RECOMMENDATIONS

RELATED TO SELECTED
DEATHS BY SUICIDE AT
ST. JOSEPH'S
HEALTHCARE HAMILTON
HAMILTON, ONTARIO

August 2021
Table of Contents

INTRODUCTION ............................................................................................................. 2
RECOMMENDATIONS ................................................................................................... 4
St. JOSESPH’S HEALTHCARE HAMILTON RESPONSE.............................................. 9
FAMILIES’ RESPONSE ................................................................................................ 18
SUMMARY .................................................................................................................... 19
ACKNOWLEDGEMENTS ............................................................................................. 20

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

INTRODUCTION
The Office of the Chief Coroner/Ontario Forensic Pathology Service (OCC/OFPS) is
mandated to investigate all non-natural deaths that occur in the province of Ontario. The
organization is committed to providing high quality of death investigation that supports
the administration of justice, the prevention of premature death and is responsive to
Ontario’s diverse communities. The OCC/OFPS may make recommendations to
organizations, such as government or hospitals, to improve public safety and reduce the
likelihood of further deaths.

For the period of 2016 to 2018, St. Joseph's Healthcare Hamilton (SJHH) was one of
the institutions in Ontario with several deaths involving patients in their institution or
while on a pass where the manner of death was classified as suicide. Over the last two
years, SJHH implemented several changes as a result of their own reviews, an external
review, individual family comments, as well as the recommendations included in this
report.

During 2016 to 2018, several families in the Hamilton area reached out to the Regional
Supervising Coroner’s Office because they were concerned with the deaths of their
loved ones, who died by suicide, that either occurred while the person was hospitalized,
on a pass, or recently discharged from SJHH. The families were concerned with the
nature of the deaths and were hopeful that they could help to introduce changes to
prevent similar deaths in the future. These changes would not only be applicable to
SJHH, but to all other institutions providing inpatient psychiatric care as well. To
address the families’ concerns, the OCC/OFPS had several meetings separately with
both the families and administrative staff at SJHH. The goal was to discuss, develop
and deliver recommendations to the hospital to prevent future deaths or injuries to this
vulnerable patient population.

The hospital was notified of the concerns regarding these deaths and was involved
during all stages of this review. They were aware from the onset that the OCC/OFPS
was working with the families to help provide useful recommendations. As a result,
when the recommendations were drafted and accepted by the families involved, these
recommendations were sent to the hospital for their consideration. SJHH then provided
responses to these recommendations including status of implementation and future
plans. The hospital’s responses were shared with the families as well as having a
combined meeting with the families and a member of the hospital staff to discuss the
outcomes. This report contains the most recent status of these recommendations and
the responses received.

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

This report includes the following:
• recommendations that were developed after several consultation meetings with
the families and an investigating coroner involved with several of the cases.
• responses from the hospital, as well as the status of each recommendation
currently; and
• families’ response to the hospital’s responses and current approach.

The hospital’s report on the current status of the recommendations, as well as the
statement from the families, have not been edited. The goal of this report was to share
these recommendations with other institutions providing inpatient psychiatric services in
Ontario.

This report does not specifically discuss any of the individuals who died by suicide to
ensure their confidentiality. Through their own personal strength, the families and
friends have chosen to work with the OCC/OFPS and have demonstrated a profound
and inspiring level of commitment to improve the provision of psychiatric services in
Ontario with the goal to reduce the number of deaths by suicide as much as possible.
As a group, they have already impacted significantly on changes for their community.
The lives of those lost must be remembered as they each represented individuals with a
network of friends and family who continue to be inspired by the love and beauty they
brought during their lives, shortened by a disease that affects so many Ontarians. It is
with the hope and strength of their family and friends that these recommendations were
developed to prevent future deaths.

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

RECOMMENDATIONS
There were 17 recommendations that were developed under the following categories:

1. In Hospital Treatment and Assessment

2. Hospital Passes
3. Outpatient Treatment
4. Review Processes for Deaths that Occur

In Hospital Treatment and Assessment:

1. Hospital staff and the clinicians involved in the assessment and care of an
individual assessed/admitted with depression and/or suicidal ideation should
base decisions on formal, defined risk assessments versus “contracting” with the
individual-at-risk.

