Report Page 2 of 10. Circumstances under which Death occurred: See attachment. Recommendations for the prevention of similar deaths: See attachment

Transcription

1 CANADA Province of Alberta Report to the Minister of Justice and Attorney General Public Fatality Inquiry Fatality Inquiries Act WHEREAS a Public Inquiry was held at the Court House in the City of Red Deer, in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 27th day of November, 2013, (and by adjournment year on the 28th day of November, 2013 ), year before Gordon G. Yake, a Provincial Court Judge, into the death of Richard David Jacknife 47 (Name in Full) (Age) of Red Deer, Alberta and the following findings were made: (Residence) Date and Time of Death: Place: November 11, 2010 at 3:45 p.m. Foothills Medical Centre, Calgary, Alberta Medical Cause of Death: ( cause of death means the medical cause of death according to the International Statistical Classification of Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose and published by the World Health Organization The Fatality Inquiries Act, Section 1(d)). Blunt neck injury incurred on November 4, 2010 at Red Deer, Alberta with resulting cervical spine fracture, described as a fracture of the lower posterior lateral body of C2 with a 6 mm displacement and disruption of the spinal canal. As a result of the traumatic injury to his cervical spine Mr. Jacknife suffered cardiac arrest and anoxic brain injury, leading to death. Manner of Death: ( manner of death means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable or undeterminable The Fatality Inquiries Act, Section 1(h)). Accidental

2 Report Page 2 of 10 Circumstances under which Death occurred: See attachment Recommendations for the prevention of similar deaths: See attachment DATED January 13, 2014, at Red Deer, Alberta. A Judge of the Provincial Court of Alberta

3 Report Page 3 of 10 Circumstances Under Which Death Occurred 1. David Richard Jacknife was a mentally retarded man who was a ward of the Public Guardian of Alberta from 1997 to the date of his death. On November 4, 2010 he was living at a group home operated by the Parkland Community Living and Supports Society ( PCLASS ), located at 140 Lancaster Drive, Red Deer, Alberta (the Group Home ). He had been transferred to the Group Home from a different Red Deer PCLASS group home in July of The Group Home is a bungalow. The main floor contains a front living room, an office, a bathroom, a kitchen, a laundry room and two bedrooms. The basement is finished and includes a bedroom. A stairway from the main floor provides access to the basement. 3. PCLASS operates a number of group homes for disabled adults in Alberta and elsewhere. 4. Mr. Jacknife s mental retardation resulted from childhood meningitis. On and before November 4, 2010 he was completely dependent, nonverbal, essentially wheelchair bound and displayed various behavioral issues. He suffered from epilepsy and asthma. While under the care and supervision of PCLASS he was administered various prescribed medications. He had significant limitations of his cognitive functions, adaptive skills and mobility. He required support and supervision on a 24 hour basis. 5. Notwithstanding his disabilities, Mr. Jacknife was able to manoeuver his wheelchair independently, and he had a tendency to wander in his wheelchair within the Group Home. According to a report prepared by Persons With Disabilities - Central Region Community Board (the PDD Report ), reproduced at Tab 56 of Exhibit 1, Mr. Jacknife was very active and into everything and he had an excessive need to open cupboards, fridges and doors. 6. To attempt to deal with this behavior, PCLASS developed a Restrictive Practice, dated August 3, 2010 (effective August 9, 2010) reproduced at Tab 46 of Exhibit 1 at pages 245 to 247 inclusive (the Restrictive Practice ). The Restrictive Practice required that the front door and the door separating the main floor area of the Group Home from the finished basement (the basement door ) were to be locked at all times unless the downstairs or outside (front) need to be accessed 7. According to an message dated November 23, 2012 sent by PCLASS Chief Executive Officer Dan Verstraete to Inquiry Co-Counsel James Mallett (reproduced in Exhibit 1 at page 165P of Tab 36), a component of the Restrictive Practice process included staff education and training which required that all staff be aware of the restrictions and signing off on the practice 8. Apart from a document reproduced in Exhibit 1 at Tab 35, titled Service Management Team Behavior Committee Review Form, signed by four of the eight members of the PCLASS Behavior Review Committee on August 23, 2010 and signed by six PCLASS staff members on September 16, 2010, the Court was not provided with any record of any notice relating to this Restrictive Practice given to PCLASS staff before November 4, No evidence was provided to the Court describing any training given to PCLASS staff relating to this Restrictive Practice prior to November 4, On or before November 4, 2010 there was no PCLASS Restrictive Practice or other PCLASS policy document that required that a formal monitoring system or recording system be established at the Group Home to ensure compliance with this Restrictive Practice.

