DATE: July 20, 2020

Ms. Jennifer Fuchinsky Fatality Inquiry Coordinator Justice and Solicitor General 9th Floor Peace Hills Trust Tower 10011-109 Street Edmonton, T5J 3S8

Dear Ms. Fuchinsky:

Re: Timothy James Olenyk – Public Fatality Inquiry, Response to Recommendations

Thank you for providing the Honourable Judge Kenneth R. McLeod’s report. This letter is to provide a response to the eight recommendations impacting AHS.

Recommendation 1

That AHS install secure double containment door systems at the entrances to every secure mental health unit at Rockyview General , in the Region, and, to the extent reasonably possible, in the province. Response AHS accepts this recommendation. (In Progress) AHS has installed, or is in the process of installing, double containment doors at all our sites with mental health units in Calgary. We are currently exploring the costs and safety implications of doing the same at other provincial sites that have mental health units. All identified sites will require site specific design studies to assess the feasibility, once options are developed, where possible, high level renovation costs will be estimated to help determine a funding source. AHS considers this project a high priority and will continue to work with Alberta Health and Alberta Infrastructure to identify capital needs and priorities.

Recommendation 2

That AHS install parkade safety enclosures at every parkade at Rockyview General Hospital, and at other in the Calgary Region or in the province which have secure mental health units.

Response AHS accepts this recommendation (In Progress). Safety fencing or enclosures are being installed around the complete perimeter of all AHS parkades commencing from levels 3 or approximately 25 feet (7620mm) above grade to top deck or level of the parkades. Safety fencing was installed at the new Red Deer parkade in 2016, at the Foothills Medical Centre central parkade which opened in 2019 as well as the Chinook Hospital parkade in 2019. Currently, installation of perimeter safety fencing for all remaining Calgary and Edmonton AHS multi-story parkades is currently underway. Designs have been completed, contractors have been hired and development permits required

to begin construction have been approved by the City of Calgary and in process for the City of Edmonton. It’s expected the new parkade safety fencing at the Rockyview General Hospital, , Richmond Road Diagnostic and Treatment Centre and remaining parkades at the Foothill Medical Centre (FMC) as well as the University of Alberta and Royal Alexandra Hospital parkades in Edmonton will be completed by the end of 2020 or by the spring of 2021.

Recommendation 3

That AHS install consistent and improved signage communicating the importance of entrance security at public entrances to AHS hospital secure mental health units. Response AHS accepts this recommendation. (In Progress) Signage has been added to the entrance of all secure mental health units in the Calgary Zone. These signs read: “Welcome to our unit. To ensure the safety of our this unit is locked. Please help keep our patients safe by ensuring the door closes behind you and that you are not followed out.”

AHS Addiction and Mental Health will review the status of security signage at all public entrances to secure units. The core messages on entrance signage will be standardized for consistent messaging. This will be completed by Aug 31, 2020.

Recommendation 4

That a security dome be installed in the ceiling beside the station on unit 45 at the Rockyview General Hospital. Response AHS accepts this recommendation. (Complete) As of May 22, 2020, a security dome has been installed in the ceiling beside the nursing station on unit 45 at RGH.

Recommendation 5

That AHS emphasize in staff training the requirement of the development of a safety plan for patients assessed as a moderate or high or imminent suicide risk.

Response

AHS accepts this recommendation. (Complete)

As of January 2020, the Addiction and Mental Health (AMH) Suicide Prevention, Risk Assessment and Management (SPRAM) Training Initiative is available and provides systematic and comprehensive suicide ______Edmonton• 14th Floor, Seventh Street Plaza• 10030 107 Street, Edmonton Alberta T5J 3E4 Tel: 780-342-2020 [email protected] www.ahs.ca

