Nearly eight years after an intoxicated woman who was tied to a wheelchair died at Edmonton’s Royal Alexandra Hospital (RAH), a public inquiry report has been released. It calls for the hospital to re-examine its security protocol when dealing with addicts and other vulnerable visitors.
Judge Janet Dixon’s report looking into the death of Sharon Lewis was released on Wednesday. Lewis died in an ambulance bay outside the RAH emergency department on Dec. 28, 2009 after hospital security put her there in a wheelchair that they later tied her to.
Health Minister Sarah Hoffman said Wednesday she expects Alberta Health Services to review the recommendations and make changes to “ensure this never happens again.”
“Sharon Lewis’ death is a tragedy that should not have happened,” Hoffman said in an email to Global News. “AHS has made many positive changes to give their staff more options when caring for patients struggling with mental health and substance use and to expand treatment options. As a community, we are working to remove the stigma of mental health and substance use and focus instead on harm reduction methods.”
Lewis became intoxicated after consuming Microsan, a hospital hand sanitizer with a high alcohol content. She was placed in the wheelchair because she couldn’t stand up on her own. She was tied to the chair with a cloth because she kept falling out of the chair.
Less than an hour before she died, an unresponsive Lewis was taken to the emergency department’s triage unit. Her death occurred just 11 minutes after she was admitted. The cause of her death was ruled to be the result of acute ethanol and drug toxicity but the manner of her death (e.g. natural, homicide, suicide) was deemed to be “unclassifiable.”
According to the report, Lewis was left in the bay to sober up and staff kept an eye on her via video and “perhaps in person.”
Dixon suggested “the evidence was inconsistent regarding the nature of supervision by the security staff.”
The report said security staff were planning to escort Lewis off the property once the alcohol wore off and issue her a trespassing summons.
Public inquiries aren’t mandated to reach legal conclusions but the review of Lewis’ death sought to answer questions like why she wasn’t taken to the emergency department earlier, why security staff wanted to issue her a trespass summons, how Lewis became so intoxicated and what policies are in place to prevent the abuse of Microsan.
“The impact of the evidence from security staff witnesses and the review by the director of corporate security was that the security staff viewed their role as protecting the RAH from nuisance visitors and trespassers,” Dixon said in her report. “The common practice of security staff in 2009 and continuing to the time of the inquiry was to intercept nuisance individuals, ban them from the property, issue summons for provincial offences and escort them from the premises.
“If the person was too intoxicated to care for him or herself, they were detained until their condition improved so they could be released.”
Dec. 25, 2009
Just three days before she died, Lewis – who was not a hospital patient at the time – was found so intoxicated at the RAH that she was taken to the intensive-care unit (ICU) and put on a ventilator.
Once the alcohol wore off the next day, Lewis was seen by a resident in psychiatry but “refused to answer questions and was irritable and angry.”
The resident couldn’t finish an assessment and suggested ICU staff fill out a Form 1 and Form 3 under the Mental Health Act to keep Lewis at the hospital and have her properly assessed. But the patient care record showed staff instead called security to escort Lewis out of the building.
Dec. 26, 2009
The next day, Lewis was discovered in the hospital again.
“She was confused, drooling and sleepy,” the report reads.
“She was swaying and unbalanced. Due to her condition, Ms. Lewis was transferred to a wheelchair. ICU staff called security staff to escort Ms. Lewis out of ICU. ICU staff did not assess Ms. Lewis. In the 47 minutes since Ms. Lewis walked away from ICU, the staff had coded her as discharged against medical advice in the computer system. Given Ms. Lewis was discharged from ICU, the unit was unable to provide her any treatment, even if staff had been prepared to do so.”
Once she was in the care of security, Lewis was arrested for trespassing and taken to emergency to be triaged and again admitted as a patient. She was also given a ticket for public intoxication. Security told medical staff Lewis had consumed Microsan and she was put on a ventilator again before a doctor completed a Form 1 Admission Certificate under the Mental Health Act so she couldn’t leave. He recommended that she be discharged to the George Spady Centre, a facility for people with substance abuse and addiction, once she was well enough to go.
A hospital record showed Lewis spent the night “thrashing and crying out” and her breathing tube was removed early in the morning on Dec. 27.
Dec. 27, 2009
The report found Lewis was “creating security concerns” and a security person was asked to watch over her. A psychiatrist saw her that evening and Lewis said she wanted to speak with her mother but forgot the phone number. The report found Lewis’ mother’s contact information was on a chart the psychiatrist had, but the psychiatrist couldn’t remember checking it.
After her interview with the psychiatrist, Lewis was discharged and nurse records show the George Spady Centre was contacted and told of the plan to bring Lewis to their facility. Documents show Lewis refused a taxi chit or bus pass to get there. A security person took her to a waiting room and left her there. Lewis then left without telling anyone.