4 Report Page 4 of On or before November 10, 2010 there was no system in place at the Group Home to monitor or record the use of the stairway or the opening, closing, unlocking and locking of the basement door. 11. On November 4, 2010, while belted into his wheelchair, Richard David Jacknife fell down the flight of stairs leading from the main floor to the finished basement of the Group Home. As a result he sustained the injuries that caused his death on November 11, On the basis of the testimony of PCLASS Group Home Supervisor Dorothy Anne Graham ( Ms. Graham ) and the information contained in the RCMP General Report of RCMP Cst. L. Jones and reproduced in Exhibit 1 at Tab 48, I find that this event occurred at approximately 11:00 a.m. on November 4, An RCMP investigation of the death of Mr. Jacknife was prompted by a call to the RCMP made by staff at the Medical Examiner s office on November 12, Acting on information received from the Medical Examiner s office, RCMP Cst. L. Jones attended at the Group Home on November 12, 2010 at 10:46 a.m. He spoke with a PCLASS staff member who identified Ms. Graham as the person who was present when Mr. Jacknife was injured. Ms. Graham was not present at the Group Home when Cst. Jones attended on November 12, On November 12, 2010, in the course of the police investigation, an audiotaped witness statement was taken from Ms. Graham at Red Deer City Detachment of the RCMP by RCMP Cst. M. McKeown. A transcript of that statement was reproduced in Exhibit 1 at Tab Ms. Graham testified at this Inquiry. The evidence that she gave was consistent with the information that she provided during the course of her interview with Cst. McKeown on November 12, Photographs taken by the RCMP during the police investigation, reproduced at Tab 53 of Exhibit 1 at pages 322 and 323, depict the stairway between the main floor and the basement of the Group Home to be comprised of 12 carpeted steps, with a carpeted floor at the bottom of the stairway, leading into a finished basement. 16. As of November 4, 2010 three PCLASS clients lived at the Group Home. Mr. Jacknife and another male PCLASS client named Bryce lived on the main floor. A female PCLASS client named Danielle resided in the finished basement of the Group Home. 17. Neither Bryce nor Danielle was present at the Group Home when Mr. Jacknife fell down the stairs in his wheelchair. 18. Danielle was completely mobile. She was allowed to walk up and down the stairway and to open and close the basement door of the Group Home. PCLASS staff relied upon her to lock the basement door after she unlocked it. She attended to the main floor from her living quarters in the finished basement regularly and often to eat, to watch television and for other reasons. 19. Bryce was also mobile. According to the information contained at page 439 of Tab 55 in Exhibit 1, he used both a cane and a wheelchair. He did not attend in the Group Home basement and was not known to open or unlock the basement door.

5 Report Page 5 of On and before November 4, 2010 the lock on the basement door was designed so that, when it was locked, that door could be opened from the basement side of that door by pulling down on the door handle on the basement side of that door. To unlock that door from the main floor a small pin-like rod or similar item was pushed into the centre hole of the locking mechanism on the handle. 21. The door handle on the basement door was described in evidence as long and narrow and opened by pushing down. No photograph of the door handle or the locking mechanism in place as of November 4, 2010 was provided to the Court. Neither that door handle nor that locking mechanism was entered as an Exhibit in this Inquiry. 22. The viva voce evidence in this Inquiry establishes that there was not an automatic lock on the basement door. Once that door was unlocked it had to be manually re-locked by pushing a button located on the basement door handle, on the basement side of that door. 23. The basement door did not have a self-closing mechanism. Once it was opened it had to be manually closed. 24. No alarm system was installed in the Group Home to alert staff and residents that the basement door was opened or unlocked. No visual monitoring system such as closed circuit television ( CCTV ) was in place in the Group Home. 25. Ms. Graham testified that as of November 4, 2010 she was the Supervisor of the Group Home. She arrived in her motor vehicle at the Group Home on that date at 8:00 a.m. She did not enter the Group Home at that time. 26. Ms. Graham waited in her vehicle outside the Group Home until Danielle exited and came to her vehicle. She drove Danielle to a medical appointment in Red Deer, and thereafter to the Red Deer Regional Hospital, where Danielle was scheduled to do some volunteer work. 27. After Ms. Graham dropped Danielle off at the Red Deer Regional Hospital she returned to the Group Home, arriving at about 9:15 a.m. Upon her return to the Group Home, PCLASS aide Shelley Elliott was present. 28. Ms. Elliott testified at this Inquiry. Her evidence establishes that she was the only PCLASS employee who worked at the Group Home from 4:00 p.m. on November 3, 2010 until Ms. Graham arrived on November 4, Ms. Elliott testified that before Ms. Graham arrived in the Group Home and during the morning hours of November 4, 2010 Danielle came up the stairs from her basement living quarters. At that time Ms. Elliott was busy caring for Bryce, and she also had to supervise and care for Mr. Jacknife. 30. After Danielle came upstairs Ms. Elliott either told her to close and lock the basement door or asked her whether she had done so. In response Danielle said she had done that. Thereafter Ms. Elliott did not lock that door or check to see whether or not it was locked. 31. On the basis of the evidence presented in this Inquiry I find that Danielle did not lock the basement door after she ascended the stairway and entered the main floor of the Group Home on November 4, 2010.

