Report to the Minister of Justice and Solicitor General Fatality Inquiries Act

Public Fatality Inquiry

WHEREAS a Public Inquiry was held at the Provincial Court of Alberta in the City of Calgary , in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 3 day of December , 2015 , and on the 4 day of December , 2015 , and on the 12 day of January , 2016 , and

on the 26 day of February , 2016 , and

on the 5 day of July , 2016 before Michael C. Dinkel , a Provincial Court Judge, into the death of Wayne Lannie Pratt 68 (Name in Full) (Age) of 74 Elgin Drive S.E., Calgary, Alberta and the following findings were made: (Residence)

Date and Time of Death: July 18, 2012, at 17:00 hours

Place: Glenmore Reservoir, Calgary, Alberta

Medical Cause of Death: (“cause of death” means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization – The Fatality Inquiries Act, Section 1(d)).

Drowning

Manner of Death: (“manner of death” means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable – The Fatality Inquiries Act, Section 1(h)). Accidental

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Circumstances under which Death occurred:

On July 14, 2012, Mr. Pratt (Pratt) was admitted to the Rockyview General Hospital (RGH) for assessment due to dementia with agitation and delusions. On July 18, 2012, at approximately 16:15, Mr. Pratt was observed leaving RGH through an emergency exit. He was originally seen running north and then east of RGH. He eventually went west towards the reservoir from where his body was recovered two days later following a search.

Introduction

On July 14, 2012, Pratt was apprehended by the Calgary Police Service under the Mental Health Act and taken to RGH. His family was concerned about his delusional and wandering behaviour arising out of his dementia. Pratt was eventually admitted to RGH and placed on a Hospital Unit that was not secured. On July 18, 2012, at 4:00 p.m., Pratt left that unsecured Unit without permission and under his own power and was last seen running away from RGH. A search of the nearby Glenmore Reservoir was conducted and Pratt’s body was found on July 20, 2012. He had drowned in the reservoir.

The Procedure Related To Fatality Inquiries

This Fatality Inquiry is a public inquiry under Part 4 of the Fatality Inquiries Act of the Province of Alberta to hear evidence so as to make certain findings in respect of the death of Pratt. The Attorney General did not direct that a jury be summoned. Accordingly, I held the Inquiry as a Provincial Court Judge sitting alone with all the powers of a Commissioner appointed under the Public Inquiries Act. It was not a trial. It was a factual inquiry. At the conclusion of the Inquiry, I am required to submit this written report to the Attorney General.

The Report must contain my findings as to the following: the identity of the deceased; the date, time and place of death; the circumstances under which the death occurred; the cause of death; and the manner of death.

My report may also contain recommendations as to the prevention of similar deaths. However, I am not permitted to, nor will I, make any findings of legal responsibility (see Section 53(3)) or draw any conclusions of law (see Section 48(1)). What follows is a review of the Inquiry including the circumstances of the death of Pratt, and my final decision on recommendations.

It is my understanding that the Government of Alberta, in receiving this report, may do one of the following:

1. Accept recommendations made and implement them; or 2. Accept recommendations made, but not implement them; or 3. Not accept any recommendations.

The Scope Of This Fatality Inquiry

It is important to note that the focus of this Inquiry is extremely limited. To address matters outside the scope of the Inquiry would be improper. The focus of this Inquiry is to make recommendations that will prevent similar deaths from occurring in the future.

The Course Of The Pratt Fatality Inquiry

The Fatality Inquiry heard evidence over the course of three days. Evidence was heard from December 3, 2015, to December 4, 2015, and again on July 5, 2016. There were other appearances where various matters were discussed. In particular, on January 12, 2016, there was a discussion about the nature and quality of the evidence heard to that point in relation to LS0338 (2014/05) Report – Page 3 of 22

what types of technology could be employed to either prevent patients from eloping from an RGH Unit or to track them after they had left. An additional date was added to hear evidence and Counsel for the Attorney General added two witnesses. The first had expertise in the area of RFID and GPS technology, while the second witness was a high-ranking official from RGH who was familiar with certain aspects of the technology previously considered and currently employed at RGH. Ms. McCurdy and Mr. Ghesquiero appeared on behalf of the Attorney General. Ms. Rico appeared on behalf of Alberta Health Services (AHS). Finally, Mr. Pratt’s son appeared as an observer on the last day of evidence and made a brief statement to the Court.

Eight witnesses were called in total including a CPS Detective, RGH Security Staff, various medical professionals and a technology expert. At the conclusion of the Inquiry, all parties involved were permitted time to make representations in writing as to what, if any, recommendations should be made. I received written correspondence from Ms. Rico, Counsel for AHS, in October and December of 2016.

The Evidence At The Fatality Inquiry

Since a copy of the transcript of the Inquiry will not be attached to this decision, I intend to review the relevant evidence and then proceed to analyze it before addressing any recommendations.

The Witnesses

Detective Lee Wayne (CPS)

Detective Wayne was the primary Calgary Police Service (CPS) investigator on the elopement of Pratt.

He took over the file two days after the July 18, 2012 elopement of Pratt from RGH. I note that, “elopement” is the technical term used to describe those situations where individuals leave a hospital when they are not permitted to do so.

Prior to Detective Wayne’s involvement, four police officers and the HAWCS Helicopter had been called in to conduct a search. Pratt was not located immediately, so steps were then taken by CPS to follow up with Calgary Transit (LRT and buses) and taxi companies. The family was contacted and it was determined that Pratt had $50.00 in cash and his debit and credit cards. Checks were made at his local bank for activity on his debit and credit cards, but there had been no activity. In addition, the RCMP were asked to check on a previous residence of Pratt’s in Welling, Alberta. Portions of the Glenmore Reservoir (the Reservoir) area were also checked. All checks were negative. Pratt was declared a vulnerable and high-risk missing person because of his history of dementia and diabetes.

On July 19, 2012, the search continued. Further checks were made with Calgary Transit and Homeless Shelters. The family released a photo and it was circulated to those agencies. That same day at approximately 3:00 p.m. a civilian, who was kayaking on the Reservoir, reported that he had observed some clothing and a wallet on a rock on the east shore of the Reservoir, just west of RGH. The wallet was confirmed to be Pratt’s. As a result of the discovery, a CPS Search Coordinator was assigned and the CPS Marine Unit and the Glenmore Reservoir Patrol Unit were asked to circulate the shoreline. The search met with no success that day. On July 20, 2012, when Detective Wayne first became involved, the Calgary Fire Department Dive Team also became involved. At around 2:20 p.m. on July 20, 2012, Pratt’s body was located approximately 50 yards offshore submerged in water eight feet deep. Detective Wayne described the location where Pratt’s clothing and wallet were found as being at the bottom of a path to the Reservoir from the RGH. No foul play was suspected as there was no evidence of a struggle prior to Pratt entering into the water and there were no injuries found on his body. This was later

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confirmed by the Medical Examiner and the death was ruled an accidental drowning.

CPS worked with RGH Security, also known as Protective Services. They secured the RGH CCTV footage and confirmed it was Pratt who was seen leaving RGH on his own. He was observed on the video initially going north, he paused, and then turned south and went past the Paramedic Bays. Pratt was last seen on the video heading south of RGH near the helipad and he paused on the pathway to the Reservoir shoreline and then proceeded down that path towards the location where his personal effects were located. RGH Protective Services did not initially search RGH (this is termed a Code Yellow) because Pratt was seen leaving the RGH grounds. Their search did extend to the neighbourhood of Eagle Ridge, just to the south of RGH.

Detective Wayne described elopements from the Rockyview as being “common” during his six years working at the District Six Office, where such incidents were reported. The Detective described the CPS search for Pratt as being more intense than the typical search, as it involved HAWCS and other resources (Marine Unit and Fire Department Dive Team). He said Pratt, and others, were often seen as a risk because of their medical circumstances. Pratt was specifically seen as a risk because of his special diabetic diet and possible suicidal ideation. The intensity of each search, however, is based on a case-by-case basis as determined by the District Sergeant.