prevention training for AHS employees. SPRAM consist of a series of seven (7) sequential eLearning modules that align with best evidence to guide clinical response across suicide prevention, risk assessment and management as relevant to AMH community, residential, mental health inpatient and corrections. AHS AMH also consistently meets the highest level of health care standards as identified by Accreditation Canada. Within these standards there is an ROP (Required Organizational Practice) and Test for Compliance that includes: assessment of risk of suicide for each AMH at regular intervals or as needs change, addressing the immediate safety needs of patients at risk of suicide, and identification, implementation, and documentation of treatment and monitoring strategies for patients at risk of suicide. AHS AMH has met this criteria at 100% for each accreditation audit since 2012. Suicide Risk Management is also included in provincial AHS AMH policies and procedures. These governing documents require that screening, and assessment of risk of suicide for every patient is completed in an ongoing therapeutic process. Safety plans are developed for all patients assessed as being at a moderate or high/imminent risk for suicide by the patient's health care professional and in collaboration with the patient, as clinically appropriate. Safety plans include the need of observation levels, use of hospital attire, and searching the patient and his/her property, where appropriate. Documentation of the assessment, treatment and safety planning are maintained within the patients chart in accordance with AHS’s clinical documentation guidelines. The implementation of Connect Care is providing a standardized level of practice in suicide risk management for AHS AMH. Screening and assessment are completed using the Columbia-Suicide Severity Rating Scale (C-SSRS). Connect Care’s clinical decision support capacity will support appropriate suicide risk management for health care providers in all settings who use Connect Care.

Recommendation 6

That AHS consider implementing a policy that mandates a staff only debriefing following the death of any patient on a secure mental health unit related to an elopement or absence without leave within a reasonable time after that death.

Response AHS proposes an alternate solution. (Complete) For Addiction and Mental Health teams in the Calgary Zone, this is considered standard practice on all sites. An immediate informal debrief occurs with the staff who were present on the unit at the time of the critical incident or death. Staff have the option to attend a more formal debrief, usually held the day after the incident, where the Employee and Family Assistance Program (EFAP) support is available for those who need it. This is usually a decision made with input from staff to determine if this more formal debrief is required. After all incidents, staff are reminded that they can access EFAP individually.

Additionally, Effective November 2017, AHS approved a Patient Safety Policy suite that includes procedures for the immediate and ongoing management of a clinical adverse event with the objective of ensuring the needs of the patient, staff and medical staff involved in CAE are managed appropriately according to evidence-based principles and practices.

______Edmonton• 14th Floor, Seventh Street Plaza• 10030 107 Street, Edmonton Alberta T5J 3E4 Tel: 780-342-2020 [email protected] www.ahs.ca

Recommendation 7

That AHS ensure that fatality inquiry reports and any AHS responses to them be made available to AHS employees, online or otherwise, within a reasonable time following the release of those reports or responses, and that the availability of those materials be expressly communicated to all AHS staff working in the affected unit or who testified at the relevant inquiry within that reasonable time. Response AHS proposes an alternate solution. (In Progress) Since June 2017, AHS has participated in providing a public response to Fatality Inquiry recommendations directed to AHS through the governments Open Data Portal. AHS Provincial Patient Safety will develop and implement a process to distribute a Patient Safety Learning Summary for Fatality Inquiries to all AHS staff that provided testimony or are working in either the affected unit or similar units to ensure the outcome of the inquiry and the AHS response to the recommendations is communicated. The learning summary will contain a link to the Open Data Portal where the full report and AHS response can be reviewed. It is anticipated that this will be complete by January 2021.

Recommendation 8

That AHS consider making publicly available responses to fatality inquiry recommendations a standard practice.

Response AHS accepts this recommendation. (Complete) In June of 2017 the Ministry of Justice and Solicitor General (JSG) launched an online system to track organizational responses to fatality inquiry recommendations. Since that time, a written response to all fatality inquiry recommendations directed to AHS has been submitted to the government’s Open Data Portal within four months of the reports public release. This portal is open to the public and houses the Fatality Inquiry Reports and organizational responses to all recommendations.

Sincerely,

______Dr. Francois Belanger Vice President Quality and Chief Medical Officer

______Sean Chilton Vice President Health Professions and Practice Alberta Health Services

______Edmonton• 14th Floor, Seventh Street Plaza• 10030 107 Street, Edmonton Alberta T5J 3E4 Tel: 780-342-2020 [email protected] www.ahs.ca