The death of a disabled woman choked by her wheelchair seatbelt highlights the need for more staff, better communication and ultimately the closure of the Manitoba Developmental Centre.
That's the bottom line for advocates for the disabled, who are profoundly troubled by the death of 51-year-old Ann Hickey in 2011 at the MDC, one of Canada's only remaining institutions for the handicapped.
An inquest into Hickey's death was held in the spring, and final submissions from all parties, including the People First advocacy group, are due today.
People First's chief recommendation is MDC be closed and residents such as Hickey moved to group homes, where staff have only one or two residents to care for, not a dozen or more.
The facts surrounding Hickey's death in March 2011 were not much in dispute at the inquest.
At about 7:30 p.m., Hickey was belted into a wheelchair while staff were busy getting other residents ready for bed. As the night staff came on shift about 11 p.m., they saw Hickey wheeling herself down the hall using her feet. It wasn't until midnight when one noticed she was no longer in the hall.
She was found in the lounge, where she had slid down in her wheelchair. Her head lay on the seat with the belt strangling her.
She died a few days later in the Portage la Prairie hospital.
The night Hickey died, there were only two staff members monitoring more than 25 residents. They did not know Hickey had a history of sliding down in her wheelchair and ought to be watched closely.
"Obviously, somewhere along the line there was a communication breakdown," said Public Interest Law Centre lawyer Bev Froese, who represents People First.
People First has recommended improvements to staff communication, especially between shift changes and as it relates to patient-safety plans.
They want protocols on restraints followed so residents aren't strapped down only when staff are busy with other duties.
Hickey had been an MDC resident since she was 10 years old and has no immediate family. For at least a year before her death, she was on the MDC's transition list, meaning she was waiting to be discharged into a community group home.
The inquest judge has six months to release his report and recommendations.
The Manitoba government could not offer a comment by deadline Tuesday.