“Contracting,” as noted by families, appears to be considered as a statement the patient

makes, much like a promise. Families commented that contracting in suicidality should
not be a promise and it is not clear to families what the intention and validity of
contracting is.

2. Institutions and the decision-making clinicians should ensure there is clear

documentation of the risk-assessment tools used, their decision-making
pathways, and follow-ups are clearly documented. This would include the
documentation of reasons for the release of individuals within the 72-hour period
on a documented Form 1. Consideration should be given to screening all patients
for risk to ascertain risk more globally (i.e. all patients in ER regardless of
presentation).

It was noted in the review of various charts by the families and the death investigation
system that there was not always clear decision-pathway documentation to allow for
agreement regarding the discharge or granting of passes.

3. Safety specialist: To ensure continuity, it is recommended that a single clinician

be assigned to each patient to oversee hospitalizations that require the presence
of more than one Most Responsible Physician (MRP). This individual could
document weekly reviews of the individual with all pertinent multi-disciplinary
caregivers and the agreed upon care plan.

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

The importance of continuity of treatment for a person with multiple admissions can be
ensured by the review of previous and ongoing risk assessment tools. Having an
individual clinician responsible for reviewing the care of an individual regardless of the
changes to the MRP will ensure consistency of care and that one person has the big
picture and nuances of the individual case.

4. Ensure that there is a system to ensure inpatient safety that is inclusive of

multiple factors. This includes prevention of illicit drugs from being used on the
psychiatry floor, as well as ensuring patients feel safe from violence from other
inpatients. This may require working with partners from public health and the law
enforcement community as required. It may also include use of unscheduled
checks of the patient and/or their rooms.

It has been noted by families/friends visiting their loved ones that there is occasionally
evidence of illicit drug use that originated in the hospital. As well, it was noted that there
were risks of further self-harm while they were hospitalized.

5. Re-evaluation and documentation of seclusion usage: Indications, criteria,

medical evaluation, monitoring of restrained (medication/physical) individuals,
visiting policies, limitations, and exclusionary issues (e.g., certain trauma history,
medical history) should be included. Consideration of the impact and nature of
seclusion of patients should be assessed. Also, there should be medical
clearance, as well as ongoing medical surveillance as required, for all individuals
to ensure their safety.

The seclusion of individuals for prolonged periods of time by families was felt to be too
punitive and counter-productive to enhancing the well-being of their loved one. It was
also noted to increase the risk to those with underlying medical issues.

6. Ensuring that the medical record is as accurate as possible when documenting

the individual’s demographics, concerns, and history. A method of confirmation
with family or friends should be considered.

Inaccuracies are difficult for families as they are often perceived as inattentiveness to
the patient/family.

7. Leadership hierarchy in hospitals should become more transparent and

encouraged to involve family, friends and community agencies. Awareness of
who is responsible for specific decisions should be clear and presented to those

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

 involved in the circle-of-care. This could be provided to all families when a family
member is admitted to the institution.

In accordance with the principles of restorative justice, the involvement of as many

individuals as possible in decision-making can support provision of patient-centred care
for the individual-at-risk.

8. Although a person may not want family/friends informed of their status, there
needs to be an ability for the family/friends to communicate with the clinical staff
and ensure the information is available and being appropriately
processed/managed. Also, the request for privacy needs to be addressed in an
ongoing manner (often day passes require consent by those that will be
accepting the individual), as well as a patient may agree to changing their
restrictions during a hospitalization.

The recognition of family/friends and their role in circle of care must be evaluated in an
ongoing, evolving manner based on circumstances.

9. Hospital notification of family/friends prior to discharge should be strongly

considered as a mandatory requirement and a safety plan documented in the
chart if the location of discharge involves any of these individuals.

Ensuring full communication with all supports for an individual should be encouraged for
all discharges to ensure full engagement of all available supports.

10. Individual service plans documenting the issues, concerns, progress, and
challenges that are linked to each hospital visit/admission should be available for
subsequent admissions. This should include documentation of all treatment
modalities (e.g., therapy/medication) used and proposed.

Ensuring continuity of care between visits is important to ensure the appropriate

learning points (e.g. diagnoses, proper medications, dosages, therapy-related learnings)
will be shared and implemented as required.