When asked if he had any insights or recommendations for the Inquiry based on his knowledge of the circumstances of the CPS investigation, Detective Wayne said he was concerned that Pratt was not on a secure unit considering his history. In his evidence he stated,

And so he literally walked out of the hospital unimpeded, and that for me isn’t an acceptable cost – it’s not acceptable to have someone who’s subject to wandering to be able to just walk out of the hospital at any given time.

When examined by Ms. Ricco, Detective Wayne confirmed that the information provided by RGH was satisfactory and RGH Protective Services were cooperative.

When asked about the nature of the other elopements he was aware of, Detective Wayne said it could occur when patients were on a pass or when they just left RGH on their own. He made specific reference to the case of Trinh Tran approximately 12 months before this incident. Tran was also found dead in the reservoir in circumstances very similar to that of Pratt. He said incidents occurred on a regular basis, anywhere from daily to every two days, where patients on a secured unit were allowed to go for a cigarette break outside and never came back.

When questioned by the Court, Detective Wayne confirmed Pratt’s clothing and wallet were discovered only 200 metres west of RGH.

Ms. Jennifer Nash (Registered Nurse)

Ms. Nash was a Registered Nurse assigned to Unit 94 and on duty on July 18, 2012, when Pratt eloped.

Unit 94 dealt with patients with Respiratory and Internal Medicine issues. Her duties included assessing patients, administering medications and maintaining the patient’s fluid balance. On July 18, 2012, she was also the Charge Nurse, which meant other nurses reported to her. More specifically, she was Pratt’s Registered Nurse.

It was her understanding that Pratt had been admitted to RGH because “he was exhibiting some changes in his pattern of behaviour, and his family had been concerned and brought him to the city [of Calgary] to be assessed.” He was initially placed in Room 1, but was moved to Room 6 because of concerns over elopement.

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She recalled entering Pratt’s room and meeting with him and advising him that if he needed anything that she was his nurse. She noticed he was in his “street clothes” and asked him if he would be more comfortable in hospital pyjamas. He said that he would not be and she made no further effort to have him change into the pyjamas. She did acknowledge that patients on that floor were typically in hospital gowns. She expressed concern that there was nothing about Pratt’s clothing to indicate that he was a patient of RGH. She did not have any concerns about Pratt’s demeanour at that time and felt he wouldn’t be a problem to take care of. She did acknowledge that she had been made aware of Pratt’s elopement risk on the previous shift.

Nash eventually noticed that Pratt was up and out of Room 6 and walking the various hallways around the desk. She felt his agitation was escalating at that point and it was necessary to intervene. However, she was busy with something related to her Charge Nurse duties and unable to deal with Pratt. It was at this moment that Pratt headed towards the Emergency Fire Exit. She asked one of the Nursing Assistants, Cresencia (aka Chris) Madriaga, to follow Pratt out the door and down the stairway. When Pratt exited the floor, he set off the alarm. Although the Nursing Assistant did take chase, she failed to catch up to Pratt and returned saying she had lost track of him.

Nash then called Protective Services who confirmed that because Pratt was on a Mental Health Warrant and required to remain on the Unit, they could pursue him. Protective Services attended on the Unit and initiated a search. Once it was clear that nobody could locate Pratt, Nash called CPS, her Unit Manager, the On Call Administration for the City of Calgary and the Pratt Family.

Nash stated that Pratt was placed on Unit 94 simply because they had a bed. It was understood that he had been exhibiting a change in his cognitive behaviour and the doctors wanted to check out his electrolytes and do some other testing to determine if that was what was causing the unusual behaviour. Unit 94 was not a Secure Unit and dementia patients were not typically placed there, but it did happen fairly frequently. The only Secure Unit in RGH was Unit 47 and it had a locked door. It was also confirmed that Pratt was in an Isolation Room (Room 6). This was because it was available, it was close to the Nursing Station and it was private. This would have allowed the Nursing Station to keep a better watch on him as the walls were glass and allowed for observation. Still, Pratt quickly realized he was being watched and simply put the Venetian blinds down.

The Clinical Nurse from the previous shift gave Nash, as Charge Nurse, a detailed report on every patient on the Unit. She had been made aware that Pratt had been exhibiting early signs of dementia or Alzheimer’s, he had exhibited aggressive behaviour in the Medical Assessment Unit (MAU) requiring him to be confined to a Broda Chair, and that Pratt was an elopement risk. She was unaware of the recommendation to transfer Pratt to a Secure Unit. From all the information she had, Nash personally believed Pratt to be a suicide risk.

Although she had never dealt with an elopement involving a patient that had left RGH, Nash said she knew what to do. She knew she had to call a Code Yellow and notify Protective Services. A Code Yellow was not in fact called because that only applied to a patient who was wandering within RGH and Pratt was outside the building. Protective Services were called within about five minutes of the initial elopement when it was known that the Nursing Assistant had not stopped Pratt.

Nash confirmed that since this incident some procedures had been changed. A Yellow Wristband Program was introduced so that all patients who were an elopement risk wore a yellow wristband and if they were seen to be wandering RGH, Protective Services were to be called and the patient was to be returned to their Unit. The front door to the Unit was also changed so that patients could only leave when they pushed a button and anyone at the Nursing Station could override this action. Previously, the door would simply open when someone was standing close

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enough to the door to activate it. However, Pratt did not exit from the front door, he exited through the Emergency Fire Exit.

When questioned by the Court, Nash confirmed that Unit 94 was not an Alzheimer’s or Dementia Unit. And when a person was admitted to RGH the key was not to place a person on the correct Unit, but rather to simply find them a bed on any Unit. The bottom line was that there were not enough beds in RGH to accommodate patient demand, so patients were not guaranteed a bed in the Unit that was most suited to their problem. In fact, Nash said it was rare for her to go through a shift and not have a patient that didn’t belong in the Unit she was covering. Nash said that looking back on the situation she would have been more firm about Pratt removing his street clothes and putting on the hospital clothing as this would have made him stand out more in public. She said that whenever people get on a bus wearing the hospital gowns, RGH is contacted right away. Ms. Nash confirmed that since this incident, RGH does require admitted patients to remove their street clothes and put on hospital clothing. She also acknowledged that without too much trouble, Pratt could have been sedated. It would have required a doctor’s order for the drug and Protective Services to attend and hold him down, but the sedation would have reduced his agitation and his risk to elope (there was in fact a doctor’s order to sedate Pratt, if necessary).

Ms. Leni Merlini (Nursing Assistant)

Ms. Merlini was a Nursing Assistant on Unit 94 the day Pratt eloped.

Her shift started at 3:00 p.m. that day, one hour before Pratt eloped. She was aware that Pratt had recently arrived at the Unit, so she checked on him in his room and gave him a hospital gown so that he would be appropriately dressed. She was aware that he was an Alzheimer’s patient. She said she had some training with Alzheimer’s patients, but was not aware of any special practices or procedures for them at RGH. Yet she knew that Alzheimer’s patients were typically put near the nursing station so they could be observed and checked on every ten minutes.

The next time Merlini saw Pratt was when he was in the hallway. She noticed he was mumbling and bothering other patients and their families. She planned to take Pratt to his room because she feared he might strike someone because he was suffering from Alzheimer’s. However, Merlini didn’t actually take Pratt to his room, but rather lead him there and assumed he would go into the room. As they were walking towards Pratt’s room, she became involved with something else and turned her back on Pratt. It was at that point that Pratt made his way to the Emergency Fire Exit and opened the door. Merlini turned around to see another staff member following Pratt down the stairs. She followed immediately, but never caught up to either Pratt or the other staff member. She returned to the Unit to tell the Charge Nurse that Pratt had eloped and that she did not see either Pratt or the staff member. After about ten to fifteen minutes the staff member returned. Merlini identified that person as Chris. At that point Merlini returned to work.

