The judge who presided over an inquest into the 2011 death of a severely mentally disabled woman at the Manitoba Developmental Centre said in his report tabled Thursday shuttering the institution is not within his powers.
Ann Hickey, 51, died March 29, 2011, after she slipped in a wheelchair and was strangled by a seatbelt.
While her death renewed calls for the Portage la Prairie institution to be shut down and its 209 residents placed in group homes, provincial court Judge Rocky Pollack said that was not an option.
However, Pollack said in his 26-page report the Manitoba Developmental Centre (MDC) could do a better job. MDC accommodates Manitobans whose developmental disabilities make it difficult if not impossible for them to live in the community.
Hickey was admitted to MDC on Jan. 12, 1970, when she was 10 years old. At that time the MDC had a population of more than 1,200 residents.
"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.
Pollack said after Hickey suffered a fractured vertebra in late February 2011, after bumping into another resident, 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."
Hickey was found on a washroom floor by two psychiatric nursing assistants on the afternoon of March 25, 2011.
Pollack said in order to allow the nursing assistants to 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 spotted by staff 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 she should not be taken to bed until she appeared sufficiently tired.
"There is not a scintilla of evidence to suggest that anyone else was present when she encountered distress," Pollack said.
In his recommendations, Pollack said clearer MDC care guides must be produced so staff monitor patients more closely.
"It would be comforting to know that a (psychiatric nursing assistant) 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 staff training, including on wheelchair use.