Hospital Passes

11. Informed Consent: Consideration should be given to the family member and/or
friend who signs the patient out for a pass related to safety, combined
recommendations around level of supervision on the pass. Consider the concept
of informed consent to the family/person assuming responsibility for the patient

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

 on a pass. It is recommended that all passes should be earned as sign of
improvement, documented in the chart, and not as opening a bed for the period
of the absence.

This process will ensure there is awareness of the individual’s improvement. Upon
return of the individual it was stated by several family members that there should be a
documented “de-brief” session with the patient as well as others present on how the
time on pass went and any potential learning points/concerns.

Outpatient Treatment

12. Consider the importance of communication between in-patient and out-patient

treatment providers in the planning and implementation of care and goals in the
circle of care.

Continuity of care, with the individual as the primary concern, would be enhanced with
these communications.

13. Consideration for the provision of psychoeducational programs within the hospital
and community that is inclusive of the family and friends.

Helping improve the social supports of the individual, further development of social skills
and increasing the culture of help-seeking for the individual was felt to be important.

14. Utilization of all available resources in the community surrounding the hospital to
ensure transition of care is more appropriate and seamless.

This, again, will enhance continuity-of-care as well as ensuring the appropriate

resources are being engaged for the individual.

Review Processes for Deaths that Occur

15. Consider involvement of an external reviewer when reviewing cases (i.e. Quality
of Care) in an institution after someone has died.

Family request an external reviewer of the care. Several families stated there is a
greater risk of bias for the hospital when performing a care review of and by
themselves. Also, it may be seen as an obstruction of the process, for active treatment
providers, to participate in the review analysis and conclusions.

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

 16. Provision of bereavement services could be extended to the family/friends as
well as providing to staff.

The death has a profound impact on the entire circle of care around the individual and
there should be consideration that resources be applied to the whole group to
participate in together (e.g. family, friends, first responders, clinical and administrative
hospital staff).

17. Documentation of internal and external reviews with their recommendations

should have documented time limits on the status of their acceptance and/or
implementation. Outcomes of these reviews should be shared with the OCC-
OFPS when a death has occurred.

It was noted by several family members that there was uncertainty on how
recommendations that arose from internal/external reviews were managed.

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

 SJHH’S RESPONSE
Recommendation Implemented To be Implemented

1. Hospital
1 staff and the
clinicians involved in the
assessment and care of an
individual
assessed/admitted with
depression and/or suicidal
ideation should base
decisions on formal defined
risk assessments vs.
contracting with the
individual at risk.
• Between 2017 to 2019, SJHH took • Evaluating potential suicide
significant steps in developing and specific treatment interventions for
implementing the inpatient and MHAP inpatient staff
outpatient Suicide Assessment and • Expansion of Collaborative
Management Algorithm. This Assessment and Management of
algorithm represents a standardized Suicidality (CAMS) to Psychiatric
approach to suicide risk screening, Emergency Services (PES) and
assessment and management, COAST and inpatient
utilizing the tool called Columbia
Suicide Severity Rating Scale
(CSSR-S). This tool is always used
in concert with clinical judgement.
• The algorithm maps the patient’s
journey at transitional points from
first contact in the Emergency
Department, through Psychiatric
Emergency Services (PES), onto
inpatient units and in the outpatient
setting where applicable.
• Implementation of this approach
was one way to ensure that
contracting for safety is not used to
replace a well-documented suicide
risk assessment and management
plan. Clinicians have been trained in
the new approach, and
simultaneously, contracting for
safety and its lack of efficacy and
effectiveness been addressed.

