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Retired Nurse’s reflections on Alberta Hospital fatality inquiry

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The Lonesome Death of Lorraine Adolph

In the early part of two thousand and nine I received a surprise phone call from a Mr. Mark Snaterse who identified himself as site administrator at Alberta Hospital Edmonton. He asked if I would come out to the Alberta Hospital site the next day to pick up my subpoena for a fatality inquiry that was to be held in a few weeks. The inquiry involved the death of a young man, Kevin Goodhope, who had hung himself in his room, right across from the nursing desk while under close supervision. I had admitted him the day before his death in my role as admission nurse.

1024px-Alberta_Hospital_building_9_10I had retired the previous year and had no further interest in the strange goings on at the Alberta Hospital. I was nevertheless obliged to appear at the agreed hour to receive my subpoena. When I arrived at the hospital I was directed to a board room which was filled with people. All the principals who were involved that tragic day were present along with a lawyer named Mr. Guthrie and of course the site administrator Mr. Snaterse. Mr Snaterse and Mr. Guthrie wished to know what I had witnessed that day. I was reluctant to involve myself in any kind of pre-inquiry inquiry and verbally objected. I was reassured by Mr Guthrie that this was quite normal and in fact a new feature of the Fatality Inquiries Act so I told them what I had seen the day Mr. Goodhope had hung himself.

I told them that when I had heard the general alarm sound and had responded immediately to the unit in question I had witnessed the aftermath of the hanging. Mr. Goodhope was lying on his back on the floor. A young woman was frantically performing chest compressions. She pleaded with me to get her some help. I assured her that I would. Several staff members were standing around in the room with their hands in their pockets. No one was performing rescue breathing. The doctor on call, who had already arrived on the scene, was in the office making a phone call. I told them that in my twenty years on a medical unit at the University Hospital during which I had run numerous codes I had never seen a physician leave the patients’ room while life saving efforts were in progress. Anyone can be dispatched to make a phone call. I also told them that after racing to my own office just below the unit I had instructed the switchboard operator to call 911 stat. She insisted that it was not hospital policy to summon EMS. I took the phone from her hand and dialled 911. A man was lying on the floor dying, a man who we had pledged to keep safe, and I was going to give him the maximum chance of survival notwithstanding hospital policy. Fire Rescue and EMS arrived soon and I stayed beyond my allotted shift to direct the responders to the correct location.

Mr Snaterse suggested that no one had seen me there so therefore I was never present at the scene. When I convinced him that I had indeed attended the scene he said that I could not have been there long enough to have witnessed anything. I felt as if my arm was being twisted. No other witness present in the boardroom who had given a verbal statement had been challenged.

The actual fatality inquiry was a dry and narrowly focused affair. No family or attorney for the deceased was present. Mr Guthrie and the other counsel present were interested in how Mr. Goodhope had managed to retain the hoodie string with which he hung himself. The level of supervision and life saving efforts were apparently after the fact considerations.

A dark cloud followed me home when I left the courtroom that day. I had the distinct sense that justice had not been fully done.

In June 2011 I learned that a fatality inquiry was to be held into the death of a 68 year old woman who had frozen to death on December the 4th, 2008, a short distance from her supposed safe refuge and had not been found for a week. It was December and the temperature had dipped into the minus twenty centigrade range. She was found frozen solid.

I had by happenstance retired two days before this event. I was curious to see if my experience in the case of Mr. Goodhope was an anomaly or if strange goings on were the norm, so I attended the three day inquiry as an interested observer.

Day One: Lorraine Adolph Inquiry

The inquiry began with the posting of a large map of the Alberta Hospital site with its hundred and sixty acres of winding twisting roads and scattered buildings—–Exhibit Number One

Day one saw the testimony of four security guards or as Mr. Snaterse called them ” protective services agents” who were given the task of searching the hospital grounds for a 68 year old confused woman missing in severe winter weather. This is where the proceedings began to take on a farcical tone. The refrain ” I don’t recall” became a mantra that was repeated so often that I heard it my sleep. One guard couldn’t recall if he had worked at the hospital for one year, two years or three years. He had received no formal training. He couldn’t recall anyone freezing to death even though he was involved in the initial search. He conducted a vehicular search with a partner. A half hearted foot search was not conducted until nine hours later and even then the perimeters of buildings were not searched because “I didn’t want to get my feet wet”.

The four guards who testified seemed confused when referring to exhibit one in spite of the fact they had spent years patrolling the site yet it was assumed that a confused senior could negotiate her way back to her unit even though it was only her second day on the site and was experiencing olefactory and visual hallucinations. Police were summoned to the scene well after Mrs. Adolph had gone missing. They were told incorrectly that a complete ground search had been completed. Police, quite appropriately, focused their search offsite.

If not for the sound instinct of a follow-up EPS officer one week later who did an impromptu search of the grounds her body would quite likely have remained unfound until it began to smell in the spring. Her body was found frozen solid at the perimeter of an abandoned building not far from her unit.

None of the “protective services agents” were able to produce their contemporaneous notes and no record of the search or subsequent follow-up seems to have been made. One young security guard could barely recall her own name and was quickly discharged. Those present in the observer section wondered out loud how she had managed to find her way to the courtroom that morning.

The security guards seemed to be trying to create the impression that they required special equipment to access the perimeter of the buildings during the foot search, which didn’t happen until nine hours later. Testimony on day two indicated that there was approximately two inches of snow on the ground. I t seemed obvious, to me at least, that snowshoes would not be required in such a setting.

