Death of involuntary psychiatric patient prompts recommendation for better monitoring

The inquest report onthe drowning death of a 59-year-old manwho was an involuntary resident of a psychiatric facility in Selkirk, Man., calls for changes to how nurses monitor people coming and going from the facility.

Ronald Bobbie had been at the Selkirk Mental Health Centre for 12 years after he was found not criminally responsible for arson offences when he disappeared from the unit and later drowned in the Red River, just north of the Redwood Bridge, in Winnipeg in 2014.

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Provincial court Judge Lindy Choy, who was in charge of reviewing the evidence, said while she understands the family's concerns about Bobbie's medication and how he was approved for passes to leave the institution, staff responded appropriately given his history of disappearing from the facility.

Bobbie had rapid cycling bipolar disorder, says the inquest report, which was released this week. When he was hypomanic, he was irritable and oppositional and would leave the health centre without telling staff. Bobbie also made two previous suicide attempts, one where he was rescued from ariver and another where he threatened to drown himself.

When Bobbie initially went into the Selkirk facility, he was in a fully locked unit, but after many years, he was moved into a unit that was only locked overnight, the inquest report says.

While he was known to disappear from the health centre, he usually went to visit his family and didn't show signs he was a risk to himself or the public, the report says. It added that, until the night of his death, he would return before the unit was locked at 9 p.m.

In the time leading up to his death, Bobbie had made some progress, but because he was not participating in part of his treatment, he lost certain privileges, such as getting passes to visit his family. That left him in a low mood and he refused food and medications, the inquest stated.

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On Sept. 26, the day of his death, Bobbie was told he had to stay in his ward but he left without permission.

Although the health centre has a protocol for residents that leave without permission, including contacting the RCMP, because of Bobbie's history of leaving and returning, his doctor didn't think it was necessary.

Bobbie's mother called the health centre just after 6:30 p.m., saying he had gone to visit her in Winnipeg and he was supposed to take the bus back to Selkirk, the inquest report says.

But at around 8 p.m., people on Talbot Avenue in Winnipeg called 911 to reporta man in the river yelling, "Help me please."

Emergency crews, including two rescue watercraft, rushed to the scene, and about 30 minutes later Bobbie was found in the river, not breathing and with no pulse. He was taken to hospital and pronounced dead.

Recommendation

Bobbie's brother and daughter testified at the inquest, expressing concerns about high levels of medication, monitoring of Bobbie's health and communication with his treatment team. They were also concerned about how Bobbie was getting privileges, including passes to leave the facility.

Choy wrote that while dealing with the loss of a loved one is always difficult, the mandate of the inquest meant she couldn't look into the family's concerns about medication, monitoring and communication but they did examine the issue of passes.

"The family's frustration with the withholding of privileges for the purposes of controlling behaviour is certainly understandable, but I view this as a necessary aspect of his treatment plan," Choy wrote.

Choy said evidence at the inquest gave no indication that any inappropriate decisions were made at the time of Bobbie's death.

"Overall, I find that it is not necessary to make any recommendations regarding the practice of issuing passes to involuntary residents of mental health centres in Manitoba," Choy added.

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The inquest also looked at the ability of nurses to monitor patients. The Selkirk Mental Health Centreis in the process of addressing some of the issues, the inquest report says, including building a security control room to monitor and control entries and exits.

Choy's one recommendation was that nursing staff should be "equipped to enable effective monitoring of patient ingress and egress." While Choy didn't give specifics, she wrote thatcould include physical changes to the ward, an increase in staffing or both.

The inquest, which ran from December 2016 to April 2017 in Winnipeg and Selkirk, was required through the Fatality Inquiries Act because Bobbie was an involuntary patient. It was to determine what, if anything, can be done to prevent similar deaths.