2. Institutions
2 and the
decision-making clinicians
should ensure there is clear
documentation of the risk
assessment tools used,
their decision-making
pathways and the follow-up
clearly documented. This
would include the
documentation of reasons
for the release of individuals
within the 72-hour period on
a documented Form 1.
Consideration should be
given to screening all
patients for risk to ascertain
risk more globally (i.e. all
• The Columbia Suicide Severity
Rating Scale (CSSR-S) is embedded
into our electronic documentation
system called Dovetale. This system
is used throughout the organization
and when the risk for suicide is
identified, it is flagged allowing all
clinicians involved in patient care to
have access to this information. Once
the risk for suicide is identified, a
safety plan is developed and
documented. While safety plans are
based on a standardized and
evidence-based template, they allow
for customization to ensure that a
person’s individual context is well
captured.
• Quality Improvement Plans (QIP)
for 2019-2020 focuses on best
practice safety plans for high risk
patients, these focus on
techniques to reduce suicidal
ideation, resources, and supports
including family that take into
account individual risk factors and
preferences. The safety planning
template used is considered “Best
Practice” and has been widely
used by other institutions.
• CSSR-S and Safety plan
completion rate will be added to
the Dovetale dashboard so
managers can rapidly assess

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

 Recommendation Implemented To be Implemented

patients in ER regardless of
presentation).
• Patients who enter the organization adherence to the implemented
through our Emergency Department suicide risk assessment algorithm.
or Urgent Care, whether they are
admitted or not, with some level of
suicide risk are screened utilizing
CSSR-S. In an effort to facilitate a
discussion with patients in ED and
Urgent Care regarding mental health
concerns and provide information on
resources in the community, a poster
campaign has been developed with
input from patients and families
encouraging patients to discuss their
concerns with triage nurse. This
poster is present in the various
waiting rooms in the Emergency
Department and Urgent Care Centre.

3. Safety
4 Specialists: to
ensure continuity, it is
recommended that a single
clinician be assigned to
each patient to oversee
hospitalizations that require
the presence of more than
one Most Responsible
Physician (MRP). This
individual could document
weekly reviews of the
individual with all pertinent
multi-disciplinary caregivers
and the agreed upon care
plan.
• Continuity of care is paramount and • This recommendation will be further
also challenging to ensure in a 24/7 explored to identify any additional
environment with numerous units and opportunities for enhancing
providers. Currently, processes are in continuity of care.
place to share and transfer information
between all clinicians involved in
patient care. The electronic health
record also enables a more effective
access to and transfer of information.
Policy that addresses physician hand
over at points of transitions is in place
and it outlines the process for
transferring patient specific information
at various interface points, including
change of call shift or between
members of a team with shared clinical
responsibilities.

• A robust practice is in place for

interdisciplinary team discussion and
planning based on information
available in the electronic health record
across multiple encounters an
individual has had with the hospital and
also on collateral information that may
have been gathered.

4. Ensure that there is a • SJHH is committed to providing and • Development of an algorithm to

system to ensure inpatient
safety that is inclusive of
multiple factors. This
includes prevention of illicit
drugs from being used on
the psychiatry floor as well
as ensuring patients feel
maintaining a safe, professional,
healthy, lawful, caring and overall
healthy work environment to all
patients, staff and visitors.
• The approach to managing illicit
substances is outlined in the policy
which was reviewed and approved in
manage methamphetamine
intoxication and withdrawal led by
St. Joseph’s Healthcare and
implemented city wide through the
Hamilton Drug Strategy
• A pilot of utilizing drug detecting
dogs as a surveillance strategy to
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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

