Suicide sparks recommended changes at HSC psych ward

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This article was published 26/06/2015 (3902 days ago), so information in it may no longer be current.

An inquest into the 2012 suicide of a 68-year-old psychiatric patient at Health Sciences Centre recommends better procedures for noting changes in the frequency in which certain patients are observed.

James Livingston died at the hospital April 19 of that year after hanging himself with his belt.

Just four days earlier, the inquest conducted by Provincial Court Judge Robin Finlayson heard, Livingston had been found with his belt draped loosely around his neck.

That event occurred about the same time Livingston had been told to wash the clothes he had been wearing, which were soiled.

“At the time Mr. Livingston was found with the belt, he expressed no desire to harm himself,” Finlayson concluded in his report, which was released Friday.

A nurse noted that Livingston’s observation status was to be changed from ‘normal’ to ‘close’ observation. The belt incident occurred at a shift change and “for whatever reason” Livingston’s observation status was not changed. Neither was it discussed at a meeting the following day. Further, Livingston’s treating psychiatrist did not see the nurse’s notation in progress reports.

The inquest report said that with the exception of the April 15, 2012 incident, Livingston gave no indication that he wanted or intended to harm himself. “Even the psychological reports prepared only a few days before his death do not mention any potential thoughts of suicide on Mr. Livingston’s part,” it said.

Finlayson said it is “unfortunate” that Livingston’s observational status change was not implemented following the April 15th incident, but based on the evidence he was satisfied that given the patient’s overall behaviour, his observational status would have reverted back to ‘normal’ within 48 hours — or “well before” his suicide.

Nevertheless, he recommended that the Winnipeg Regional Health Authority implement a policy that the observation level of each patient on the Health Sciences Centre psychiatric ward Livingston was on be recorded in a manner that’s easily and continuously accessible to all staff.

He further recommended that prior to the conclusion of each shift, a designated charge nurse should ensure that the observation level of each patient is accurately recorded and is easily accessible.

Further, at meetings called to discuss the status of patients, attendees should be informed of the names of all patients who have had their observational level changed by any nurse or doctor, regardless of how much time has elapsed between meetings, the judge recommended.

Livingston was brought to the HSC emergency room by ambulance on March 21, 2012, after he called 911 and told the dispatcher he was going into cardiac arrest.

When paramedics arrived, Livingston denied having chest pain, shortness of breath or dizziness.

After being assessed in the ER, he was admitted with a diagnosis of organic brain syndrome. His behaviour over the next few days became more agitated and manic and he began refusing medication and treatment, according to the province’s chief medical examiner, Dr. Thambirajah Balachandra.

Livingston was seen by a psychiatrist and his status was changed to involuntary admission under the Mental Health Act.

At the inquest, a psychiatrist testified that Livingston was diagnosed with alcohol amnesia disorder or Korsakoff’s syndrome. In Livingston’s case, his short-term memory was gone. In the psychiatrist’s opinion, Livingston would have had to consume about 10 standard drinks a day for 20 years before getting Korsakoff’s syndrome.

larry.kusch@freepress.mb.ca