Inquest into 2013 suicide at Hillsborough Hospital: Day 2

WARNING: This story contains details about a suicide. Some people may find it disturbing.

The jury for an inquest into a Sherry Ball's suicide at Hillsborough Hospital in 2013 has now been sequestered to discuss its findings, including any recommendations to try to prevent similar future deaths.

Ball, then 47-years-old, died at the psychiatric hospital in Charlottetown on Dec. 1, 2013. An inquest into her death was ordered by the chief coroner.

Under P.E.I.'s Coroner's Act, an inquest must be held when there is a death at a public institution that may have been preventable.

• Read up on day 1 of the inquest

Ball shouldn't have been transferred to Hillsborough: forensic psychiatrist 

Ball committed suicide two days after being transferred from the Queen Elizabeth Hospital to Hillsborough Hospital.

Dr. Risk Kronfli, a forensic psychiatrist with the East Coast Forensic Hospital in Nova Scotia, reviewed the files related to Ball's treatment and care and testified at the inquest Tuesday.

Kronfli was careful to point out that he was speaking with the benefit of hindsight, but told the jury Ball should not have been transferred between facilities when she was.

He said progress in her mental state was too short-lived to permit a transfer to a facility offering a lower level of care. He said a psychiatric patient should be stable for two weeks, with no changes in medication, before transfer to a lower level of care is considered.

Kronfli also said Ball should not have been transferred on a weekend, when staffing levels are lower. He told the inquest a patient coming in from a higher level of care should be seen by a psychiatrist within 12 hours. He noted Ball did not see a psychiatrist from the time she was admitted into Hillsborough to the time she died. He said there was no psychiatrist on site for the weekend.

He also noted Ball was admitted to Unit 8 at Hillsborough Hospital, the unit with the lowest level of care. Policy at the hospital is for patients to be admitted into Unit 3, with a higher level of care, but Ball was diverted because of a previous altercation with another patient in that unit.

Kronfli also noted there were records Ball had expressed suicidal thoughts in the months leading up to her transfer. The day she was transferred from the Queen Elizabeth Hospital she purchased a lamp, which was taken away by a nurse over concern she could use the cord to harm herself.

At Hillsborough Hospital, hours before her suicide, another nurse took a bandage off Ball's leg over similar concerns. Kronfli noted no one removed the radio Ball took with her when she was transferred from one room to another at Hillsborough. Ball used the cord from that radio to kill herself.

Ball 'a danger to herself': psychiatrist

Inquest Coroner Dr. Roy Montgomery rescinded a temporary, partial publication ban on Ball's "private, social and medical history" Tuesday morning after reviewing arguments made by the CBC.

Details of Bell's medical history were not reportable on Monday because of the publication ban.

Monday, Dr. Susan Stewart, a psychiatrist who treated Ball for nearly 10 years up until her suicide told the inquest Ball was "a danger to herself and others, frequently and unpredictably."

Stewart said Ball was diagnosed in 2009 with schizophrenic affective disorder, a psychological disorder she described as having the features of schizophrenia and a mood disorder. Those with the disorder suffer from psychotic episodes, paranoid delusions and hallucinations.

She told the jury Ball had been subject to "numerous" episodes between 2009 and 2013, including an episode in 2009 when she assaulted her mother. As a result she ended up the subject of a criminal code review board after it was determined she was not criminally responsible for the assault.

Stewart told the jury she was aware of two previous attempts by Ball to take her own life, one in May of 2009, the other in 1994 or 1995. 

The jury also heard that from 2009 to 2013, Ball was shuffled back and forth between various community care facilities and hospitals.

Stewart said Ball had been "quite unstable" in the 12 months leading up to February 2013, and had been to the emergency room 10 times.

In February of 2013, Stewart admitted Ball to the Queen Elizabeth Hospital. From that time until her death in December she was transferred back and forth between QEH and Hillsborough Hospital three more times.

Stewart said the observation level ordered for Ball shifted many times during the last two months of her life — from requiring constant care and supervision, to being provided the freedom to move around her unit and even leave the hospital, checking in hourly with staff. 

Stewart was on holidays and did not transfer Ball to the Hillsborough Hospital. Instead, Ball was transferred by Dr. Tamara Catona, a psychiatrist on locum. That occurred on Nov. 29, 2013 — two days prior to Ball's death.

The night before her suicide, Ball was described as "agitated" by several staff at Hillsborough Hospital.

Stewart told the inquest that after getting into a dispute with her roommate, Ball was transferred first to a private room, then to an observation room where most furnishings except for a mattress were removed for her safety. There she was under "pretty well constant observation," according to the nurse supervisor on staff that night. At the recommendation of the on-call psychiatrist, a drug was administered to calm her down.

The next night she had been moved back to a private room, with staff checking on her every half hour. She used the electrical cord from a radio to hang herself from the shower curtain rod in the bathroom. 

The jury heard yesterday that the design of shower curtains at the hospital has since changed. They're now suspended from the ceiling with Velcro so items can no longer be affixed to them. Staff have testified that previously, the rods were connected to the wall in a metal casing with three screws.