 Recommendation
safe from violence from
other patients. This may
require working with
partners from Public Health
and the Law Enforcement
community as required. It
may also include use of
unscheduled checks of the
patient and/or their rooms.
5. Re-evaluation and
documentation of seclusion
usage: indications, criteria,
medical evaluation,
monitoring of restrained
(medication/physical)
individuals, visiting policies,
limitations and exclusionary
issues (i.e. certain trauma
history, medical history)
should be included.
Consideration of the impact
and nature of seclusion of
patients should be
assessed. Also, there
should be medical
clearance, as well as
ongoing medical
surveillance as required, for
all individuals to ensure
their safety.
Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre
Implemented
October of 2018.
• The need to manage contraband of
other substances or items considered
harmful is outlined in a policy which
was reviewed and approved in
February 2018. This same policy also
outlines search procedures of patient
belongings, patient rooms and
inpatient units. Appropriate signage is
posted on every unit. Unit orientation
materials, for patients and families,
includes this information
• Training on the use of search kits,
located on every MHAP inpatient unit,
is an element of mandatory de-
escalation certification and
recertification by all clinical staff.
• On a 24/7 basis, security personnel are
assigned to patrol the physical
environment and to report any
observation that may compromise
patient safety.
• Expansion of the Addiction Team’s
hours (provides clinical support in
addictions) to include 7 days a week
coverage, and overnight hours in ED
The Mental Health and Addiction
Program (MHAP) at St. Joseph’s
Healthcare Hamilton (SJHH) supports a
patient centred, trauma informed and
recovery-oriented approach to patient
care and treatment. Restraint use can
lead to a negative experience for
patients and can result in physical,
emotional and psychological trauma for
all involved; therefore, restraints must
only be used as an exceptional
measure. We know that risk for harm to
the patient or others can be decreased
with effective prevention strategies,
early intervention and individualized
plans of care.
A comprehensive restraint policy was
last updated and approved in April 2019
outlining procedures for initiating and
discontinuing restraint
(environmental/seclusion, mechanical
and chemical) as well as details on care,
supervision and monitoring required
during restraint use.
To be Implemented
locate illicit substances within in-
patient units and on hospital
grounds
• Expansion and publication of
research conducted in partnership
with the Boris Centre for Addiction
Research that includes the patient
perspective, and
recommendations for decreasing
drug use on in-patient units.
• The Seclusion/Restraint Reduction
Steering Committee workplan for
2020 includes: 1) review and revise
the four levels of debriefing (post
incident, family, peer and formal);
2) initiate reports from each service
on sustainability plans for
prevention strategies; 3) update
policy; 4) initiate a share-point
collaboration site as a repository
for staff use of resources,
procedures, and products
• Implementation of any
recommendations from discussions
on best approach within PES to
manage multiple concurrent
seclusions and/or restraints when
this occurs.
• Implementation of
recommendations related to
seclusion and/or restraint from
PES redevelopment discussions.
• Evaluation of the new Peer
Support team in PES is planned.
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 Recommendation Implemented To be Implemented

A team of Peer Support personnel was

installed in PES in May 2019. This staff
member is available on a daily basis to
provide support, comfort and assistance
to patients in PES.

6. Ensuring that the medical • It is recognized that the purpose of

record is as accurate as
possible when documenting
the individual’s
demographics, concerns
and history. A method of
confirmation with family or
friends should be
considered.
• Information obtained from collateral
clinical documentation is to record the
patient’s health information in a
manner that is accurate,
comprehensive and timely. It has to
follow minimum documentation
standards established by the
organization and standards of practice
established by the regulatory bodies
for each discipline.
sources (i.e. family or friends) shall be
included as a component of the
suicide risk assessment whenever
possible.

7. Leadership hierarchy in • We believe that effective • Family engagement visits to MHAP

hospitals should become
more transparent and
encouraged to involve
family, friend and
community agencies.
Awareness of who is
responsible for specific
decisions should be clear
and presented to those
involved in the circle-of-
care. This could be provided
to all families when a family
member is admitted to the
institution.
communication of elevated suicide risk
among interdisciplinary team
members, patients, their families
and/or substitute decision makers
(SDM) is fundamental in the provision
of quality healthcare and is imbedded
in professional standards, quality and
accreditation standards and many
policies and procedures.
• Emphasis on family engagement in
therapeutic alliance and collaboration
on care delivery is made during
orientation of all clinical staff; and
demonstrated through clinical
processes such as Keys to Discharge,
and the implementation of the “After
Visit Summary” and Safety Plans.
• Policy on Suicide Prevention –
Communicating with Families has
been in place since December 2017.
• Program orientation material and
posters inform families about service
leadership and the patient relations
process
• Consultation with the MHAP Peer
Advisory Council and Family Advisory
Council is available for issues related
to patient and family engagement
processes. Various MHAP and
outpatient, outreach and
community-based teams will
commence in February 2020.
• The Family Advisory Council is in
the process of finalizing its work
plan for 2020 which will include: 1)
review of policies that have an
integral component of family
communication; 2) initiating quality
council presentations by each
service featuring family
engagement strategies in place; 3)
hosting a 2nd Families Matter event;
4) member recruitment
• Co-design opportunities that arise
from any of these discussions will
be explored, for example in our
project to redevelop PES itself.

