Reference: Fatality Inquiry, Provincial Court – GOLTMAN, Lisa Rachel,
Edmonton. April 5-15, 2016, Edmonton Provincial Court the Honourable
Madame Justice L. Stevens presiding.

May 4, 2013, 22 year old Lisa Goltman was found unresponsive in a segregation
cell at Unit 82 B, @ 0300 hrs. at Alberta Hospital Edmonton.

Scheduled Witness – Fatality inquiry – September 08, 2016 @ 9:30 AM –
Wendy Williams, Psyche Aide, Alberta Hospital Edmonton.

We allege that prior to Wendy Williams taking the witness stand – Thursday,
September 8, 2016, @ 9:25 AM, Mr. Jay Guthrie, Counsel for Alberta Health
Services, was overheard to counsel witness, Wendy Williams to maintain
a false presence.

We allege that Mr. Guthrie intentionally counseled the witness to conceal
material facts by stating “I can’t remember”, “I can’t remember”.

—————————

Wendy Williams was sworn to testify @ 0945 hrs.
She told court she had been a Psychiatric Aide for between 17 to 18 years
She identified as having no formal training or education.
Her duties were to help patients find their clothes and help them to get
prepared for their daily activities.

She commenced her shift at 1100 hrs. on May 3, 2013
She relieved another staff member, Josh Middleton, psych aide, who was
sitting ‘CONSTANT’.

CONSTANT
Constant means “SEE IF BREATHING” – monitor every 15 minutes.

Wendy Williams stated she was working as a float on Unit 8 2B and that
she had worked with Lisa several times
She was told that Lisa was in seclusion because she acted out and was
restrained for her safety and other patients safety.

The truth is that because it was bed time, Lisa had been denied to keep
her iPod, this upset her.

THE IPOD INCIDENT

Lisa was a patient of (S.T.A.R.S.) a SPECIALIZED TREATMENT AND INTEGRATION
SERVICES a ward of only 14 PATIENTS.
Patients were to have specialized CUSTOMIZED PROGRAMS and CARE PLANS
designed for only them.
Having so few patients on the unit was likened to a family setting.

Considering that this to be a small specialized unit with only 14 patients,
one wonders why Lisa would not have been given special consideration and
allowed to keep the iPod. The iPod was known as the one thing which she
enjoyed and which kept her engaged and calm.

According to the sworn testimony of Amendra Prasad, Peace Officer,
April 7 2016, Tim Bouwsema and Josh Middleton took her (Lisa) by either
arm and lifted her and moved her to the segregation room.

According to Prasad, Lisa virtually walked there, once there she apparently
became quiet, laid down compliantly. One must ask, why then was she securely
wrapped in a strong blanket, arms in?

It appears that the results of the iPod incident caused Lisa to be seized
by male staff, restrained, wrapped in a strong sheet, arms in, placed
on her abdomen on the mattress the seclusion room door locked.
Being swaddled, Lisa would have been totally unable to move. If she had
cried out, she would not have been heard.

THE SEGREGATION ROOM

The room consists of an exterior door that is locked at the knob and opened
with a key. This door has a small window and that evening had a blanket
hanging to cover the window.

The exterior door leading into a foyer type area to the left is a small
bathroom with a toilet and sink .
The foyer area also has a door to the secure room. This door is set up
to be magnetically locked. The door had a large window that is slightly tinted.

The secure a room is approximately 15’ x 10’. There is a mirror in the
upper corner of the room for view into the room from outside. There is
no CCTV in the room.

ALBERTA HOSPTAL EDMONTON SEGREGATION POLICY

According to Alberta Hospital Edmonton policy, a patient should not be
secluded without a WRITTEN order from the ON-DUTY doctor / Psychiatrist.
Such ORDER was never obtained.

Karen Solberg-Wells has cited that families are to be notified.

Valerie Dixon RN gave the seclusion order.

Dr. Krista Leicht, the Unit Psychiatrist, had written Orders to restrain
and seclude Lisa which far exceeded her death, Orders which were in
violation of Hospital Policy – a breach of ethics.

Lisa Goltman was UNLAWFULLY RESTRAINED and SECLUDED on the night of her death.

According to court testimony, it appeared that Lisa was restrained, wrapped
and secluded in the segregation unit, almost on a nightly basis.

——————–

When Wendy Williams came on duty the seclusion room DOOR was CLOSED .

The lighting was very low. The foyer light was also off. The door was
closed to the seclusion room. Lisa was positioned with her back to window.
Williams testified that a heavy strong sheet covered her. It would
have been difficult to monitor Lisa.
(As a matter of fact when later, EMS came on the unit after 0300 hrs,
they requested a flashlight).

The clinical staff who were monitoring Lisa during the final hours of her
life, failed to observe that from the time Lisa was placed on the mattress
in seclusion she appeared to have never moved. Williams and other care
staff reported to the inquiry that Lisa LAY QUIETLY, never moved.

