Hillsborough Hospital inquest: jury makes 14 recommendations

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

The inquest jury reviewing Sherry Ball's suicide at Hillsborough Hospital in 2013 has delivered 14 recommendations aimed at preventing similar deaths in the future.

Ball, who was 47-years-old at the time of her death, killed herself at the psychiatric hospital in Charlottetown on Dec. 1, 2013. An inquest into her death was ordered by the chief coroner.

• Day 1 of the inquest: Ball "agitated" the day before her death
• Day 2 of the inquest: forensic psychiatrist says Ball shouldn't have been transferred

Among the recommendations:

• That transfers between facilities not take place on Fridays or on weekends if the patient is being moved to a lower level of care
• That all transfers include a comprehensive discharge summary outlining the patient's condition and the effectiveness and ineffectiveness of various attempts at treatment
• That incoming mental health patients be evaluated by a psychiatrist within 12 hours of being transferred
• That the condition of a mental health patient be stabilized, along with their drug treatments, for at least two weeks before they are transferred to a lower level of care
• That patient's property during a transfer be checked for any items the patient might use for self-harm
• That the physical environment of hospital units be evaluated to remove anything that could be used as an anchor — shower curtain rods, coat hooks and door knobs should all be adjusted so they cannot support a person's weight
• There should be a review of patient observation levels at Hillsborough Hospital, and patients should only be removed from the highest level of observation at the recommendation of a psychiatrist
• Patients who are required to be checked on by staff every 30 minutes should no longer be allowed to leave the hospital building unsupervised
• Hillsborough Hospital should review its admission policy, and clarify exceptions which are allowed to the overall policy of placing incoming patients in Unit 3, which has a high level of monitoring
• The hospital should employ an "optimal complement" of psychiatric and medical staff
• The province should expand its drug formulary to provide more options for mental health treatment

Most of the jury's recommendations came from forensic psychiatrist Dr. Risk Kronfli, who reviewed Ball's case and wrote a report for the coroner's office.

He said Ball should not have been transferred from the Queen Elizabeth Hospital to Hillsborough Hospital when she was as her mental state wasn't stable, and on the weekend, when there was no psychiatrist at Hillsborough Hospital to assess her.

He also said hospital staff took away a lamp and a cloth bandage in the interest of protecting Ball, but neglected to take away her radio. Ball used the cord from that radio to kill herself.

The inquest declined to give media a paper copy of the recommendations, or a copy of Dr. Kronfli's report.