She said Pratt was new to the Unit so they had little information on him. She did know that he came from the Emergency Room, but had no knowledge that he had been aggressive. She did know that he had been transferred from Room 1 to Room 6 for observation purposes. Merlini was not aware that Pratt was an elopement risk. She did know that if a patient eloped, a Code Yellow was to be called (this was only true if the patient was wandering within the building).

Cresencia Madriaga (Nursing Assistant)

Ms. Cresencia (Chris) Madriaga was a Nursing Assistant on Unit 94 the day Pratt eloped.

She started her shift that day at 3:00 p.m. Her first interaction was to bring water to Pratt in his room. She confirmed that he was wearing his street clothes rather than his hospital attire and she

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was confused as to whether he was a patient or not because of his attire. When she first dealt with Pratt she had not gone over the Patient Care Report detailing his circumstances, but the previous Nursing Assistant had verbally advised her that Pratt had dementia. She confirmed that it was common practice to keep dementia patients near the Nursing Station so they could be observed.

As she was returning to check on Pratt, someone noticed he was eloping through the alarmed Emergency Fire Exit door and she was told to go after him. She could not remember who directed her to follow Pratt. She proceeded out through the door and didn’t see Pratt until she was outside. She said he was initially going north, but changed direction and headed south through the Emergency Bay. She said that because Pratt ran so fast, she could not keep up to him. As a result, she called Security from a lobby emergency phone that direct dials to Protective Services, but she incorrectly believed it went straight to voice mail, so she hung up and called her Unit from another phone and told them to call Protective Services. She then returned to the Unit and advised the Charge Nurse that she had been unable to catch Pratt and return him. After her return to the Unit, she simply went about dealing with her patients.

Madriaga confirmed that the routine on her Unit was to check on the patients every 30 minutes. She stated that this was the first elopement that she had experienced.

Madriaga also stated (incorrectly) that the Yellow Wristband Program had been implemented prior to the Pratt elopement and there was currently no policy surrounding patients being required to wear hospital clothing while on the Unit (also incorrect).

Her only recommendation to the Inquiry was to place dementia patients in locked Units.

Andrew Olson (Protective Services)

Mr. Olson was employed as a Protective Services Officer at RGH on the day of Pratt’s elopement. Olson was not working during the days prior when Pratt was in RGH, but as the Team Leader he was made aware of the circumstances.

He stated that Protective Services Officers maintain physical security of the patients, the staff and the building, which includes fire alarms, duress alarms and fire extinguishers. This requires that they patrol RGH grounds to make sure everything is safe and secure.

Olson was told that Pratt presented at the Emergency Department and went through two Units during his stay. He was also told about an incident where Pratt was “acting out and brandishing an IV pole.” There were checks made on Pratt in the Emergency Room every 15 minutes to assure the safety of everyone involved.

Olson confirmed that there were regular patrols done of Unit 94 and occasionally there were patrols related to specific patients that would have to be ordered by a doctor or a nurse.

Olson was asked about the notes of a Protective Services guard by the name of Hansen Snokes. The notes stated that Pratt was determined to be an “elopement risk.” He stated that there were no policies that would be put into place by Protective Services when a person was determined to be an elopement risk as that was a nursing decision. On July 18, 2012 there was a call to Protective Services about Pratt’s elopement. Olson was not clear who placed that call, but it resulted in the Protective Services officers going to the area of the Emergency Department to conduct a search. A number of areas were searched by six officers including: the front of RGH, the front of the Emergency entrance, the parking lot structure and the open-air lot, around the ambulance parking, the helipad south of RGH towards the bike path and the nearby neighbourhood of Eagle Ridge. The Reservoir area was not searched

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because there was no reason to believe that Pratt had gone in that direction at that time. At that point, some 20 minutes later, the Unit was notified that Pratt could not be found and the CPS would have to be called as per RGH policy. It was Unit 94 that called the CPS and not Protective Services. Olson did not know how long it took for the CPS to arrive. The CPS did direct Protective Services to search RGH and that was done. A further complete search was done the next day.

When asked by the Court how often these elopements occurred, Mr. Olson stated that it would be between 50 and 100 times during the time he was on duty over the course of his 14 years of his employment.

Olson stated that should there be an indication that the patient was headed in the direction of the Elbow River or the Reservoir, then Protective Services would conduct a search along the edge of the water, or more technically in this case, the Elbow River, which is just west of RGH. The actual Glenmore Reservoir is located north of the Glenmore Trail Causeway and the Elbow River feeds into that.

When questioned by the Court, Olson confirmed he was aware of four elopements that ended up at the water’s edge, be it the Elbow River or the Reservoir. Of those, two others resulted in fatalities. The Reservoir Security Services boat rescued the other eloper. Olson felt that Protective Services did not have enough manpower to check the Reservoir area in all cases. Olson also confirmed that there were direct emergency lines to Protective Services and that they did not have voice mail, but rather had an initial recording that said that the call would be recorded. In addition, there are a number of intercoms on the property that previously went directly to Protective Services, but they now get routed through a Call Centre in Edmonton. The change was made to save costs. As a result of related cut backs, they have also lost two full-time people.

Olson made no suggestions as to recommendations.

Dr. David Flack (Medical Doctor)

Dr. Flack was the doctor, or Hospitalist, who was caring for Pratt during his time in RGH.

On the night of July 14, 2012, another doctor consulted Dr. Flack for the purpose of admitting Pratt. He agreed to see Pratt and assess him for admission. It was Dr. Flack’s understanding that Pratt was brought to RGH because he was not managing his dementia very well. This included elopement issues and physically threatening family members. Dr. Flack reviewed all of the pertinent nursing and physician notes and labs and the Form 10 Mental Health Warrant and Form 1 prepared by the other doctor. He also interviewed Pratt and his son. Finally, he performed a physical exam on Pratt. This lead to a confirmation that admission was necessary because it was not safe for Pratt to be in the community. The diagnosis was dementia with aggression. However, there was some concern over delirium because of Pratt’s confusion and agitation. This required various tests and labs to look for common concerns such as infections, electrolyte imbalance and renal failure. As a result, Pratt was admitted.

Dr. Flack felt that Pratt should be certified for longer than the 24 hours permitted by the Form 1, because of the risk of elopement and self-harm. As a result, he did a second Form 1, which was good for 30 days, and asked for a consultation from Geriatric Psychiatry. Dr. Flack confirmed that, at that time, he made no request for a special Unit or type of bed for Pratt as technology such as surveillance and WanderGuard did not exist (Ms. Thurber, however, stated that there was a WanderGuard in place on one Unit at that time). Dr. Flack stated that, generally, admitted patients would go to Medical or Surgical Units that had available bed space. This included patients, such as Pratt, who were deemed to be elopement risks. However, Flack said Pratt

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stayed in the MAU for two days prior to his admission (this appears to be incorrect as Pratt was admitted on July 14, 2012, and eloped shortly after arriving on Unit 94 on the 18th, so it may be that he waited up to four days to get a bed). The MAU was a holding area for patients who were finished with the ER, but had not found a bed for admission. It is no longer in existence.

Dr. Flack noted that of every 250 people to be admitted to RGH, 100 of them are confused, old people and there are only 30 beds in Unit 48, the Geriatric Psychiatry Unit. On top of that, the Unit is selective in terms of whom they take. They would tend to take people with treatable psychiatric conditions such as depression. As a result, dementia patients would not typically be placed in Unit 48.

As it turns out, Dr. Madan, of the Geriatric Psychiatry Unit, did interview Pratt and recommended that he be transferred to Unit 48. In fact, Dr. Madan recommended that Pratt receive long-term dementia care in a secured Unit. Dr. Flack agreed with that assessment, but, Pratt never made it to Secure Unit 48.

