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Lisa Goltman Fatality Inquiry

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Lisa Goltman Fatality inquiry Day # 7

Dr. Krista Leicht, Pychiatrist.

Fatality Inquiry, Dr.Krista Leicht addressed Inquiry this
morning. Participates in STARS specialized 14 Bed Unit.
Dr. Leicht informed the Inquiry that Lisa’s demographic clearly
matched the DiGeorge Syndrome.
Lisa had spent some time in the U of A and Grey Nuns Psych unit.
There she was diagnosed as having “terrible behaviour”, and “explosive
episodes”.It was said that “nothing helped her”, nevertheless, psychiatrists
wished to have her admitted to a “Group Home”. Mother Jackie objected,
felt she would not be safe because Group Homes are open / Lisa, Psychotic
would have wandere away.

When she was finally admitted to the STARS program, her diagnosis was

1) DiGeorge syndrome
2) Bipolar disorder
3) Seizure disorder

She also suffered from Tachycardia which was controlled Propranolol, a
beta blocker.
Dr. Leicht told inquiry, 14 bed ward was made as home like as possible.

Also told Inquiry that they attempted to minimize antecedents “triggers”.
When asked what some antecedent was for Lisa, the response was “music”.

– Strategy to de-escalate, diversion
– Engage in compatible behavior
– Engage in converstation

May 1, 2013 – Jackie called attention to markedly / edematous, swollen legs
Clinical staff had NOT noted marked edema nor had they charted it.

Then discussion entered around SECLUSION ORDERS

According to Dr. Leicht-

1) SECLUSION meant put in room by yourself (seclusion room with
mattress)

2) SECLUSION & RESTRAIN – MEANS Seclude and restrain with Strong
Sheet – WRAP.
The night of her decease there was a SECLUSION ORDER.
Nevertheless she was also WRAPPED RESTRAINED FROM SHOULDERS TO FEET in a
Strong Blanket.
Dr. Leicht stated – they DO NOT normally restrain unless danger to themselves
or danger to others

A….. {March 25, 2013 incident, Lisa was reclining on the couch
until approached by two PSYCHE AIDES}
{Aides challenged her to
a) have a shower
b) GO TO SECLUSION ROOM}

Dr. Leicht informed Inquiry it was up to nurses to MAKE DECISION AS to seclude.
AIDES, who have no training requirements, obviously also make decision.

B….. {May 3, 2013, evening of her decease, alleged aggression was
TRIGGERED by staff who demanded she turn in her IPod to which she was listening music}
{Those were the rules – 9:30 PM, turn in IPods etc, go to bed.}
{Then punitive measures, SECURITY CALLED – FIVE MALES SEIZED HER AND
ESCORTED HER TO SECURE CELL.}

We allege Order to seclude SECLUDE had not been validated because Dr. had not seen
Lisa in the morning.

There was no validated 24 hour written order.
FURTHERMORE the invalid order DID NOT include RESTRAIN.

Dr. Leicht was asked if she was familiar with Procedures snd Policies.
DOCTOR’S ORDER TO RESTRAIN – VALID 24 HOURS.
She said she was NOT AWARE of this directive.

It was stated to the court that Lisa’s pre-morbid disposition was SWEET, QUIET & HAPPY.

Dr. Leicht informed the Inquiry that some of Lisa’s urinary incontinence was VOLUNTARY,
THOUGH SHE admitted that she HAD NOT OBSERVED THIS.

Lisa was observed DRINKING FORM THE TOILET.
Her mother had testified that Lisa was thirsty and WATER TURNED OFF AT SINK.
Mother had also informed the court that LISA HAD BOWEL MOVEMENT on her hands because
she had NOWHERE TO WASH HANDS.
Dr. Leicht said that patients could wash in the LOCKED BATHROOMS THAT ARE NEAR BY.
(Lisa was known to be PSYCHOTIC and out of it, especially towards the last part of her life).

(We also have been told that water has been turned off for periods in Forensic Unit, Alberta
Hospital Edmonton and at the Remand Centre. The person who reported this to us also reported
that prisoners drank from toilet when this was done).

Dr. Leicht wrote Orders to SECLUDE LISA dating from nn JULY 3/13
JULY 4/13.
JULY 5/13.
JULY 6/13.
JULY 7/13.
JULY 8/13.
JULY 9/13.

Following this she wrote
Order to SECLUDE LISA -July 3/13 in order to VALIDATE July 3/13 Order.

Dr. Leicht explained to Inquiry that she places decision to seclude Lisa
“INTO HANDS OF NURSING STAFF”.
It should be noted that in this small 14 patient unit, the Registered Psychiatric
Nurse, when questioned, did not know Lisa’s diagnosis.

Dr. Leicht said that they MINIMIZE TRIGGERS as much as they can.
When asked what was used to minimize triggers for Lisa, she replied MUSIC to CALM
DOWN LISA.

Dr. Leicht was asked how Lisa was on May 3, 2013, the day before her decease, the
day she was restrained and secluded.
She replied UNREMARKABLE – NOTHING UNUSUAL.

Nurse Valerie Dixon wrote in her notes concerning the evening of the SECLUSION-
“RELIED ON ORDER OF MAY 3, 2013”
Dr. was asked if Dixon had phoned to validate SECLUSION ORDER, Dr. Leicht responded
did NOT RECALL.
Nurse Dixon further charted in patient file, SECURITY WAS CALLED, PATIENT RESTRAINED
IN STRONG BLANKET
It must be noted, there was NO ORDER FOR RESTRAINT – VALIDATED OR NON-VALIDATED.

Later stated NO HISTORY OF HEART DISEASE.

MOTHER CALLED attention to Lisa having GRAND MAL SEIZURE and accompanying INCONTINENCE.
Dr. Leicht concurred that it had been a Grand Mal seizure and incontinence of urine a
cardinal sign of seizure.

URINARY TRACT INFACTIONS ALSO RESULT IN INCONTINENCE, especially with Lisa.
Frequent UTI’s and infections common with such persons as LISA because she suffered
from a COMPROMISED IMMUNE SYSTEM
Some staff accused her of VOLUNTARY INCONTINENCE, then were PUNITIVE WITH HER,
SECLUDING & RESTRAINING HER (WRAPPING HER).
Although the Inquiry was told by Dr. Leicht that Lisa suffered from AUDITORY & VISUAL
HALLUCINATIONS AND COULD NOT COMPREHEND WHAT WAS GOING IN AROUND HER.

it was discussed that mother had reported that she had found Lisa BEING ADMINISTERED
MEDICATIONS THT SHE WAS NOT TO BE RECEIVING.
BECAUSE THE PRN BOOK HAD NOT BEEN UDATED.
When Dr. Leicht was told that this had HAPPENED BEFORE, she responded QUITE POSSIBLY.

DR. LEICHT WAS ASKED if Lisa had ever BEEN AGGRESSIVE TOWARDS HER? NO

Dr. was asked if she had been ordered to write a Report after the decease of Lisa,
she replied, NO.
Said she had received INSTRUCTION NOT TO DISCUSS DEATH WITH ANYONE, MEDIA, FAMILY
OR ANYONE”. 06/04/ 13

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