Lisa Goltman Fatality inquiry Day # 6 April 12, 2016

Jackie Goltman, mother of Lisa Goltman, addressed Inquiry
April 12th, 2016.
She told the Inquiry that Lisa always presented as a sweet, quiet, polite young person.
Jackie told the Inquiry that Lisa began to demonstrate the DiGeorge syndrome, a chromosomal disorder, at about 17 years
of age, such as strabismus, defect in the palate, immune disorders due to reduced T cell numbers, learning disability
& recurrent infections. Later she developing psychiatric disorders.
Growing up, she was known to be unusually clean and tidy
& also to be extremely generous and kind.

After she became ill, she spent some time in the U of A
& Grey Nuns Psychiatric units. At the U of A Hospital.
Lisa was in a locked unit, her street clothes were taken
from her and she had on a hospital gown. Lisa was in a
room to herself in the beginning. A short while later
they put another girl in with Lisa to share the room, who
it became known after the fact that this girl had full blown herpes.
Lisa wanted to go home and thought (this was at the start
of her illness) if she put on her roommate’s clothing she
might be able to walk out of the ward unnoticed. Lisa was
found wearing the roommates clothing & because she is
severely immune compromised due to her syndrome, she contacted herpes from the under clothing.
When the hospital did an examination and found Lisa had herpes they were surprised. It was only after that, did they determine what had taken place.
At the psyche wards, she was described as having “terrible behavior”, and “explosive episodes”. Attending psychiatrists
said that “nothing helped her”.
It is shocking to note that nevertheless, psychiatrists
wished to have her admitted to a “GROUP HOME”.
Generally, Alberta Group Homes are unlicensed, unmonitored
& unsafe. Mother Jackie objected to this placement, felt
Lisa would not be safe because Group Homes are open. Mother opined that Lisa, who demonstrated some psychosis would
have walked away.

Because there was difficulty finding a place for Lisa,
her family took her to Scotland to a small mental health
facility where she was cared for, for one and a third years.
It is noteworthy that she was not subjected to takedowns & seclusion while at this facility.

Finally they wished to return home to be with the entire
family. Lisa was brought home and in June 2012, was
admitted to the Specialized Treatment and Rehabilitation
Services (STARS) Program.
This was perceived to be a small, home like, 14 bed unit
which promised that Lisa would receive specialized care,
care specially designed for her needs.

Lisa was not known to be incontinent. The family informed
staff that wetting was never a problem, only when she had
a seizure. Nevertheless, it appeared that she was being incontinent.

Mother had brought to the attention of staff that Lisa was on occasion suffering
1) Grand Mal seizures
2) Urinary tract infection
(Lisa complained of back pain to the family)
both conditions could explain incontinence.

a) Dr. Leicht told the Inquiry that staff suggested the incontinence was voluntary. Dr. Leicht expressed to also believe this.
b) Dr. Leicht told the Inquiry that Lisa was having pseudo seizures.
These expressed attitudes by Dr. Leicht, Psychiatrist, may explain why staff dealt punitively with Lisa.

LISA SCREAMING Jackie told the Inquiry that once when
she came on the ward, she HEARD LISA SCREAMING.
The screams were coming from the shower room.
When she came to the shower area she found Lisa standing
TOTALLY NAKED next to the shower and a MALE PERSON BY
HIMSELF, who was preparing to shower her.
Lisa had again and again expressed fear of bath.

April, 2013, Lisa’s hands were turning in, Lisa would
say, “mom, mom,mom”.
Toes were curling in.
Concerns were raised with staff about legs and hands.

Friday evening, May 3/13, Lisa told her family that
SHE WAS GOING TO DIE. The family’s visits had been
restricted to three times per week. Family were allowed
to visit between 6:00 & 8:00 PM, under SECURITY WATCH.
A nurse stared through the window at them, watching them.
This discomfited Lisa.

Jackie told that Lisa was incompetent of feces. There
was “POOP” ON HER HANDS -NO WATER IN THE SINK. –NO
WHERE TO WASH
LEGS WERE PURPLE AND SWOLLEN TOES WERE CURLING IN –
GRANDE MAL SEIZURE brought to the attention of the staff.

Jackie told the Inquiry how Lisa loved the IPod, the music.
She had ear phones so no one could hear.
IT WOULD COMFORT HER.
Jackie told the Inquiry that during that FINAL VISIT, May 3,
2015, Lisa was acting AS IF SHE DID NOT KNOW WHAT WAS
HAPPENING around her.

That evening, after the family left, Lisa was denied to
keep her I Pod. Because she objected, she was dealt with punitively and placed in seclusion.
According to the police report, At 3:00 AM, May 4, 2013
she was found dead.
Jackie told the Inquiry, that family was not allowed to
touch or view Lisa at time of death because according
to police, they did not like “the position of her body”.

DEADLY POSITIONING
According to nurse’s notes, staff punitively restrained
her again and again, then placing her on her abdomen in the secure room.

1) seized her
2) ) took her to the seclusion room
3) strongly wrapped her in a strong
(canvas) blanket – (arms in)
4) placed her face down on a mattress
5) closed the door.
Sometimes she was restrained (wrapped in the Strong blanket)
on the ward, then taken by stretcher to the seclusion room.
– police are instructed not to position prisoners on face.
– Dr. Leicht had knowledge that Lisa suffered Grande Mal seizures – sleeping on stomach is contraindicated for people
who suffer seizures.

(March 25, 2013 restraint was initiated & carried out by untrained staff)

“Sudden unexpected death is the main cause of death in uncontrolled epilepsy and usually occurs unwitnessed during sleep,” said study author James Tao, MD, PhD, with the
University of Chicago in Illinois and a member of the
American Academy of Neurology.

New research shows that stomach sleepers with epilepsy
may be at higher risk of sudden unexpected death, drawing parallels to sudden infant death syndrome in babies. The
study is published in the January 21, 2015, online issue
of Neurology®, the medical journal of the American Academy
of Neurology.

According to testimony, when family inquired about
bruising which was evident on Lisa’s arms and legs, they
were told it was probably a result of being restrained
and wrapped.