While Pratt was in the MAU Dr. Flack saw him daily as part of his rounds and evidence of Pratt’s agitation initially decreased. He was being given a low dose of Risperdal, an anti-psychotic. This was a form of chemical restraint, as physical restraint, such as tying a patient to a bed, was not ordinarily done as the patient could try to flip the bed or gurney and hurt him or herself. On the night of July 17th, Pratt’s agitation escalated and he grabbed an IV pole and began to swing it around in the MAU and then tried to leave. Dr. Flack increased Pratt’s Risperdal the next day because of the incident and the effect of “sundowning” (increased agitation after sunset) that demented patients tend to experience. He said that the medication was to continue on admission at a dose of 0.25 milligrams at 2000 H. Dr. Flack had no other concerns for Pratt at that time other than to deal with his displacement from his family and his familiar surroundings with family visits, in an attempt make Pratt more comfortable.

Dr. Flack’s summary note regarding Pratt read as follows:

New admission, July 14, 2012 dementia with aggression, caregiver burnout. See Geriatric Psych notes. No acute issues. Continue medication titration for sundowning. Needs long- term care placement and EPOA PD activation. MAF completed and on chart.

Dr. Flack felt that the primary issue upon Pratt’s admission was not one of elopement, but one of aggression.

When asked if he felt Unit 94, the Respiratory Unit, was the appropriate placement for Pratt, Dr. Flack said that he felt it was because he preferred to have his patients on a Medical Unit rather than a Surgical Unit, as there was more expertise to deal with the type of patients he typically dealt with.

On reflection, Dr. Flack felt there was nothing else he could have done with Pratt considering he did not exhibit any suicidal tendencies. If he had, then Geriatric Psychiatry would have been involved on a more immediate basis.

Dr. Flack confirmed that some changes had been made since the incident including the installation of WanderGuards on two units, other than the Geriatric Psychiatric Unit, and the Yellow Wristband Program. The Yellow Wristbands were simply a means of identifying patients at risk for elopement. The WanderGuard involved a device worn by a patient that would trigger the Unit door to lock when the patient got close to the door. Dr. Flack stated the WanderGuards were currently available on two Sub-Acute Units at RGH, which house a total 60 beds. These Units act as holding areas for long-term placement patients.

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In terms of recommendations, Dr. Flack said that it would be preferable to place patients such as Pratt on Medical Units rather than Surgical Units. And he suggested keeping patient moves to a minimum so as to decrease patient confusion. He did not suggest an increased role for physicians in the placement of their patients as they already made specific recommendations in their Admission Orders. He did add that patient elopements still happen all the time.

Teresa Eileen Thurber (Current Rockyview Hospital Executive Director of Critical Care and Women’s Health – Former Patient Care Manager for Units 93 and 94)

In her position as Director of Critical Care and Women’s Health, Ms. Thurber reports to the Senior Operating Officer of RGH. All of the frontline managers from each department under her report directly to her.

At the time of Pratt’s elopement, she was the Patient Care Manager for his Unit. She was an Administrator who managed the day-to-day activities of the Unit, but had no direct contact with the patients.

On the day of Pratt’s elopement, Pratt entered her office around 3:00 p.m. looking for a sink to wash his hands. He was wearing his own clothing, but this did not concern her. Thurber stated there was no policy for patients to wear hospital clothing at that time in 2012. She began to escort him back to Unit 94 and was intercepted by a nurse in the hallway and the nurse returned Pratt to the Unit.

As she was leaving for the day, around 4:00 p.m., Thurber was alerted to the fact that Pratt had eloped. She was told that two staff members, Leni and Cresencia (Chris), were right behind him, so she proceeded to leave assuming that Pratt would be found and returned to RGH. At some point thereafter, Thurber completed a form that advised her leadership that a patient was missing from the Unit. It was not until the next morning that she was informed that Pratt had not been found.

Thurber was aware that Pratt was admitted because of concerns over dementia. His being lost in the hallway was consistent with that. However, she did not have any concerns with agitation or aggression.

At the time there was one Unit that was fully secured (Mental Health Unit required swipe cards) and one Unit that was semi-secured (Transition Unit with a WanderGuard). Thurber described the WanderGuard Unit as using, “a radiofrequency bracelet, either on their wrist or on their ankle, and when the[y] get within a certain vicinity of the exit door, an electromagnetic lock engages and the door can’t be opened or closed while the patient is within exit range of that doorway.” It was the nurses who determined which patient would wear the WanderGuard bracelet or anklet. Since Pratt’s elopement an additional WanderGuard had been installed on a second Transition Unit where patients were no longer able to manage independently in the community and they were waiting for a long-term care placement. The Transition Units hold between 29 and 32 patients, but patients cannot be admitted directly to the Units. Pratt could not have been admitted to a Transition Unit because a doctor had not medically cleared him. Thurber also stated that the Secured Units had Emergency Fire Exits that would only open when an alarm was activated. This was contrasted with the Units that were not secured, but did have an alarm that would go off when opened. Thurber stated that Pratt was placed on Unit 94 because that was where the first bed became available. There was no specific Unit where a dementia patient would be placed. Part of the reason for this was because dementia patients can escalate each other if too many are placed on one Unit. There was no formal education at RGH to deal with dementia patients, but interested staff would attend conferences or seminars dealing with the topic. Thurber was unaware of any specific procedures, practices or policies on Unit 94 for dementia patients. She did acknowledge

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that there are specific observation levels for certain patients, but Pratt was not subject to an observation order. However, it was her understanding that he was observed on a regular basis by staff because he was wandering. There was also no formalized practice for the placement of dementia patients on Unit 94. Thurber stated that this was simply a “clinical judgment call,” made by the nurses on the Unit. A patient could be moved closer to the central nursing desk, if there was a concern, as was the case with Pratt, who was moved to Room 6 across from the nursing station.

When a patient was moved from one area of RGH to another, Thurber stated their Patient Care Record followed them. Emergency would be the first to input information in the form of a “Transfer of Care Summary.” The receiving nurse on the Unit would review this information. There was also an opportunity for verbal communication should the nurses in the sending or receiving areas have any concerns. Thurber described the reporting structure as “comprehensive.” The Transfer Summary included information about how and why the patient presented, their vital signs, the immediate medical interventions and the patient’s status at the time of transfer. However, activity such as wandering or aggression was not necessarily part of the Report, unless it required a significant amount of time for the staff to intervene with the patient. At the time, issues such as wandering were communicated from one staff member to another verbally. Since Pratt’s elopement, a new process was put in place that requires that a “Confusion Assessment” be done on every patient. The Assessment used a validated research tool called the Confusion Assessment Model (CAM), which addressed a number of clinical indicators. If the patient were CAM positive, then they would typically be triaged to a bed closer to the nursing desk.

When nurses arrived for their shift, they had a 15-minute overlap with the preceding shift. This allowed them to review electronic and paper patient records and a report prepared by the departing nurse to bring them up to speed on their patients. Thurber stated that any issues of aggression while in the Unit would have been reported verbally from nurse to nurse. Thurber confirmed she was not notified of any risk of elopement when Pratt was transferred to Unit 94, but that would not have been unusual.

When asked what measures could have been put in place to prevent Pratt’s elopement, she said moving Pratt to the room closest to the nursing station was appropriate. Following the incident, Facilities and Maintenance were contacted to change the sensors on the entry and exit doors. The sensors were deactivated so that the doors would no longer open when someone approached. The only way to open the doors after the change was to use a button on the wall. The clear glass on the Unit entry doors was also covered with an opaque film, which removed the appearance that the sliding doors were a window that could entice wandering patients to elope. Patients were also required to change from their street clothes to hospital clothing as soon as it was safe to do so. This had the effect of deterring them from eloping as well. The nursing staff also created a White Board, located in a room off the common pathway, where any patient risks were noted including elopements and falls. Additional security could have been ordered, but in Pratt’s case there was no indication that was necessary. Chemical restraints were also available, but that was a last resort as Thurber described it as inhumane. Thurber also referenced the Yellow Wristband Project as being a new means of identifying patients at risk of wandering. All staff members were educated on the Program and encouraged to return wandering patients to their Units. Finally, patients at risk for wandering had their photos taken (with their consent or the consent of their guardian) and the photos were placed on their charts along with a physical description of the patient. There was a recommendation that Pratt be transferred to a secure Unit in a long-term care facility. Thurber agreed that this was made, but deemed it to be for future care and not immediate care. She said that transfers to long-term facilities could take in excess of a year.

