The Vancouver Island Health Authority on Friday released a report outlining recommendations aimed to prevent patient deaths, in response to the suicide of a teenage patient last December.
Hayden Kozeletski walked away from Ledger House, a youth psychiatric facility in Saanich, on Dec. 19, 2010 after returning from a weekend away, having been released on a day pass.
Seven recommendations were made after an internal quality review found room for improvement, namely in how a patient is assessed as a suicide risk, how staff communicate internally and externally, and how release passes are distributed.
“We use the case and look at it from all angles in terms of where and how could we make improvements,” said Dr. Richard Crow, VIHA’s executive vice-president and chief medical officer. “Obviously the actual case only involved a couple sites, and yet we want to (implement the recommendations Island-wide) in order to make sure things are improved everywhere.”
The recommendations are:
• ensure that suicide risk assessment guidelines are updated and used in all emergency departments and urgent care centres;
• develop written procedures outlining which patients can be released on day passes, and documenting their exit and return from a facility;
• revise Ledger House’s day pass protocol so a patient’s family is aware of behaviour that should prompt a return to the facility;
• improve communication between shift workers at Ledger House;
• create a clear protocol with Saanich police so if a child goes missing, VIHA staff and police communication staff understand how at-risk the child is;
• give all emergency departments and urgent care centres access to mental health and addiction services medical records;
• add alarms to exits at Ledger House.
Kozeletski’s family was involved in the review process, Crow said, to help make suggestions on recommended actions to be taken.
The release of VIHA’s report came just three days before an B.C. Coroners Service inquest in the death is set to begin.
The five-day inquest is expected to run until Friday (Dec. 16). At the end, the jury will have an opportunity to make more recommendations to prevent future similar deaths.