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Inquest into patient's death calls for better communication

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Clearer patient care guides and better communication between staff are two of the recommendations in an inquest report released today on the 2011 death of a severely mentally disabled woman at the Manitoba Development Centre.

Ann Hickey, 51, died March 29, 2011 after she slipped in a wheelchair and was strangled by a seatbelt.

Her death renewed calls for the Portage la Prairie to be shut down.

However, Provincial Court Judge Rocky Pollack found otherwise. In his 26-page report, he said the Manitoba Development Centre (MDC) accommodates Manitobans whose developmental disabilities make it exceptionally difficult if not impossible for them to live in the community. Hickey was admitted to MDC Jan. 12, 1970 when she was 10 years old.

In the report, Pollack said a birth injury had left her in profound mental retardation.

"She was there because she required significant resources to assist her with ordinary life skills, health care, socializing and – importantly - personal safety," Pollack said in the report.

"Known as "Annie" to her staff, she was found to have a fierce independence of spirit, a sense of humour, likes and dislikes. The inquest testimony, when observed in the hearing room, was checkered with facial expressions and body language, and some tears, demonstrating that Annie’s presence was remarkable and she is surely missed."

Pollack said after Hickey suffered a fractured vertebra, after bumping into another resident, in late February 2011 she was transferred to another wing (Westview) at MDC. She had use of a wheelchair adjusted to her condition, but was also walking at times.

"When that decision became an emergency decision, however, a detailed transition policy was not followed," Pollack said. "What this meant for Ann Hickey and the Westview

staff was that she was transferred without a transition plan, meaning that she was transferred without specific individualized instructions."

On the afternoon of March 25, 2011, Hickey was found on a washroom floor by two psychiatric nursing assistants (PNA).

Pollack said to allow the PNAs tend to other residents, Hickey was placed in a wheelchair.

"Her wheelchair was not where it was supposed to be and it could not be found," Pollack said. "Another was appropriated and she was placed in it. While it is not clear when, at some

point the seatbelt of that wheelchair was fastened around her."

It was near midnight when Hickey was seen seated in front of her wheelchair with the seatbelt tight around her neck holding her upright. Hickey was the only resident who was not yet in bed as staff were following instructions that she should not be taken to bed until she appeared sufficiently tired.

In his recommendations, Pollack said clearer MDC care guides must be produced so that staff monitor patients more closely and document what they see to improve communications.

"It would be comforting to know that a PNA observing a resident sliding in a wheelchair had the instant opportunity to log that observation for the benefit of the medical,

therapy and management staff. This is how to collect intelligence about trends and cycles in the institution as well as specific resident issues," he said.

He also recommended wider get staff training, including on wheelchair use.

"Obtaining a wheelchair for an MDC resident is not like buying a pair of runners," he said. "The seating clinic works through a multi-page questionnaire and makes determinations such as what the seating areas are made of, the firmness necessary, required measurements and other minutiae that go into making a wheelchair safe. There are differences

between the two wheelchairs and no steps were taken to preserve the wheelchair in the state in which it was found nor was an analysis of the difference between the chair in which Ann Hickey died and her own chair performed."

Specifically, he recommended:

Recommendations about wheelchairs

MDC has taken steps to make sure that wheelchairs are legibly tagged with the owner’s name. It has a policy in place that, if a resident is in an alternate wheelchair, that will be charted and communicated. That is a good start but, taking cognizance of the disabilities of MDC residents, there are some further simple steps to be taken.

It is therefore recommended:

  • that MDC require a highly visible tag or label to identify for its staff:
  • that a wheelchair is not the user’s own wheelchair;
  • that a wheelchair user is at risk for repositioning.

It is further recommended:

  • That therapists include in the Care Guide a statement whether or under what circumstances a resident must be kept in constant view when walking, using a wheelchair or other assist.


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