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Lisa Goltman fatality Inquiry

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Fatality Inquiry Day # 4

Lillian Slashinsky, Registered Psychiatric Nurse,(RPN)
Graduated from Alberta Hospital Edmonton 1987, then known as Oliver
Hospital. Lillian Slashinsky informed the Inquiry that she had worked
at AHE for 35 years.
She informed the court that on the evening of May 3, 2013,she worked
the 11:15 PM shift to 7:00 AM shift. At Change of Shift Report, she was
informed that Lisa Goltman was being detained in the secure room with door
closed. Lisa was on a mattress on her stomach with face, facing the wall
with the window.
In discussion with staff, Lillian & Wendy Williams, decided to “give her
more time to settle”, though she had been lying quietly, the Strong Blanket
which was covering her, had not moved.

It should be understood, that Lisa was cared for in a small specialized
ward at the Alberta Hospital Edmonton known as –
Patients were to have specialized,CUSTOMIZED PROGRAMS & CARE PLANS designed
for only them.
Having so few patients was likened to a family setting. Lisa’s Hospital family
should have known that Lisa was a poor sleeper, that she often wakened, that
she had difficulty breathing at times because of the syndrome from which she
However, the clinical staff who were monitoring her during the final hours
of her life, failed to note that from the time Lisa was placed in seclusion
@ 11:00 PM, she appeared TO HAVE NEVER MOVED, the Strong Blanket allegedly
All nursing staff, reported under oath to the Inquiry that Lisa LAY QUIETLY,
never appeared to have moved.

Lisa was on CONSTANT while in the secure room. CONSTANT means “SEE IF BREATHING”
be monitored every 15 minutes. Lillian told the Judge that at 23:45 Hrs, yes,
there was a recollection of breathing. At 3:00 AM, Lillian was making rounds,
told the Inquiry that she entered the secure room, shone a flashlight in Lisa’s face,
shook her and was aware that there was noresponse.
She told the Inquiry that it was the FIRST TIME that she saw Lisa’s face. She said
she could not recall if the eyes were open but she did observe that the face was
cyanotic on the left side.
She removed Lisa from the mattress and said that the body was WARM TO TOUCH.

When she had been interviewed by Detective Nienhaus after Lisa’s decease, she
informed him that Lisa had been WRAPPED IN STRONG SHEETS.
She told the inquiry that Lisa was NOT WRAPPED but COVERED.

When Lillian was asked to identify Lisa’s diagnosis, she said she did not
“remember exactly”.

It was discussed that physicians / psychiatrists write Orders in advance.

On the evening of May 3rd, 2013 @ 11:00 PM, Clinical staff, Valerie Dixon RPN &
Tim Bouwsema RPN & Joshua Middleton psyche aide, had NO VALID DOCTOR’S ORDER
The Order on the patient’s Doctor’s Order Sheet had expired. The attending
charge nurse, had failed to call for a valid order from ON DUTY / ON SITE

Much discussion also entered around the fact that the RPN’s charting on the
Observation Sheet did not necessarily reflect the care that had been given.
For example 0300 hrs, 0315 hrs, 0345 hrs & 0400 hrs were initialed as indicating
that ROUNDS had been carried out. This had not happened.
Furthermore, in some instances entries were written over or even altered. Patient
charts are legal documents.
Lillian was asked if she was aware of the errors. She responded that Lawyer for
AHS had discussed this with her prior to the Inquiry.

Dr. Abdullah was called to Unit 8 2B, @ 3:25 AM, when Lisa was found non-responsive.
He identified himself as the On Duty Medical Officer.
When he examined Lisa, he found that she had no carotid pulse, she appeared cyanotic,
was COLD TO TOUCH and exhibited rigor mortis.
He administered the GPS consciousness scale, had to open her eyes in order to flash
the light in – found no response.
Upon being questioned by counsel, he stated that SECLUSION SHOUlD BE A LAST RESORT.

William Hilton, senior Paramedic was called to the Inquiry.
He and his partner, Leslie Cebuliak an Emergency Technician were informed,
most knowledgeable and provided articulate answers.
He informed the Inquiry that the secure room was so dimly lit that they had to use a
flashlight to carry out procedures such as attempting to start an IV.
When William inquired of Clinical staff when they had last seen Lisa ALIVE, they
When William attempted to introduce a laryngoscope, he told the Inquiry that he
could not because the jaw was in rigour mortis.
Similarly Leslie could not start an IV because the arm was too stiff to rotate.
William again inquired as to when they had last seen Lisa alive. He found the
jaw stiff, mouth wide open, he could not intubate.
When they rolled Lisa’s body over, they noted marked lividity, mottling.
Both said SKIN was COLD TO TOUCH.

Posture at death – hands and feet TURNED IN suggesting a seizure at time of death.
Because family had many times informed staff that Lisa was suffering epileptic seizures,

Parameds indicated that clinical staff were very calm in their demeanor when
they carried out compression and other activities.
Fatality Inquiry will continue on Monday, April 11, 2016. 08 / 04 / 16