The 70-year-old Alzheimer's sufferer who fatally attacked another resident at a care home was originally supposed to go to a psycho-geriatric hospital ward, an inquest heard Thursday.
The inquest into the death of 87-year-old Frank Alexander heard that days after Joe McLeod was jailed for injuring his wife, the Winnipeg Regional Health Authority recommended he be placed in the mental health unit at Seven Oaks General Hospital.
McLeod had been at the remand centre for assaulting his wife, but was later moved to Parkview Place, where the fatal attack took place.
A Sept. 10, 2010, letter from the WRHA recommending McLeod not be put in a personal care home until his behavioural issues were addressed was presented at the inquest by Tracey Epp, the lawyer for Revera Inc., which owns Parkview Place in downtown Winnipeg.
"There were discussions among a number of people at the long-term care access centre about referring McLeod to a psycho-geriatric unit," Epp said. Instead, after news got out Oct. 6 a senior with Alzheimer's disease had been sitting in the lockup for 30 days, the WRHA asked Parkview Place to take him.
Parkview Place executive director Don Solar testified he was not aware the WRHA originally wanted McLeod in a psycho-geriatric ward and not a personal care home because of behavioural issues.
"If we had these notes, we would have asked for... (more) findings before we would've considered admission," Solar said.
McLeod moved into Parkview Place on Oct. 8, 2010, after an assessment that included a social worker from the care home. He found McLeod to be no different than many other Parkview Place residents with dementia.
Weeks after moving into a shared room in Parkview, McLeod wasn't getting along with his roommate and had to be transferred to a private room.
By the new year, the retired welder attacked and threatened Parkview Place staff, the inquest heard earlier. He grabbed a worker from behind by the shoulders and said "You're going to die."
In February, he went after a flooring installer who had to protect himself with a chair and police were called. The next day he went after a nurse and tried to attack her with a table. A week later, McLeod shoved a nurse into an elevator, pushed her face into the elevator buttons and choked her.
"This is potentially a life-threatening situation," Bill Gange, the lawyer for the Alexander family, said to Solar. "Did it not occur to you that by Feb. 27 that Parkview Place could not handle Joe McLeod?" Gange asked.
"In retrospect I would say we should've taken quicker action with Mr. McLeod," said Solar.
No action was taken to try to move McLeod out of Parkview or to ask for more funding to help manage the resident, whose aggressive behaviour was escalating, Solar said.
A week before McLeod fatally shoved Alexander to the floor, he shoved another resident to the floor. The nurse on duty reported the March 17 shoving incident by phone to the Protection for Persons in Care Office as required by law. The office closed the file on March 21 but there is no documentation showing the incident was investigated or explaining why the file was closed, the inquest heard. On March 24, 2011, McLeod shoved Alexander to the floor and he died days later from a traumatic brain injury. The incident happened in Parkview's recreation area, and the only witness was a resident.
Since Alexander's death, Parkview has increased supervision in the recreation area, said Solar.