Daughter of suicide victim wonders if death could have been prevented

The daughter of a woman who killed herselfwhile a patient at HillsboroughHospital three years ago says she wonders ifthe P.E.I. government may have missed an opportunity to make changes at the psychiatric facilitywhich might have saved her mother's life.

• Hillsborough Hospital inquest: jury makes 14 recommendations
• P.E.I.'s chief coroner investigating 2010 Hillsborough Hospital suicide

Sherry Ball died Dec. 1, 2013. The inquest into her death held in February resulted in 14 recommendations from the inquest jury meant to prevent similar tragedies from occurring in the future.

Ball's daughter Sophia attended her mother's inquest. But she only learned afterwards about another suicide at Hillsborough Hospital in 2010, three years prior to her mother's death. There has been no inquest held to examine the events surrounding that previous suicide.

'Angry and betrayed' at lack of inquest

"I felt quite angry about that, and betrayed in a sense," Ball said about learning ofthe 2010 suicide after her mother's inquest had concluded.

"I think that whenever we have a death in a mental health facility or in a care facility, it's so important to take a look into why and to give a public notice. And especially if it's a suicide, to have an inquest."

Ball said she wants to know the circumstances surrounding the 2010 death, and how Health PEI responded.

"If there was any sort of inquiry or hard look at those circumstances, I'd love to know if any of the recommendations were the same. And if they were the same as my mother's recommendations, the recommendations that came out of that inquest, it's entirely possible that my family's tragedy could have been averted or prevented. That's incredibly important."

Death led to internal review

The fact that a suicide at a public facility occurred in 2010 was revealed through a ruling by Prince Edward Island'sInformation and Privacy Commissioner in Nov. 2015.

In March of this year, a spokesperson for the P.E.I. Department of Justice confirmed that the death was a suicide and that it took place atHillsborough Hospital, the province's main psychiatric facility.

Other than that, no information has been made public including who died, or how or when specifically the death occurred.

Health PEI provided a statement to CBC News on Friday saying an internal review had been conducted:

"Unfortunately, there was a sudden and unexpected patient death at Hillsborough Hospital in 2010," said the statement.

"Out of respect for the privacy and confidentiality of the patient involved and their family, we are unable to share related details.

"Health PEI did carry out an internal review to determine what transpired and identify opportunities, if any, to put measures in place to reduce the likelihood of such an event happening again. Several recommendations were identified and have since been implemented."

In some cases, inquest required by law

According to P.E.I.'s Coroners Act, an inquest must be held when an inmate or involuntary patient at a public facility dies, unless the coroner determines the death was entirely due to natural causes.

In the case of a patient who's there voluntarily, there's no automatic requirement for an inquest. However, the Act does direct the chief coroner to hold an inquest any time he or she believes one is necessary to "bring dangerous practices or conditions to light and facilitate the making of recommendations to avoid preventable deaths."

There has been no word from government whether the person who died bysuicide at Hillsborough Hospital in 2010 was a voluntary or involuntary patient, or indeed whether they were a patient at all.

Dr. Desmond Colohan became P.E.I.'s chief coroner in 2015. In March 2016, hetold CBC News he was "reviewing the sequence of events which occurred during the initial investigation of this death to better evaluate whether any additional action is required going forward."

He has since referred all further inquiries to the P.E.I. Department of Justice, which has not indicated whether any further steps will be taken to review the incident.

14 recommendations from Ball inquest

Sophia Ball said it was difficult to sit through the public inquest into her mother's suicide, but she "wanted to make sure there was a sense of accountability I think it's important to make sure that when we have really vulnerable persons in our society, and in our care, that we have the best possible systems in place. And sometimes that means taking a really hard look."

The jury at Sherry Ball's inquest came up with 14 recommendations, most taken from a report prepared by Dr. Risk Kronfli, a forensic psychiatristfrom Nova Scotia who conducted a review of the incident.

Many of the recommendations centred around patient transfer and admission processes and patient observation levels.There was also a recommendation that the physical environment of the hospital be evaluated, removing any fixtures such as coat hooks or shower rods, which could be used as an anchor to support a person's weight.

Sophia Ball says sheconsulted a lawyer about the possibility of bringing a lawsuit against the province, but decided against it.

"Ultimately I decided not to, because if anything it would just take more funding and resources out of a system that's already drastically underfunded."

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