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Kaytlyn Hemsworth was just 19 years old when she died while a patient in the Dr. Georges-L.-Dumont University Hospital psychiatric unit on April 11, 2023.
A coroner’s inquest was held this week in Moncton, N.B., before deputy chief coroner Emily Caissy and a jury of five. The inquest was held in French and made seven recommendations on Wednesday after three days of testimony into Hemsworth’s death.
Those recommendations included having a dedicated staff person on hand to “monitor for suicide prevention” at the facility.
Sahir Samb, the nurse assigned to the 19-year-old, testified at the inquest that he “did not see this act coming” and Hemsworth told him that morning she was not feeling suicidal.
Dr. Colette Aucoin, a psychiatrist who was assigned to Hemsworth, testified the young woman had been admitted to the unit several times prior — having first been placed under Aucoin’s care during a prior stay in August 2022.
Aucoin said Hemsworth had multiple psychiatric diagnoses, including borderline personality disorder and substance use disorder, and had dealt with homelessness in the past.
She had been admitted to the Dumont psychiatric unit in mid-March 2023 after experiencing a psychiatric crisis spurred by the loss of her housing.
According to Aucoin, Hemsworth had experienced some crisis situations over the course of her hospitalization but was showing improvement.
In her last meeting with Hemsworth a few days before her death, Aucoin said Hemsworth seemed hopeful for the future and spoke of plans like going to college, living on her own and getting a cat.
There was no date set for her discharge, and Aucoin said she made it clear to Hemsworth that she would not be discharged without a plan for her housing in place.
Hemsworth and the hospital social worker were making calls to organizations that could accommodate her after she left the hospital.
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Samb said on the morning of her death, Hemsworth got upset over the food she was being served. She was given Ativan to calm down, and Samb said after the incident, she seemed relatively calm and was colouring in her bed.
Per Aucoin’s instructions, Hemsworth was supposed to be checked on by staff every 15 minutes.
On Tuesday, RCMP Sgt. Nicolas Potvin testified that security camera footage showed no one had interacted with Hemsworth between 1:16 p.m., after the hospital dietitian left Hemsworth’s room, and 2:45 p.m., when she was found in a closet by a nurse. She died at the scene.
Potvin said the footage showed that the door was closed from the inside at 1:47 p.m.
On Wednesday, Vitalité’s assistant director of integrated quality management, Caroline Ringuette, testified the health network had implemented recommendations from an internal review committee following the incident.
These included a new form staff must fill out to document when patients were checked on, including what their emotional state was at the time and the removal of coat hooks and rods from the closets in the psychiatric unit.
They have also launched an ongoing review into what objects patients are allowed to keep with them, including shoelaces.
Hemsworth was allowed to have her clothes, including shoes with laces, at the time of her death.
Eric Blanchard, a nurse who worked at the unit at the time of her death, testified on Tuesday that patients are permitted to wear their own clothes, rather than a hospital gown, if they are compliant with their treatment.
Ringuette also said there is a new directive in effect that those who are hospitalized involuntarily can no longer leave unless it’s for medical or legal obligations.
Following her testimony, the jury deliberated for two hours and came back with five recommendations for Vitalité.
They suggested Vitalité hire “dedicated monitoring staff for suicide prevention” in order to eliminate monitoring lapses “caused by multitasking or staff shortages.”
They also suggested patients be equipped with wearable devices to track their vital signs in order to allow for early detection of physiological distress and possibly prevent harm.
Their third recommendation was to keep the windows in the door of the unit clear of obstructions to allow staff to see patients more easily.
They also suggested decreasing the patient-to-nurse ratio.
Blanchard testified at the inquest that most nurses typically were assigned between four and six patients.
The jury’s final recommendation was to implement the resulting changes to all of Vitalité’s psychiatric units.
Caissy, the deputy chief coroner, also made two recommendations, including that nurse’s stations be equipped with “J-Knives” in order to quickly intervene in cases of emergencies.
She also recommended that Vitalité put a policy in place to ensure compliance with the new documentation system for patient check-ins.
Rino Lang, Vitalité’s assistant vice-president for professional services, said in a statement after the recommendations were announced that they “are committed to carefully reviewing the coroner’s recommendations and remain dedicated to providing a safe and compassionate care environment for all our patients.”
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