Dr. Roy Montgomery leaves the P.E.I. Supreme Court building in Charlottetown Monday after overseeing a coroner's inquest into the death of Sherry Jean Ball in 2013.
©THE GUARDIAN/Ryan Ross
A coroner's inquest into the death of a woman at the Hillsborough Hospital has finished with the jury making five recommendations for changes at the facility.
They include adopting a report from forensic psychiatrist Dr. Risk Kronfli, which itself included 10 recommendations.
Sherry Jean Ball was a patient at the Hillsborough Hospital when she hanged herself in a bathroom on Dec. 1, 2013.
Ball had a schizoaffective disorder, which can involve symptoms of psychotic episodes that include delusions, hallucinations and extreme withdrawal.
The inquest was called to determine the facts of Ball's death, and after almost two days of testimony the jury spent several hours on Tuesday reviewing the evidence before making recommendations.
Among Kronfli's recommendations was a call to end psychiatric patient transfers on weekends unless it is to a higher level of care.
Ball was transferred from acute care at the Queen Elizabeth Hospital to the Hillsborough Hospital for non-acute care.
Kronfli also recommended no transfers be made while a patient is actively ill or their medication hasn't been stabilized for two weeks.
The jury heard Ball's medication levels were not stable over that period of time before her death.
Some of the other recommendations from Kronfli's report and the jury dealt with how patient belongings are handled, changes to supervision and an update of the provincial drug formulary for injectable medications.
The inquest heard Ball was required to remain in hospital under an order from the Criminal Code Review Board after she assaulted someone.
Ball was also under public guardianship when she was first admitted to the Queen Elizabeth Hospital and then the Hillsborough Hospital in November 2013.
Between 2009 and 2013, Ball had 24 placements in community care facilities and hospitalizations.
During the inquest, the jury heard Ball would try a placement, be unsuccessful and then return to hospital.
The jury also heard testimony that Ball had made at least two prior suicide attempts.
At times, Ball wouldn't take her medications, and hospital staff had to crush them into food.
On Dec. 1, a resident care worker found Ball in a bathroom where she had hanged herself from a shower curtain using a cord from a radio.
Kronfli's recommendations included doing evaluations and removing anything that could be used as an anchor in patient rooms.
Since Ball's death, the showers in the Hillsborough Hospital no longer use rods and have curtains that attach to tracks with Velcro.
While she was at the Hillsborough Hospital, the level of observation for Ball changed several times, including moving her to a single room where she was checked on every 30 minutes.
Kronfli made recommendations about changes to observation levels, including that staff can't move patients to a lower level without a psychiatric evaluation first.
Coroner Dr. Roy Montgomery ordered a partial, temporary publication ban on the first day of the inquest, but he lifted it Tuesday with Ball's family's support.
Crown attorney Jeff MacDonald said the family was most concerned with seeing positive change come from the inquest.
All of the jury's recommendations will be forwarded to P.E.I.'s chief coroner.