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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

 Recommendation
8. Although a person may not
want the family/friends
informed of their status
there needs to be an ability
for the family/friends to
communicate with the
clinical staff and ensure the
information is available and
being appropriately
processed/managed. Also,
the request for privacy
needs to be addressed in
an ongoing manner (often
day passes require consent
by those that will be
accepting the individual) as
well as a patient may agree
to changing their restrictions
during a hospitalization.
Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre
Implemented To be Implemented
corporate leaders have attended
council meetings when
needed/requested.
• The MHAP Family Charter of Rights
as well as the MHAP Family
Orientation Handbook were developed
in collaboration with the Family
Advisory Council in fall 2018.
• Family engagement presentations to
all MHAP inpatient units were
completed by March 2019 offering all
staff and physicians of the units, a
plaque of the charter, a plaque of
Patient Bill of Rights and a file of
resources that included the handbook,
information on the Family Resource
Centre, brochures on any MHAP
family education program.
• The Family Resource Centre first
developed in 2017 was relocated to
the 1st Floor Main Entrance at the
West 5th Campus for greater visibility
and access to families. Utilization has
significantly increased.
• SJHH is committed to providing Completion and dissemination of
person and family-centred care an educational video
which emphasizes involvement, demonstrating the use of
partnerships and collaborations therapeutic techniques and a high
between healthcare providers, level of engagement with family
persons receiving services and their members for situations in which
families. consent has not yet been obtained
• In 2017, SJHH developed a
Guideline for
communicating the risk of suicide to
family members. This guideline
outlines the following principles:
➢ with the consent of the person
receiving services, family should
be contacted, and involved in
care planning and provided with
information about the progress
of their family member.
➢ The person receiving services
has the right to grant or deny
consent for family involvement
and release of information to
family members at any time,
except in such circumstances
wherein the family member has
been appointed as the
Substitute Decision Maker.
➢ When the person receiving
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 Recommendation Implemented To be Implemented

services does not wish his/her

family contacted and does not
provide consent for disclosure,
staff cannot provide any
personal or clinical information
however, staff may receive
information from family
members.
➢ If clinically appropriate and
supported, the person receiving
services’ previous choice not to
have family contacted should be
validated at regular intervals.

9. Hospital notification of Discharge planning is a complex

family/friends prior to
discharge should be
strongly considered as a
mandatory requirement and
a safety plan documented in
the chart if the location of
discharge involves any of
these individuals.
10. Individual service plans
documenting the issues,
concerns, progress, and
challenges that are linked to
each hospital
visit/admission should be
available for subsequent
admissions. This should
include documentation of all
treatment modalities (i.e.
therapy/medication) used
and proposed.
process of resource coordination and
communication which should lead to an
optimal transition from hospital to
community.
Through clinical processes such as
Keys to Discharge, the “After Visit
Summary”, Safety plans and family
meetings, patient and family
engagement in the process of discharge
planning is well embedded in practice
and is further guided by relevant policies
and procedures and adherence to
professional, quality and accreditation
standards.
• It is recognized that the purpose of
clinical documentation is to record the
patient’s health information in a
manner that is accurate,
comprehensive and timely. It has to
follow minimum documentation
standards established by the
organization and standards of practice
established by the regulatory bodies
for each discipline.
• Information is available in the
electronic health record across
multiple encounters an individual has
had with the hospital.

11. Informed consent:
Consideration should be
given to the family members
and/or friend who signs the
patient on a form out for a
pass related to safety, and
recommendations around
level of supervision on the
pass. Consider the concept
One focus of the inpatient health care
team is to expand the opportunity for
patients to be exposed to a broader
environment in as least a restrictive
manner as safely possible. Each patient
has an individual plan of care that is a
dynamic interplay of managing risk,
personal liberty and community re-
integration.
• Expansion of initiative which
focusses on the inclusion of family
members in pass planning
including the discussion of risks
and management strategies for
self-harm
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Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