Lisa’s family reported that Lisa was a RESTLESS SLEEPER.
Her hospital family should have known that Lisa was a poor sleeper that
she often wakened, that she had difficulty breathing at times due to the
Di George syndrome from which she suffered. Allegedly staff made hourly
rounds of the patients.

Lisa was on “constant” while in the secure room and was allegedly being
carefully and constantly monitored, first by Josh Middleton, then Wendy
Williams. Because of the way Lisa was positioned in the dimly lit room,
door closed, no one could have monitored her breathing.
In fact no one did.

When Williams was asked if windows are tinted she said she could not remember.
She informed the court that Lisa was LYING ON HER ABDOMEN, facing away from her.

NOTE:

Being placed on abdomen is contraindicated for babies and persons who suffer
from seizures. It was known that Lisa suffered from Grand Mal seizures.

Study published in the January 21, 2015, online issue of Neurology®, the
medical journal of the American Academy of Neurology.

For the study, researchers reviewed 25 studies that included 253 sudden
unexpected death cases where body position was recorded.

The study found that 73 percent of the cases died in the stomach sleep position,
whereas 27 percent died in other sleep positions. Looking at a subgroup of 88
people, researchers found that people younger than 40 were four times more
likely to be found on their stomachs at the time of sudden death than people
over 40. A total of 86 percent of those under 40 were sleeping on their stomachs,
compared to 60 percent for those over the age of 40.
_______________

Williams reported that a strong sheet covered Lisa with HER ARMS IN.

When questioned, she reported two strong sheets were the only bedding in
seclusion room.

UNTRUTHFUL, INACCURATE TESTIMONY, FILE ENTRIES

Under oath, Williams reported to the court that Lisa’s SHOULDERS WERE
MOVING SLIGHTLY, that Lisa’s breathing was shallow.

Under oath, Williams testified that she checked Lisa every five minutes.
She said that the seclusion finished at 1145 hrs.

William testified to the court , (recorded – initialed on the file) that
Lisa slept peacefully at 0200 hrs; 0215 hrs; 0230 hrs; 0245 hrs,
“lying on mattress”, “shoulders moving slightly” .

The CONSTANT was discontinued by nurse Lillian Slashinsky @ 1145 hrs.
May 3, 2013, who opened the segregation room door. Slashinsky did not
enter the room.

According to testimony, Rounds were made every hour, which included
Lisa – 1200 hrs; 0100 hrs; 0200 hrs.

At 0300 hrs, May 4, 2013, nurse Slashinsky, entered the cell,
using a flash light, examined Lisa and found her totally non-responsive
and cyanotic.

Slashinsky then directed that Lisa be removed from the mattress.

– EMS, was called.

– Police were called because of the ongoing assault investigation of
April 11, 2013 dating back to the assault that caused Lisa to be sent
to emergency with injuries, on March 2, 2013,

William Hilton, EMS, noted that he found Lisa supine on floor of segregation cell.

He noted:

– Face cyanotic
– Apneic
– Mottling to arms & legs, core, chest and abdomen
– DECEREBRATE POSTURING
– Unable to open pt. jaw, stiff
– Temperature body – cold
– Color – mottley
– Cyanosis to lips
– Epistaxis
– Fixed pupils
– RIGOR MORTIS to entire body
– OBVIOUS DEATH –

EMS also noted Intravenous access was impossible because patient’s arm was
stiff to move and cold to touch –due to rigor mortis.

————————————————————————

According to findings of the EMS, the full body rigor mortis and lividity
of the decedent, death must have occurred immediately or shortly after she
was placed in seclusion about 1100 hrs. the day before.

Wendy Williams made entries in Lisa’s File citing that Lisa was “sleeping”
@ 0430 hrs & 0500 hrs. May 4, 2013, this was long AFTER Lisa had been found
DECEASED and in full rigor mortis.

When questioned by the Court whether Lisa was breathing at 0245 hrs, Williams
responded, ”ABSOLUTELY”.

In ATTEMPTING TO EXPLAIN her untruthful entries which she had made in Lisa’s
file, she said, “everything was happening”, “chaos on the ward”,
“yelling and chaotic”.

However EMS staff when questioned under oath, denied that there was any chaos,
he testified everyone was calm.

DECEREBRATE POSITION

When asked by the court as to what position was Lisa in at time of death
(decerebrate according to EMS) , Williams responded, ‘I can’t remember”,
although she testified to the court that she had helped to get her (Lisa)
off the mattress.

At time of Lisa’s decease, the police alluded to the decerebrate positioning
of Lisa and denied family to see Lisa’s body, informing them that they “did
not like the position of the body”.
It was several hours before family were allowed to see Lisa’s body.
26/04/17