Dixon found discrepancies with the nurse records and security records of how and when Lewis left that night. She said they raised questions about what procedures are in place to inform security of the status of patients who have been previously banned from the RAH and who are in the process of being discharged.
Later that night, Lewis was found to have locked herself in a washroom at the RAH and was suspected of being intoxicated from consuming Microsan. She was put in the hospital’s ambulance bay to sober up and “may have been handcuffed to the bench overnight.”
One security person said Lewis told him she was banned from shelters and had nowhere to go, but he said he did not check with shelters. The report found at least once, a member of the public voiced concerns about Lewis to security.
Lewis is believed to have stayed at the ambulance bay for 12 hours and the report’s findings of what happened next suggest a combination of confusion and lack of due diligence came into play.
“Another nurse on shift asked the triage nurse if Ms. Lewis needed to betriaged and she told her not to triage Ms. Lewis as she had already been discharged,” the report reads. “The triage nurse surmised it might have been appropriate to re-triage Ms. Lewis after 9 a.m. when a social worker came on duty, but she did not pass on that thought to the triage nurse who replaced her on shift at 7 a.m.”
Dec. 28, 2009
On the morning of Dec. 28, a nurse who was coming in for work said she saw Lewis crawling on the floor near the door of the ambulance bay.
“She started to go to check on the person but a security staff got to the person first and said it was OK, so she proceeded into emergency on the assumption the security staff had matters in hand.”
The report details the last few bleak hours of Lewis’ life, which saw her in a wheelchair in the ambulance bay and then again arrested for trespassing and again taken to be triaged by emergency staff, before she eventually died in a wheelchair.
Report’s recommendations
Dixon’s report came up with eight recommendations in response to Lewis’ death and acknowledged some changes were implemented soon after she died, although they weren’t substantive.
However, Dixon suggested the systemic issues that resulted in the dreary turn of events that made up Lewis’ final days may be difficult to resolve, even if all of the recommendations are acted upon.
“The successful implementation of all these recommendations may still be ineffective in preventing future similar deaths at the RAH,” the report reads. “Underlying all of the evidence heard in this inquiry was a fragmentation of policies and procedures designed to meet various issues that have arisen over time, without considering the collateral impact on the individual involved.”
Among Dixon’s recommendations are that RAH management create a department to integrate its security standards with health standards to ensure seccurity and health personnel are working together to respond to both “respond to the social and health circumstances of every individual apprehended by security for intoxication on RAH property throughout the period the individual is held” in custody or detained.
The report also recommends the RAH take steps to better track the abuse of Microsan by visitors and patients in the hospital, provide more education for hospital staff about the challenges of addiction and to implement a procedure to ensure “immediate assessment” and “accelerated discharge plans” for people who are patients by virtue of being in custody.
“The challenge of recovery for someone struggling with a serious addiction, coupled with mental health issues, is significant,” the report reads. “Sometimes task-driven public resources can lose sight of those challenges.”
Dixon noted Alberta Health Services (AHS) has made a proper case for the use of Microsan because of its effectiveness in mitigating the risk of bacteria spreading in hospitals. But she suggested the use of the sanitizer comes with negative consequences.
“The RAH is an inner city hospital. Much of the evidence described the challenge for professional staff in dealing with the demands of individuals coming to emergency while intoxicated on drugs and alcohol, panhandling, looking for food or trying to get warm,” she wrote.
“The attraction of the RAH was undoubtedly enhanced upon (by) its introduction of Microsan.”
Dixon suggested Lewis got lost in the cracks of the health-care system and rules and procedures that didn’t bend to adapt to her situation.
“It was a matter of record that she (Lewis) was unemployed, frequently homeless, suffered from substance abuse, depression and other mental illnesses,” the report reads. “She was known to have a supportive family, who would always support her, but could not always provide housing to her depending on her level of addictions.
“In the case of Ms. Lewis, it appears the health system lost sight of the context of Ms. Lewis’s struggles, responding to her with frustration and seeing her as a nuisance. An ongoing program of education for RAH professional and security staff may provide that same reminder the Supreme Court of Canada sought to give the criminal justice system about the importance of considering the circumstances of every individual when making decisions that have a profound impact on someone’s life.”
Dixon also suggested there were already some developments that had the potential to make positive changes.
“The inquiry heard evidence of exciting new community programs to respond to the needs of these vulnerable inner city populations. But for these programs to be successful for the most vulnerable, the invisible walls around the RAH must come down. Vulnerable individuals suffering from addictions and other mental health issues should be assumed to have a health purpose in coming to the RAH and not be treated as nuisances and trespassers.”
This report said its findings were delayed and only released eight years after Lewis’ death because of a number of factors, including other investigations and reviews looking into the death.
You can read Dixon’s report in its entirety below: