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 LS0338 (2014/05) Report – Page 2 of 22 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 LS0338 (2014/05) Report – Page 4 of 22 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.