The medical examiner investigator, who attended the scene, testified that given what he had observed she had died where she lay. She had removed her false teeth and glasses and carefully placed them beside her as if she was going to bed.

Mrs. Adolph had been confined behind locked doors under the authority of the Mental Health Act for her own safety. The terrible irony of this fact cannot be overstated.

Day Two: Lorraine Adolph Inquiry

Day two was reserved for the professionals. First came the attending psychiatrist Dr. Granger, a psychiatrist with a special interest in geriatric psychiatry. He repeated twice, during his testimony, that one of the overriding considerations in terms of patient treatment plans was the chronic understaffing situation. He was aware from documentary evidence and discussion with a Stony Plain Hospital physician that Mrs. Adolph was suffering a psychotic break. He testified that he could have ordered that an aide accompany the patient when she went outside for a smoke but didn’t because understaffing was an issue so she went for a smoke by herself and never came back. In a telephone message to her family he seemed to express regret that he had placed Mrs. Adolph in unnecessary danger. He never spoke to security to check on the progress of the search at anytime yet he testified he expected that a comprehensive ground search would have been done.

The afternoon saw the swearing in of Mark Snaterse who identified himself as site administrator at Alberta Hospital when this event took place. He stated that there were 37 buildings on site with ten of them decommissioned and boarded up. The one where Mrs. Adolphs’ body was found frozen had been boarded up for about twenty years. No consideration had been given during those two decades what to do with this and other abandoned buildings. He stated that Mrs. Adolph was housed in a unit which could not be accessed without a master key therefore it was physically impossible for the patient to leave without assistance from a staff member. His status report on December 5th, the day after she went missing, stated that “numerous” ground searches had been conducted. In the ensuing week he received regular updates but was ” not actively involved” after December 4th. He stated that security had ” a flawless track record”. He also stated that when he left at about 5:00pm on December 4th the snow was about two inches deep and he expected that the amount of snow would not have deterred a thorough ground search.

The next witness was Robert Henderson, head of security during this period. It should be noted that both Mr. Snaterse and Mr. Henderson were promoted not long after this event. Mr. Henderson stated that the main focus of security at the Alberta Hospital site was forensic psychiatry and other areas were serviced as manpower permitted. That included ground searches. He was aware that the main roads on site were lit by street lamps but didn’t know if the perimeters of the abandoned buildings were illuminated. ‘He stated he was unaware that Mrs. Adolph was missing however he stated that he fully expected that she would have been found. In spite of his expectations he stated he was satisfied with the actions taken by his staff on December 4th even though no documentary evidence of any kind exists in relation to searches conducted that day. He testified that although thirty two surveillance cameras with recording capability were situated around the property none had been used to try to locate the missing patient.

After Mr. Henderson, the charge nurse who was present on Mrs. Adolphs’ unit ‘the day she went missing was sworn in. She testified that although she had done several rounds during her three to seven shift when Mrs Adolph was present on the unit that she never met the patient in person and was therefore unable to give evidence as to the patients state of mind on the day in question, although she “vaguely recalls staff talking about the patient”. She testified that she had followed the hospital policy in relation to missing patients and had actually used the check list prepared for this purpose and therefore felt that she had discharged her duty appropriately. She was rather blasé in her recounting of the actions she took that day as if the occurrence was mundane and run of the mill. Testimony secured from others however indicated that the disappearance of a geriatric patient was a rare event. She seemed remarkably disconnected both in tone and tenor of her speech and in her response to questions from counsel.

Day Three: Lorraine Adolph Inquiry

Day three was a half day session. Through a teleconference link the court accepted the testimony of Dr. Graeme Dowling, recognised expert in forensic science, who was not able to offer much definitive testimony. He stated that his best estimate of how long an individual could survive in such weather conditions was two hours. A foot search was not conducted until nine hours later and a feeble attempt at that. Family members then provided their accounts of how events had transpired from their perspective. They were clearly frustrated by what they perceived as stonewalling on the part of hospital authorities. They had requested information on when and how the search had been conducted but there was no documentation available and no representative from ” protective services” available to speak with them.

Conclusions

In my experience and from what I heard at this inquiry I am convinced that this sprawling site which was originally named “The Institute For The Feeble Minded” when opened in the nineteen twenties is a dysfunctional anachronism. Resources are lavished on forensic psychiatry while ordinary citizens are discounted. Dr. Granger spoke twice to the issue of understaffing in his testimony and from my experience overcrowding and understaffing are both serious chronic issues.

In my opinion it was folly to place the Helen Hunley pavilion (forensic psychiatry) right next to general psychiatry.

A generalized lassitude exists at the Alberta Hospital site that leads to all manner of unanticipated consequences. That combined with chronic understaffing and overcrowding leaves the whole patient population at risk. If this is not addressed in a meaningful way nothing will ever change at the hospital even if they do keep developing new check lists. The hospital will remain, for all intents and purposes, an institute for the feeble minded and I’m not necessarily referring to the poor unfortunate souls who find themselves confined there.

Mrs. Adolphs sister Esther, without whom the inquiry might never have happened, stated on the witness stand that all her sister ever really needed was a little ” love and support”. What she got was a stone cold bed from which she never awoke.

Nikola Juric, RN (Retired)

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