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Thurber stated that she was aware of at least one elopement per month on an ongoing basis. She stated that most of those who eloped were patients who had conditions similar to Pratt.

When asked if the elopement issue was as a result of not having enough secured Units, Thurber said that it was only part of the problem and the greater concern was seeing that there was a proper medical assessment, testing and a comprehensive plan created. This would insure whether there was an underlying medical reason for the patient behaviour. She specifically disagreed with the concept of creating a Dementia Unit. This was because it would create “a very unattractive place for staff to work and then nobody, except the staff working on those areas, develop an advanced skill set to manage this population of patients.” She felt it was better that all staff had some dealings with the dementia patients. She did feel that ongoing training and updating (refresh and revisit) was always good for staff, but that seemed to be happening already. Thurber felt training for identifying patients at risk for elopement was not practical as it was difficult to identify any one tool that would assist in identifying at risk patients. Thurber believed the current practice of identifying and communicating the risk was still the most practical tool for the staff.

Thurber noted the cost for each WanderGuard was $28,000.00 per door and outfitting each Unit would be cost prohibitive as each Unit has three to four doors. Practically speaking, RGH might install one or two doors per year. More importantly, she noted that the WanderGuard was not foolproof as it did not secure the Unit completely and some patients were able to remove the WanderGuard bracelets.

When asked about the possibility of using different coloured hospital gowns for patients at risk of elopement, she stated that it had been considered, but there were significant issues related to patient privacy, as the simple wearing of the gown would reveal private information about the patient to the public. Other ideas such as yellow vests were also deemed to be inappropriate as they act as both a barrier and a label and were easily removed by the patient. In the end, Thurber felt that every change that could be made to improve elopement prevention had been made and education to deal with dementia patients was ongoing.

When questioned by the Court, Thurber agreed it was crucial that the patients at risk for wandering be placed into hospital gowns as soon as possible. She stated there was now a greater recognition by staff as to how important it was to have the patient change into hospital clothing. Thurber also confirmed that there was no requirement that Protective Services search the banks of the Reservoir as it was off RGH property and was left to the CPS to search. She said there was no policy as to who should go after an eloping patient; it was simply a matter of who was the closest and most available individual regardless of their ability to deal with the situation.

She confirmed there were three secure Mental Health Units and two Units have the WanderGuard installed. She was unaware if the Emergency Fire Exits were still operational in those Units that had WanderGuards installed in them as opposed to the swipe card Units that had Emergency Fire Exits that would only operate when a Fire Alarm went off. The only other technology that Thurber was aware had been investigated by RGH was RFID, but it was rejected based on cost.

She confirmed that the property that leads down to the Reservoir next to RGH has not been fenced off. She confirmed that the property belonged to the City of Calgary and she believed they were unwilling to entertain the cost of building such a fence. She was also unaware of any fencing that had been erected as per the comments of Judge Jivraj in the Tran Fatality Inquiry.

She did state that had Pratt been acting aggressively on the Unit, she would have considered having him sedated, but there was no indication of aggression on the Unit, just in MAU. Still he

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was already on Risperdal and Haldol after the incident in the MAU. Thurber admitted that having patients wear specific coloured hospital clothing would be beneficial in more readily identifying at risk patients and it could possibly save lives. She also agreed that having more Secure Units would be a good thing, assuming cost was no object.

Discussion Between the Court and Counsel

Upon the conclusion of Thurber’s evidence, the Court and Counsel entered into a discussion about what possible technology existed that could address the elopement problem in a low cost and effective manner. The end result was that it was agreed that Counsel would take the time to procure a witness with some technological expertise that may be able to speak to that issue and explain what other facilities around North America are doing to combat the problem of elopement. As a result of that discussion, the matter was adjourned to speak to the setting of a further date for continuation. The return date to speak to was February 26, 2016. On that date, a continuation date of July 5, 2016 was set where two additional witnesses would be called.

Alfred Glen Kathler (Wireless Technology Instructor)

Mr. Kathler had been an instructor at SAIT since 1997 and in 2008 took a role as an Applied Research Chair in an RFID Application Development Lab at SAIT.

He stated that about 90 percent of tracking applications were either GPS or RFID. The remaining ten percent were Bluetooth communication. He explained the nature of GPS and how satellites allowed outdoor tracking within about three metres accuracy. He went on to say that GPS devices are typically battery operated and therefore consume power or energy. GPS can both locate and report the position of the object in question. In contrast, RFID is typically intended for indoor use and did not use a battery and involved the use of a smaller and less complex tracking asset that can be a wearable device that allows the tracking of individuals through a reader. When a person passes by an RFID reader, the chip is detected and sends a message confirming the location of the RFID chip. The range for the passive RFID without a battery supply is 30 feet. Battery assisted passive RFID can increase the read range to 1000 feet and much more complex active RFID tags can go up to a kilometre. The battery-assisted tag requires a reader, while the active RFID would work off a building’s Wi-Fi system. Locations on a map could be plotted based on the location of the tags. Department stores use UHF RFID to both locate an item that is leaving the store and identify what that item is. The key issues with this technology are what is to be tagged and where is it to be tracked.

Kathler confirmed that his department at SAIT had been contacted by AHS to look into the possible use of RFID technology in relation to elopements at the Foothills Hospital. This project never went ahead due to lack of funding. There was a similar request from RGH, but it was for different applications than elopements.

Kathler stated he was familiar with the nature of the RFID technology used in the WanderGuard system. He said that when using that type of technology it would be important to cover all areas of ingress and egress. It also used a battery in a wristband, which required ongoing maintenance. In addition, the WanderGuard merely alerted staff that a person had passed the door and it no longer tracked that patient. Kathler confirmed that there was a hybrid version of the WanderGuard that also used Wi-Fi to track the patient, but it came with its own set of concerns including the size of the device, recharging the device or replacing batteries. He also spoke of Project Life Saver, which involved the emission of FM radio signals and the ability to track the patient with either 3G or a wireless component. This provided location via a cellular phone service provider, but it would come with a fee.

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When asked which approach would work best, Kathler said he would like to research each first, but generally, he preferred RFID because it was light in weight, low cost and easy to replace. The weakness being that it was not effective outdoors. The ideal approach would be a combination of the RFID for indoor tracking and GPS for outdoor tracking. Unfortunately, that solution would require a large device to be worn by the patient that could weigh up to a pound. Kathler stated that research into a solution would be required and he could not currently recommend one technology over another.

Kathler confirmed he was sitting on a health care sub-committee. He said that RFID was already being employed in healthcare to track samples from labs and medications. He said he was the only person on that committee to raise the issue of RFID tracking for patients at risk of elopement. With the RFID technology, an antennae would be placed at a doorway and it would typically require a network connection to a console for monitoring; the network could be wired or wireless.

He confirmed that the RFID could also be used on Emergency Fire Exits as well. He felt GPS was a last resort (GeoFencing) and the better idea was to have layers of RFID coverage so the patient would be discovered leaving the Unit and then wandering around the hospital and then heading to a door that could be locked by the RFID. Kathler felt the RFID technology could be deployed fairly rapidly (less than a year) and would be successful at detecting patients who were eloping. He also confirmed he was aware of RFID tags being placed on newborn babies. He was unaware of RFID being used in hospitals in the United States other than the WanderGuard system.

In the end, Kathler was very well versed in the area of RFID. However, his personal knowledge as to its application to the hospital setting was extremely limited, so many of his answers were guarded or qualified. He had no specific knowledge of whether hospitals in the United States employed tracking technology to monitor elopement risk. Quite rightly, his go to response was to say that research would be required to determine the applicability of any one technology to the issue of elopement.