 Recommendation
of informed consent to the
family/person assuming
responsibility for the patient
on a pass. It is
recommended that all
passes should be earned as
sign of improvement,
documented in the chart,
and not as opening a bed
for the period of the
absence.
12. Consider the importance of
communication between in-
patient and out-patient
treatment providers in the
planning and
implementation of care and
goals in the circle of care.
13. Consideration for the
provision of
psychoeducational
programs within the hospital
and community that is
inclusive of the family and
friends.
Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre
Implemented To be Implemented
• The policy addressing therapeutic
passes has been in place since
January 2018 and clearly states that
determination of therapeutic pass
levels should include involvement and
communication with patients; and with
family as permitted within the context
of the plan of care. Decisions about
therapeutic passes is a dynamic
process that is continuously assessed
by the clinical team.
• Feedback from family is sought out
after pass completion to assess how
the pass went and inform future pass
decisions.
MHAP is committed to providing
excellent continuity of care between
inpatient and outpatient providers. To
assist with this:
• The electronic health record is
recognized as a single source of
information for all encounters that an
individual has had with the hospital
and can be accessed by circle of care
clinicians.
• Transfer of accountability processes
are implemented.
• After-Visit Summary implementation
that is distributed to the patient and
other key stakeholders.
• Warm hand-offs are increasingly used
• The MHAP Family Resource Centre, •
located at the W5th Campus, has
been in place since October 2017. It
provides a comprehensive inventory of
books, journals, brochures and on-line
resources that family members can
access with the assistance of Family
Resource Centre personnel and with
the support of volunteers who
themselves are family members of a
loved one with mental illness or
addiction and specially trained to
provide peer support.
• A Family Liaison Peer Support staff
member is available to support any
family member of a patient of the
MHAP.
• All services within the MHAP
implement a family
Page 15 of 20
 Recommendation
14. Utilization of all available
resources in the community
surrounding the hospital to
ensure transition of care is
more appropriate and
seamless.
15. Consider involvement of an
external reviewer when
reviewing cases (i.e. QoC)
in an institution after
someone has dies.
16. Provision of bereavement
services could be extended
to the family/friends as well
as providing to staff.
Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre
Implemented
education/orientation program.
The MHAP has many and varied strong
partnerships with numerous community
agencies (mental health services,
housing, finance, social services, Public
Health, etc.) and accesses them as
needed by the individual patient.
Our commitment, demonstrated most
recently as a stakeholder in the
Hamilton Health Team, is to strengthen
collaborations with partners for optimal
transition and integration.
• SJHH has a strong commitment to
quality improvement. We use a
standardized Critical Incident Review
Process to facilitate timely reporting,
management and follow up of deaths
by suicide. This process involved a
fulsome review of the contributing
patient, system and team factors.
When a quality of care review is
conducted, it is currently chaired by an
internal stakeholder who has not been
involved in the care of a patient to
ensure objectivity of the review.
• Currently, when a death occurs,
support is offered to family members
with offer for additional support if
needed. A memorial service for
patients may be planned with
Spiritual Care.
• The MHAP, in partnership with
others has implemented a number
of annual events to memorialize
patients who have died:
- The Candlelight Vigil (in
collaboration with Peer Support
and Spiritual Care) – launches
Mental Illness Awareness Week
in October. 2019 marked the
16th annual event.
- The Butterfly Release (in
collaboration with the Suicide
Prevention Council of Hamilton)
– on September 10th
To be Implemented
• In Year 1 of the Hamilton Health
Team plans are underway to
proceed with partnership within the
network e.g. Shelter Health; to
continue geographic hotspot work
at Vanier Towers, and to develop
care paths to ensure increased
capacity for the prescribing of
addiction medicine across
Hamilton, with the Rapid Access
Addiction Medicine clinic serving
as a source of entry, transitional
support and access to other levels
of service
• SJHH is currently re-examining
the existing critical incident
review process in order to
strengthen it and to increase
opportunities to include the
perspective of patients and
families.
• Plan to review current efforts to
ensure family engagement.
• Based on this, the MHAP will
consider other strategies that
may be helpful to families.
Consultation with the Family
Advisory Council and Peer
Advisory Councils will help to
inform this.
Page 16 of 20
 Recommendation
17. Documentation of internal
and external reviews with
their recommendations
should have documented
time limits on the status of
their acceptance and/or
implementation. Outcomes
of these reviews should be
shared with the Office of the
Chief Coroner/Ontario
Forensic Pathology Service
when a death has occurred.
Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre
Implemented
• All formal death reviews are
monitored through the corporate
Patient Safety Steering committee
which oversees implementation and
all timelines.
• Once approved, review progress is
tracked monthly and colour coded
(red, yellow, or green).
• All recommendations approved
through this process must be
implemented and accounted for.
To be Implemented
• As described above, SJHH is
currently re-examining the existing
critical incident review process in
order to strengthen it and to
increase opportunities to include
the perspective of patients and
families.
• This improvement is expected to
improve clear timelines and
guidelines for sharing of the
recommendations/actions internal
and external to the organization.
Page 17 of 20
FAMILIES’ RESPONSE:
On behalf of the families who were involved in this report, we want to sincerely thank
Coroner Reuven Jhirad for including us in this process.

