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Could tragedy have been averted?

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Written by Delon Shurtz LETHBRIDGE HERALD   
Friday, 29 May 2009

It will likely be months before recommendations, if any at all, are made to Alberta’s justice minister stemming from a fatality inquiry in Lethbridge this week.

But the son of Sydney James Salter, who died in 2007 after wandering away from his residence, believes there should have been more communication among care providers.

Michael Salter told the inquiry into his father’s Dec. 31 death that after hearing two days of evidence Thursday and Friday in Lethbridge provincial court, he believes a policy should be developed that ensures once a client’s health changes, steps are taken to ensure the proper authorities are notified.

When he died, Sydney Salter, 88, was living in an independent living complex in Lethbridge, and was receiving some part-time home support through We Care Home Health Services. However, in the week before he died, he was becoming increasingly confused and exhibiting greater signs of dementia, yet that information was never relayed to other health-care providers.

“The system is there, but people have to access it,” said Lethbridge lawyer Ken Lewis, who represented Alberta Health Services at the inquiry.

Salter was also reportedly found wandering outside his apartment in the days before his death, and at least on one occasion in October had wandered outside late at night and had to be let in through locked doors.

During Thursday’s hearing, court heard witnesses testify that Home Care — a service provider employed by Alberta Health Services — had been notified of Salter’s failing health. But Neil Boyle, lawyer for Alberta Justice, said Friday the witnesses were mistaken and there likely hadn’t been any communication between We Care Home Health Services and Home Care in the week before Salter’s death.

Salter’s body was discovered about 8:30 a.m. Dec. 31, 2007, lying on the ground outside the complex. He may have been lying in the snow for several hours before his body was found by another resident. His death was reportedly caused by hypothermia.

Court heard Salter was barefoot and only wearing a light, long-sleeve shirt and pants. He also had abrasions on his fingers and toes, indicating he may have crawled some distance before dying. There was also a thin blanket of snow on the ground, but no tracks other than those of the resident who found the body, which suggests Salter may have been lying there at least since 2 a.m. when it had started snowing.

Joy Dykslag, who was Salter’s case worker for Home Care in 2007, testified Friday she, as well as other doctors and nurses, conducted assessments of Salter’s mental health in the weeks before his death — he may have also had Alzheimer’s disease — and recommended he be moved to a facility with greater security and full-time care providers.

“I did feel it was something we really needed to consider,” she said.

But they didn’t at that time consider the move urgent, and when a studio-style apartment became available Dec. 11 at another facility, Salter and his son decided to wait until a larger unit was available before moving.

Lewis noted in his concluding submission that Alberta Health Services was prepared to move Salter to another facility, which likely would have prevented him from wandering outdoors. He added, however, he’s not sure if Home Care could have done more even if providers knew his health was deteriorating in the days leading to his death.

The fatality inquiry does not look for blame but was held to determine circumstances surrounding Salter’s death and whether he was living in an appropriate facility given his mental and physical health.

Judge Ron Jacobson said at the inquiry’s conclusion, he will provide the minister of justice a report which may or may not include recommendations that could prevent similar tragic incidents. He also noted the minister could let the matter rest, or even order another inquiry.

Courtesy The Lethbridge Herald