Kathryn Marian Schultz (Executive Director of the Rockyview Hospital)

Ms. Schultz had been the Executive Director of RGH (Medicine, Cardiology, Neurology and Correctional Health Care) for the past eight years. She first became aware of Pratt’s death four days after it occurred when she returned from a holiday. The person handling the matter in her absence advised her of the details of the event.

At the time of Pratt’s elopement RGH was experiencing eight elopements a month. As of the date of the Inquiry that had been reduced to four to six per month. Schultz stated she was made aware of each elopement. Her role in such situations would be to take the lead in investigating the situation and acting immediately upon the elopement by assisting in finding out what happened and providing all of that information to senior leadership.

A working group called the Calgary Zone Working Group on Elopement Issues was created in 2012 and Schultz was the co-chair in conjunction with Joan Campbell of Addiction and Mental Health. The Committee included members of Addiction and Mental Health, Protective Services, Legal, Seniors Health, Communications, Emergency and Disaster Management, CPS, physicians and their leadership from the Foothills Hospital, Peter Lougheed Hospital, the South Health Campus and the Children’s Hospital. There was no representative from the technology community. The mandate of the Group was to look into the concerns over the rising number of elopements from various hospitals. Meetings took place approximately one time per month. The Group only operated for one year. A Report (Tab 17 of the Exhibits), outlining recommendations, was prepared for senior leadership. Since the disbanding of the Group, ongoing Quality and

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Safety Committees at the various hospitals have continued to follow up on the issue of elopement.

The Group made nine recommendations, which were broken into various sub-categories. They included a recommendation to develop criteria guidelines to identify, manage and document cognitively impaired patients at risk of elopement. After reviewing related literature from across Canada, an assessment tool (CAM) was created to indicate whether a patient had a history of wandering with the family or long-term care or hospital staff. The initiative was rolled out to all four hospitals in the Calgary area and training followed.

Another recommendation was to work with the Code Yellow Provincial Group. That was done and as of the date of the Inquiry the Emergency Disaster Management Group was attempting to develop the Code Yellow in such a way as to adopt it across the province. In the meantime, RGH continued to use its own Code Yellow algorithm.

There was a recommendation that came under the title of Communicating the Risk of Elopement. This lead to the Yellow Wristband Project where patients would wear a yellow wristband to identify them as elopement risks. In addition, patients were no longer able to wear their street clothes in the hospital, thereby making them more identifiable should they leave RGH. Finally, notification was posted outside each Unit indicating that the doors must remain closed at all times. All three initiatives remain in place.

Another recommendation was to photograph at risk patients and put that photo on their chart. In conjunction with Legal, the plan was to do it with the consent of the patient or a guardian, but if that consent was not received, then the photograph was still to be taken. This was implemented in all hospitals with all patients except mental health patients, for fear of stigmatizing them by taking their photograph.

There was also a recommendation as to the Patient Pass Process. This developed from a problem arising from family members who took their loved ones out of RGH for a meal or outing and then dropped their loved ones off at the front door of RGH rather than seeing them back to their Unit. This often led to the patient being found wandering around RGH. The recommendation was to have the family member sign their loved one out of RGH and agree to return them to the assigned place in RGH. This form is now in use in all four Calgary hospitals.

Under the topic of Communications there was a recommendation to have ongoing discussions within the hospital setting regarding elopement. The end result was to keep staff and the physicians well informed about the issue. Another recommendation that came under the heading of Surveillance was to upgrade the WanderGuard system. The existing WanderGuard system at RGH was upgraded to a more sophisticated system and a request for WanderGuard funding had been made to the Government of Alberta. The current cost of a WanderGuard system is $80,000.00 per Unit. Not surprisingly, it fell well behind other areas in terms of priority.

There was also a recommendation to replace the security cameras at the entrance to RGH, as the quality of the video was inferior. This was done. Also under the heading of Surveillance was a recommendation to consider the purchase and trial of GPS devices, which could be attached to patients to allow them to be tracked. This was to be trialed at all of the hospitals. The idea was to track patients inside the hospitals on Wi-Fi and outside the hospitals on satellite. However, the trial was disbanded because infrastructure and Wi-Fi was inadequate in the older hospitals. However, it was workable at the more recently built South Health Campus, which had stronger Wi-Fi. Cost estimates were done to determine the cost to upgrade the Calgary hospitals. Rockyview was $1.5 million, Foothills $1.9 million and Peter Lougheed $1.5 million. This did not include the cost of each tracking watch ($300.00) and

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the monthly service fee. Funds for this type of upgrade were clearly not earmarked in the government budget, but Schultz did say that if a donor pledged funds to be directed to the implementation of such a project, it would be done.

RFID was also considered as part of a pilot project in conjunction with SAIT and rejected for similar reasons of aging infrastructure and the prohibitive cost to update that infrastructure. The pilot project alone would have come at a cost of $100,000 for the Foothills Hospital. There was also concern that the RFID antennas would only track patients within the hospitals and not once they left the building. No other technologies were considered and the discussions with SAIT led Schultz to believe that no other jurisdictions were employing technology to track patients.

No other new initiatives were being considered. The total expenditures by the Group were less than $10,000. Although there was an attempt to review the approaches of other Canadian jurisdictions, there was no attempt to review what hospitals in the United States were doing to address wandering patients.

Schultz concluded that the best approach would be to use GPS location via Wi-Fi and satellite to locate patients. The practicality of implementation was, of course, limited by the associated costs. She also encouraged an expansion of the WanderGuard system, but noted that it obviously failed when patients cut their bracelets off. Schultz said that any new facility (a so-called “greenfield” site) should consider the implementation of technology such as GPS or RFID during the course of construction planning with the intent of using the technology to reduce elopement.

Schultz opposed the forming of a specific Dementia Unit, as it would unnecessarily complicate treatment for patients. The example given would be that a dementia patient could come in with pneumonia or a heart attack and would require different care than a person who came in with a diagnosis of dementia and was waiting for placement in a care facility. The flexibility to move patients according to their needs was a key component of their treatment. She was also opposed to the idea of having at risk patients placed in colourful hospital clothing, as it would affect their dignity.

Schultz confirmed that the aging population would require further long-term care beds in the future. She stated that there are significantly more beds than in the past and more were coming in 2017. Still, it would be very difficult for supply to catch up to demand.

Summary

All witnesses described the problem of elopement from RGH as being common and frequent. Since Pratt’s death, elopement from RGH has been reduced from eight patients per month to four to six patients per month according to Schultz. According to Olson, of RGH Protective Services, there have been four incidents in his 15 years of employment that have ended with eloping patients being found at the water’s edge of the Glenmore Reservoir and Elbow River areas. One of those resulted in a rescue, while three others resulted in fatalities. All of the deaths have been the subject of Fatality Inquiries. On June 5, 2011, Trinh My Tran eloped from RGH and was found dead in the Reservoir area. Judge Jivraj conducted the Fatality Inquiry and prepared a Report dated April 14, 2014. On July 12, 2014, Lianjie Ma eloped from RGH and was found dead in the Reservoir area. Judge Durant conducted that Fatality Inquiry and prepared a Report dated May 22, 2016. And the subject of this Inquiry, Mr. Wayne Lannie Pratt, was found dead in the Reservoir area on July 18, 2012. That amounts to three drowning deaths in a period of only two years.

It is clear to me from the evidence presented at this Inquiry that significant steps have been taken by RGH and Alberta Health Services to remedy the elopement issue. I also understand that many

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elopements differ in nature to that of Pratt’s. Full credit must be given to RGH for making a number of positive changes to reduce overall elopement. Still, despite these efforts, elopements continue at RGH.

While there were a number of obvious failures that lead to Pratt’s elopement, it is not for me to assess blame in that regard. I simply state the obvious when I say that it is impossible to legislate, regulate, order or recommend the implementation of common sense. Unfortunately, there was a massive failure of common sense by a number of people involved in the elopement of Pratt.

