg, left, and his brother Kenneth Berg. Kenneth Berg went missing after he was discharged from the Thunder Bay Regional Health Sciences Centre in October 2009 and was later found dead. (Submitted by Richard Berg)

A coroner's investigation raised questions about the Thunder Bay hospital's discharge practices for vulnerable patients almost 10 years before a 19-year-old First Nations man was found dead hours after he was discharged, CBC News has learned. 

According to an Ontario coroner's report into a 2009 Thunder Bay death, Thunder Bay Regional Health Sciences Centre managers met with the coroner and a family member of the deceased in 2010 and said the hospital would come up with a communication strategy to deal with at-risk discharged patients "to ensure a safe return home." 

The hospital's discharge practices are again under question following the death of the 19-year-old First Nations man in September. His body was found hours after his discharge, less than a kilometre from the hospital in a secluded area of the Lakehead University campus. The death is a suspected suicide. 

The 2010 coroner's investigation probed the death of Kenneth Berg, 60, who disappeared after he was discharged from the Thunder Bay hospital on Oct. 26, 2009. 

Berg, who had schizophrenia and lived in a group home, arrived at the hospital by ambulance after he fell and hit his head on a curb. Berg's brother said he was released at about 11 p.m. after receiving a bandage for his head. The buses had stopped running and his brother left on foot from the hospital area. He was missing for the next five months.

Kenneth Berg's body was found the following April in a drainage ditch, after the ice melted. He had ended up on a road several kilometres from the hospital where he fell into the water-filled ditch and drowned. 

The hospital's discharge practices were raised during a June 17, 2010, meeting between coroner Dr. David Legge, hospital managers and Richard Berg, the brother of Kenneth Berg, according to the coroner's report. 

The report said that the high number of emergency department patients was a "theoretical challenge" to developing a universal policy that would identify individuals at risk of not getting home safely. 

However, "The hospital then will be focusing on a communication strategy involving standardizing a verbal questioning of each discharged patient considered at any substantial risk, with an open-ended offer of assistance, if required, to ensure a safe return home," said the report. 

Unclear if hospital implemented changes

It remains unclear whether the hospital ever implemented the strategy.

"I have never seen a copy of the discharge policy that was in force when my brother was discharged and I received no communication from the hospital regarding any changes," said Richard Berg.

"There has been absolutely no communication with me." 

A spokesperson for the hospital couldn't say whether the changes mentioned in the 2010 meeting were ever implemented.

The Thunder Bay Regional Health Sciences Centre's emergency department in 2014.

Richard Berg is a retired professor who taught philosophy, including classes on biomedical ethics, at Lakehead University. He sat on the Thunder Bay hospital's ethics committee for nine years. 

Berg said hospitals have a responsibility to ensure at-risk patients make it home alive.  

"Care doesn't end with the door," said Berg. "You have a responsibility to do what's best for the patient."

Berg said the doctor who discharged his brother asked him if he was "good to go" and his brother said yes. 

"He was discharged late in the evening and he was waiting in front of the hospital for a bus that never arrived," said Berg. 

"He wasn't competent to find his way around the city. He had some cognitive impairments in terms of direction ... but he was let go with a casual question."

Berg said he was concerned that the hospital's discharge practices contributed to his brother's death and that he raised the issue with the coroner during the investigation.

"[Berg] has concerns about hospital policy when 'vulnerable' individuals such as his brother are discharged from an emergency/outpatient setting, with the view of attempting to contact a responsible individual to ensure safety," said the coroner's report. 

Berg sent letters to the hospital's then-director of quality and risk management pressing for changes to the discharge practices. In a June 28, 2010, letter, Berg included several recommendations and noted that hospital officials had agreed that a similar situation could well repeat itself.

"I viewed the crux of it not merely as a particular decision by an individual medical caregiver about a particular patient, but as a systemic failure," said Berg, in the letter. 

"The attending physician was as vulnerable to erroneous decision-making as my brother was vulnerable to death by misadventure. The two vulnerabilities have to be seen as linked together in order to see the system at work."

He said he never received a response.

Hospital says policies, procedures always updated

Tracie Smith, senior director of communications for the hospital, said discharge planning usually occurs for patients who are admitted for treatment in the hospital. 

However, patients who come into the emergency department and then leave without needing additional treatment are not considered to have been admitted to the hospital. 

"It's not black and white. If a person comes in and we provide the care, and if that care, if that situation requires additional steps, additional planning, yes of course that occurs," said Smith. 

"If someone comes in with an ear infection and needs antibiotics, it might be the provision of antibiotics. But if someone has a chronic ear infection and it needs to be connected to community care, we do that."

In a follow-up emailed statement, Smith said the hospital's policies, procedures and practices are informed by quality of care reviews and they are updated regularly. 

"We have robust processes in place to ensure and monitor implementation," she said. 

Coroner investigating September death

The Ontario Office of the Chief Coroner is investigating the Sept. 27 death. Chief Coroner Dirk Huyer said the investigation will look for systemic failures that may have contributed to the death.  

The 19-year-old arrived at the hospital on Sept. 26 in "distress" and after discharge is believed to have been walked by a hospital security guard to the Lakehead University campus, which is roughly 900 metres away from the hospital. 

Nishnawbe Aski Nation Grand Chief Alvin Fiddler has called for a thorough investigation of what happened. Fiddler wrote a letter to the hospital's CEO raising questions about the hospital's discharge practices. 

Nishnawbe Aski Nation Grand Chief Alvin Fiddler is calling for a full investigation into the death of a 19-year-old First Nations man hours after he was discharged from the hospital. (Justin Tang/The Canadian Press)

Fiddler said in the letter that discharged patients are often walked from the hospital to the nearby Lakehead University campus. He said this happens so often that university security guards routinely carry taxi vouchers to give away. 

"Surely, the hospital has procedures to support people in crisis... And surely this does not include walking them onto a university campus and leaving them alone to fend for themselves," said Fiddler in the letter.

"This practice is unconscionable."

Brandon Walker, a spokesperson for Lakehead University, confirmed that the university's security personnel carry taxi chits. 

"They are shared primarily with students (but on occasion with someone from the public visiting our campus) who need help getting home," said Walker, in an emailed statement.

Smith has said the hospital's quality review team found no issues after it examined the 19-year-old man's ambulance visit to the hospital. She said the incident is undergoing a full quality review and the hospital is co-operating with the coroner's office. 

"We are committed to providing the best care to all our patients, including those from the historically marginalized communities that we serve," said Smith, in the emailed statement. 

"Our hearts go out to this young man's family and community."


Jorge Barrera is a Caracas-born, award-winning journalist who has worked across the country and internationally. He works for CBC's Indigenous unit based out of Ottawa. Follow him on Twitter @JorgeBarrera or email him