We support the recommendations which he presented to St. Joseph’s Hospital

regarding the suicides involving our family members. We know he put great thought and
consideration into this document and allowed our voices to be heard in these
recommendations.

Although we greatly appreciate the work he has done, our families lack trust in the
hospital’s commitment to implement these recommendations. Their responses look
good on paper, but in our experience, the hospital lacks the accountability to follow
through on best practices. Many policies were in place during the time our loved ones
were in their care, and if they had followed the guidelines, our family members would
still be alive today. We must also state our disappointment in the lack of interest and
respect the hospital showed in engaging with us during this review. It’s this lack of
engagement and respect for families/caregivers that has caused many of the problems
and lack of care for our family members. If the family concerns were truly respected and
listened to, there likely would have been better outcomes in many of these tragic
suicides.

Due to the experiences which led to our lack of trust, we must strongly urge the
province create an independent committee to ensure accountability and follow through
on these recommendations. This group must be independent from St. Joseph’s, but with
a clear mandate to work with the hospital to improve practices.

We look forward to working with the province, community members involved in mental
health (including police) and of course families/caregivers who have been victims of the
system that let down patients who were in the trust of this hospital. Again, we want to
thank Coroner Reuven Jhirad for his work on this and his compassion showed to us
during this extremely painful process.

Although nothing can bring back our loved ones, knowing that by addressing gaps in
hospital processes, and ensuring better accountability by all involved, this work will
provide a legacy for our community. Our loved ones deserve nothing less. Nobody
should lose a family member to suicide while in the care of those responsible for their
lives.

Page 18 of 20

Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

SUMMARY
The 17 recommendations generated during this process were intended to help inform
St. Joseph's Healthcare Hamilton as well as all hospitals improve the provision of
psychiatric services and prevent further deaths by suicide in the Province of Ontario.

The recommendations are being sent to the following:

• St. Joseph's Healthcare Hamilton (SJHH)

• Ontario Hospital Association
• College of Physicians and Surgeons of Ontario (CPSO)
• College of Nurses of Ontario
• Canadian Mental Health Association
• Mental Health and Addictions – Ministry of Health, Government of Ontario
• Ontario Health
• Ontario Patient Ombudsman
• Dr. Nick Kates, Chair of the Department of Psychiatry and Behavioural
Neurosciences at McMaster University
• Accreditation Canada
• Hamilton Police Service

The organizations will be requested to respond to the report and recommendations

within six months.

Page 19 of 20

Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre

ACKNOWLEDGEMENTS
This report could only have been completed with the assistance of several people. The
cooperation, commitment, and willingness to participate by the staff involved at SJHH
was appreciated and contributed to the completion of the report. At our office, Julia Man
and Kathy Kerr both helped with the completion of this report. It is also important to
recognize the staff at the Hamilton Regional Coroner’s Office, specifically Ms. Charlotte
Watson and Dr. Karen Schiff. The investigating coroner in several of the cases was Dr.
Jane Morgan, and her dedication to investigating these cases, working with the families
and providing her insights was greatly appreciated and essential to the development
and completion of these recommendations.

Special recognition must be given to the families and friends who, through the pain of
the loss of their loved ones, continued to be dedicated to working with our office to
develop these recommendations to improve service provision and prevent further
deaths. Their strength and commitment are inspiring and reflects the importance of the
necessity to ensure open, honest dialogue with the unified goal of improving the care
and services provided to those living with mental health issues and their respective
families.

Page 20 of 20

Recommendations Related to Selected Deaths by Suicide at St. Joseph’s Health Centre