The issue of patient elopement at any hospital is a complicated one. At RGH it is further complicated by the fact that there is a large body of water next to the hospital that may attract patients intent on ending their lives. I cannot imagine this was an issue that was considered by those who designed and built RGH, yet it has sadly been the focus of three Fatality Inquiries in the recent past.

From my perspective, there are four key aspects to address in terms of elopement. They are as follows:

1. Identify

This is a reference to identifying the potential eloper. This is done at the Admission stage and every stage thereafter as the patient is continually re-assessed. A Confusion Assessment is now done on every patient when they are admitted to RGH and photos are taken of the at risk patient. All of these help to identify the patient at risk for elopement.

2. Communicate

The risk of elopement must be communicated to all staff who deal with the at risk patient. This is done starting with a Patient Care Record that must be continually updated and reviewed by all staff that deal directly with the at risk patient. If anyone dealing with a patient is unaware of a potential elopement risk, then the likelihood of a successful elopement increases exponentially. The Yellow Wristband also communicates the concern of elopement to all staff. It is a valuable tool to communicate to others that they are in the presence of an at risk patient. Placing the patient into hospital clothing as soon as possible after admission also communicates that the individual is now a patient rather than a civilian and therein reduces the risk of elopement. Coloured hospital clothing (Yellow as in Code Yellow) could also make the eloping patient more visible to staff and the public but, like the Yellow Wristband, it would affect the patient’s privacy and dignity.

3. Deter

At risk patients must be deterred by properly secured doors and fencing. The WanderGuard can effectively deter a patient from leaving through the Unit entry way. However, Emergency Fire Exits that remain locked unless and until an alarm is sounded are also crucial in securing each Unit. Fencing that prevents patients from easily accessing the water’s edge can act as a significant deterrent.

4. Track

The ability to track a patient who is at risk is crucial. Whether it is RFID or GPS technology, or some combination of the two, the future of elopement prevention will likely come from the use of cost effective technology.

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Considerations and Recommendations to Prevent Similar Deaths The following are a combination of issues that I have considered and rejected and recommendations that I have specifically made to prevent similar deaths, that is, deaths of cognitively impaired patients who elope from RGH.

1. Should there be a Secure Unit for Dementia and Alzheimer’s Patients?

No. While I, and others including Detective Wayne, may think that this would make sense, I rely on the evidence of the medical professionals, Thurber and Schultz, in this regard. On balance, the witnesses leaned away from creating a secured Unit because of the problems it would create in getting patients to a hospital bed as soon as possible and receiving the care they need. It is important to note that the care they need may not relate directly to their dementia or Alzheimer’s. Creating a Dementia Unit could also have the negative effect of escalating the dementia behaviour amongst the patients. Staff may also find it an undesirable place to work.

2. Should there be better internal communication regarding the history of a patient.

Yes. I encourage, but don’t recommend, better communication between various departments in RGH. Each subsequent person or department that deals with a patient should have the same up to date information, including any risk of elopement. It appeared to me that each person giving evidence had slightly different, and at times incomplete, information on Pratt. Not everyone who dealt with him appeared to be aware of the key issues: dementia, aggression, risk of elopement or wandering and risk of self-harm. I encourage RGH to include issues related to wandering and agitation in the Transfer Summary that follows the patient. This would presumably be part of the Confusion Assessment Model (CAM) that is now done on every patient admitted to RGH. The Nursing White Board, implemented after Pratt’s elopement, also provides a means of immediate, updated contact and communication between staff. The use of a patient’s photo and a physical description of the patient on the medical chart has also been a valuable upgrade since Pratt’s elopement.

3. Should patients be allowed to wear street clothes in the RGH?

No. This would have been a recommendation, but it has already been implemented at RGH. It is clearly done with the intent of discouraging patients from eloping and making them more visible to RGH staff. The practice should be maintained as I find it to be of critical importance. 4. Should all RGH Medical Unit Emergency Fire Exit Doors only be able to open when a Fire Alarm is activated?

Yes. If the Emergency Exit Fire Door on Pratt’s Unit could only have been opened in the event of a fire alarm, then it would have eliminated his means of escape. He would only have been left with exiting the Unit via the entrance, which was under much greater observation. This approach is already in place in Secured Units at RGH as per the evidence of Theresa Thurber. If there is one recommendation that would have stopped Pratt from eloping, this is it. I recommend that all Emergency Fire Exit doors on RGH Medical Units be configured in such a way that they can only be opened when a fire alarm is triggered.

5. Should the Yellow Wristband Program be expanded to include a Yellow Hospital Gown Program for patients at risk of elopement?

Yes. The Yellow Wrist Band Program was a good start and it too has its own privacy issues and its own problems. A patient can easily remove or conceal something as small as a wristband, while it would take a much greater effort to remove a hospital gown and still elope unnoticed. It is crucial to put barriers in front of the patient to deter them from acting in the first place. I cannot imagine Pratt would have gone unnoticed had he been running through the RGH Emergency LS0338 (2014/05) Report – Page 19 of 22

Bays wearing yellow hospital clothing. Common sense would have led you to believe that someone from the RGH staff would have seen this and taken steps to stop Pratt or alert Protective Services as to which direction he was going. More importantly, the presence of the coloured hospital clothing would have been one more factor that deterred Pratt from leaving in the first place.

Although I accept that there are significant privacy concerns related to coloured gowns, pyjamas or clothing, I strongly recommend that RGH undertake the implementation of a Yellow Hospital Gown/Pyjamas Program to more readily identify cognitively impaired patients who are found to be at risk of eloping. I recommend the Program be on a trial basis for one year from the date of its implementation. I would leave it up to RGH, after one year, to determine if the Program has met with any success and should be continued or terminated.

I note Counsel for AHS was vigorously opposed in oral argument and written submissions to such a Program, going so far as to say there was no evidence to support such a recommendation. With the greatest of respect, I disagree. The evidence from Nash was that patients are more readily identifiable in hospital clothing and it would only follow that the same would be true of uniquely coloured hospital clothing. Although Thurber stated she felt that such a Program was inappropriate, she did admit that such a Program would more readily identify eloping patients and potentially save lives. I do note that Schultz was firmly against such a Program on the basis of the balancing of privacy and safety. In an attempt to preserve every patient’s right to dignity and privacy, I limit my recommendation to only those individuals who are cognitively impaired and have been identified as an elopement risk and there must be express written permission of the patient or a guardian to wear the coloured gown.

At some point the balance must swing in favour of patient safety and away from concerns for the patient’s dignity and privacy; even those sacrosanct concepts must take a back seat when the safety and lives of patients are in the balance. How many deaths must there be to go this one step further. Judge Durant said the following in the Ma Fatality Inquiry Report when discussing the very issue of balancing safety versus dignity:

It is here where the difficulty in maintaining the balance between respecting the dignity of the patient and ensuring the safety of the patient is the most challenging. However, as was clear from the evidence of this Inquiry where there is no safety, dignity sadly becomes moot.

I agree wholeheartedly with Judge Durant.

6. Should the entrance to each RGH Unit be secured with a WanderGuard?

No. Although I heard no empirical evidence to indicate that it had reduced elopement, the WanderGuard is by all accounts a valuable tool in doing just that and it should be deployed in those Units where it would be of value. For example, it appears to me that it would not make sense to place a WanderGuard in a Surgical Unit, where patients are typically confined to bed. Because cost is a major factor in the installation of WanderGuard units, I strongly encourage, but do not recommend RGH deploy the WanderGuard, when financially feasible to do so, in those Units where it would provide the greatest utility. And in those Units where WanderGuard is not installed, I would encourage RGH to consider, as per the evidence of Teresa Thurber, changing the remaining doors to open by way of a button rather than being activated to open when someone simply approached. I also note that the WanderGuards would work well in conjunction with the Emergency Fire Exit Doors, which could only be opened when an alarm is sounded, to provide more fulsome safety for all patients. WanderGuards are not the only answer to the issue of elopement, but they do play an important part in the overall solution.

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7. Should there be more hospital beds available so patients like Pratt do not have to wait as long to be settled in a bed?

Of course. This long running battle to properly fund hospital beds is not likely to end any time soon. Availability of hospital beds is one of the keys to treating all patients and it can reduce the likelihood of elopement. Dr. Flack made it clear that minimizing the movement of Pratt was crucial in reducing his confusion. Pratt had to wait between three and four days in the MAU before getting placed on a Medical Unit. If Pratt had been placed in a bed on a Unit immediately, it may have allowed him to acclimate to his surroundings more readily and therein reduce his desire to elope. In addition, if there was sufficient bed availability, Pratt would have been moved to the Geriatric Psychiatry Unit (as per Dr. Madan’s recommendation), which was much more secure. However, a recommendation for more hospital beds is beyond the scope of this Inquiry. Having said that, I strongly encourage the Government of Alberta to make every effort to properly fund all Alberta hospitals and care for the aging or so-called “greying” population of this province. The Boomers are not coming, they are here and they are in need of the medical and hospital care. Failure to properly fund AHS would be negligent. Universal, high quality health care is a right for every Albertan who is registered to receive Alberta Health Care.

8. Should patients at risk of elopement be chemically restrained when that risk becomes elevated?

Not necessarily. Chemical sedation or restraint and the use of Broda Chairs and other physical restraints are options available to RGH staff. These are simply additional tools that exist within their theoretical toolbox. However, the use of these is something that must be left to the discretion of the treating physician and the assigned nurses. It is beyond the scope of this Inquiry for me to tell doctors and nurses how to directly treat their patients.

9. Should hospital staff, including Registered Nurses and Nurse Assistants, be required to take additional training in how to deal with Dementia or Alzheimer’s Patients or patients at risk for elopement?

No. Based on the evidence I heard, it would appear to me that that training already takes place to a certain degree and courses are available to the staff to take upon request. As long as the existing training continues to be available to staff, I am satisfied that it is sufficient.

10. Should Protective Services have more say in addressing the security of patients who are elopement risks?

No. This has been and should continue to be a nursing or physician responsibility as they are the ones who are dealing with the patients on a regular basis.

11. Should RGH Protective Services be required to search the Elbow River and Glenmore Reservoir areas adjacent to the RGH every time a patient elopes?

Preferably. This is a difficult issue. Olson, of Protective Services, stated there was not enough staff to manage such a task. He also stated that the Reservoir area was not searched in the case of Pratt because Pratt was seen going away from the Reservoir (until subsequent review of CCTV showed otherwise). That makes sense. However, in my mind, had Protective Services known that Pratt was such a high-risk patient, they may have acted differently, even though he was not seen heading to the Reservoir. In situations such as Pratt’s, where there is a high-risk, the patient’s attraction to the Reservoir is elevated. How such crucial information is communicated to Protective Services is critical. I therefore recommend that any time an eloping patient is considered a risk to himself or others, or is seen heading in the direction of the Reservoir area, that this information be communicated to Protective Services immediately upon

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elopement and Protective Services must engage in a search of any shoreline within 500 metres of the end of the RGH property line.

Just as important is the need to properly staff Protective Services and provide anyone trying to contact them with direct communication (rather than being routed through a Call Centre in Edmonton). Although I do not make a recommendation in this regard, I encourage those responsible to provide adequate staffing and adequate tools to allow Protective Services to do their job safely and efficiently.

12. Should patients in Pratt’s condition be sent directly to the Geriatric Psychiatry Unit?

No. Again, this is beyond the scope of the Inquiry. It is up to the doctors and nurses involved in an individual patient’s care to make this call. Dr. Madan did interview Pratt and did recommend that Pratt be placed in Unit 48, the Geriatric Psychiatry Unit, and receive long-term dementia care in a secured Unit. The reason Pratt did not make it to the Geriatric Psychiatry Unit is because there were not enough beds. Again, this appears to be the root of this and many other problems in the Health Care System. As much as I would like to recommend that the Government of Alberta create sufficient beds for all types of patients, I am precluded from doing so. Suffice it to say, the Government has a responsibility to its citizens and it must provide adequate funding to care for everyone who is entitled to that care.

13. Should the property owned by City of Calgary adjacent to RGH be fenced off?

Yes. I note that Judge Jivraj, in the Tran Inquiry stated:

…a fence of sorts has been erected bordering the bank of the reservoir in the general area where her [Tran’s] body was located to prevent accidental falls down the embankment.

Thurber was unaware of any fence having been erected in that area. This leaves me somewhat confused as to whether or not a fence is in place. I therefore recommend that, if it has not already been done, the Government of Alberta consult with the City of Calgary and arrange to have the area immediately adjacent to RGH, on City of Calgary, property, fenced off so as to prevent patient access to the shores of the Reservoir area.

14. Should RGH employ RFID or GPS or some other form of cost effective technology to track patients at risk of eloping?

Yes. After hearing the evidence of Kathler, it is clear to me that further investigation must be undertaken to research the issue of patient tracking to reduce elopement. However, it is not for me to say which technology, or combination of technologies, is most appropriate. I recommend that RGH strike a committee to consult with an outside consultant, who is an expert in the field of tracking technology, so as to investigate what options may be employed on a cost effective basis to track patients at risk of elopement. I encourage the Government of Alberta to fully fund this committee in a meaningful way. I am aware that a committee (The Calgary Zone Working Group on Elopement Issues, whose recommendations I generally endorse) was previously struck for a one-year period to deal with elopements specifically, but little to no attention was paid to the concept of using technology as an answer to the elopement problem as they did not have the budget to do so and the tracking trial was abandoned. That was disappointing to hear. I was told the cost to upgrade the Foothills, Rockyview and Peter Lougheed Hospitals to allow tracking to take place was a total of $4.9 million dollars. I understand that this is an expensive proposition even in the face of what I understand to be an Alberta Ministry of Health budget of $21.1 billion dollars for 2016-17 (as per the Ministry of Health website found at alberta.ca), but research may

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well prove that such an outlay will reduce elopement and save lives while still protecting patient privacy and dignity. If the research bears fruit, then it is incumbent upon the Government of Alberta to invest that money to save lives and keep all at risk patients safe.

I also strongly recommend that Alberta Health Services consider the inclusion of patient tracking technology in any future hospital construction in Alberta.

15. Should the Code Yellow Provincial Group’s “Code Yellow Procedure” be implemented across the Province?

Yes. I recommend The Code Yellow Procedure be implemented as soon as it is available.

Concluding Remarks

Judge Rosborough of Edmonton Provincial Court recently commented in the Wolski Fatality Inquiry (dated November 10, 2016) that there was no way to determine if recommendations made by a Judge in Alberta were ever implemented, unlike in Ontario where a follow-up report is mandated.

I add my voice to that of Judge Rosborough in calling for change. I believe it is imperative that there be some mechanism that tracks the recommendations of the Court and confirms whether or not the recommendations have been implemented. Accountability and transparency are key. Otherwise, the only utility in a Fatality Inquiry is in the hearing of the evidence. The public reporting of Fatality Inquiries tends to be all too brief and often fades from the collective public memory all too quickly. The public is entitled to a sense of certainty in knowing that the recommendations of a Provincial Court Judge in a Fatality Inquiry are, in fact, being acted upon or not.

As Judge Rosborough stated in Wolski:

And, while it is for the Government of Alberta to determine whether any or all of these recommendations should be implemented, it is important for community agencies, the media and members of the public to know what action (if any) has been taken pursuant to those recommendations.

I concur with the sentiments of Judge Rosborough.

DATED February 28, 2017 ,

Original signed by at Calgary , Alberta. Michael C. Dinkel A Judge of the Provincial Court of Alberta

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