6 Report Page 6 of As of November 4, 2010 Ms. Elliott had not reviewed the Restrictive Practice. However, she did know that the basement door was to be kept locked when not in use. 33. Upon returning to the Group Home Ms. Graham met briefly with Ms. Elliott. Ms. Graham did not check or lock the basement door. She did not ask Ms. Elliott whether it was locked. 34. Ms. Elliott then left the Group Home and Ms. Graham went into her office located on the main floor of the Group Home. Ms. Graham began working in her office on an Annual Service Plan. She left the door to her office open. 35. By that time Bryce had departed from the Group Home to work at a local business that employs disabled adults. Therefore only Ms. Graham and Mr. Jacknife were inside the Group Home. 36. At that time Mr. Jacknife was dressed and was moving around the main floor of the Group Home in his wheelchair. Ms. Graham could not see Mr. Jacknife from her office when he was moving around other areas of the main floor. She heard sounds that indicated to her that he was moving around the main floor in his wheel chair. 37. Although the basement door was only a short distance away from her office, Ms. Graham could not see the basement door from her office, due to the floor plan of the main floor. 38. Ms. Graham signed a copy of the Restrictive Practice on September 16, Her signature appears on page three under the heading Staff Orientation Signatures, in the section of that document titled Staff Education/Training Requirements. On and before November 4, 2010 she knew that the basement door was to be kept locked at all times unless access was required to the basement area. 39. A few minutes before 11:00 a.m. on November 4, 2010 Ms. Graham exited her office with the intention of taking Mr. Jacknife for a walk outside of the Group Home. At that time she saw Mr. Jacknife in his wheelchair in the area of the main floor front room of the Group Home. She went into the main floor bathroom. She was in that bathroom for a few minutes and then she went directly into the main floor laundry room adjacent to the bathroom. 40. From Ms. Graham s testimony and from the hand drawn partial floor plan of the Group Home reproduced at page 427 of Tab 55 in Exhibit 1 (a more legible copy of which has recently been provided to the Court by Inquiry Counsel) I conclude that while Ms. Graham was in the bathroom and the laundry room she could not see the basement door. 41. Ms. Graham had been in the laundry room for a very brief time when she heard a loud crash, whereupon she immediately exited the laundry room and proceeded to the basement door. Upon her arrival at that location she saw that the basement door was open, and she saw Mr. Jacknife at the bottom of the stairway, still belted into his wheelchair. 42. On the basis of the evidence presented in this Inquiry I find that, while Ms. Graham was in the bathroom or the laundry room, Mr. Jacknife approached the unlocked basement door and opened it, and after he opened that door Mr. Jacknife accidentally fell down the stairway while he was belted into his wheelchair. 43. Upon seeing Mr. Jacknife at the bottom of the stairway Ms. Graham immediately ran down the stairs. She found Mr. Jacknife at the bottom of the stairway, belted into his upturned wheelchair. It was apparent to her that Mr. Jacknife was injured. She shouted his name and he did not respond.

7 Report Page 7 of Ms. Graham immediately called 911. A transcript of her call to 911 at 11:02 a.m. on November 4, 2010 is reproduced under Tab 51 of Exhibit 1. She reported that Mr. Jacknife had fallen down the stairs while in his wheelchair and that he was still breathing and that he seems to be going unconscious 45. City of Red Deer emergency medical services personnel ( EMS ) were en route to the Group Home by 11:11 a.m. and arrived at the Group Home at 11:14 a.m. Mr. Jacknife was found in his wheelchair at the bottom of the stairway. He was unresponsive, had a very slow heart rate, an undetectable blood pressure and slow agonal respirations. He suffered cardiac arrest and received cardiopulmonary resuscitation from EMS for two to three minutes. 46. He was transported by EMS to the Red Deer Regional Hospital, arriving there at 11:38 a.m. on November 4, After initial examination and assessment at that hospital he was transported on the same day by STARS in a comatose state to the Calgary Foothills Medical Centre ( FMC ). 47. Medical evaluation at FMC revealed that Mr. Jacknife had anoxic brain injury and a C2 vertebral fracture with spinal cord compression and edema extending from the C 2/3 to the C3/4 level. He remained at FMC in a comatose state until he was taken off life support on November 11, 2010, with the consent of his mother Clara Jacknife, his sister Elizabeth Jacknife and the Public Guardian. He died at 3:45 p.m. on November 11, The Certificate of Medical Examiner Dr. Mike Belenky reproduced at Tab 2 of Exhibit 1 describes the immediate cause of death as blunt neck injury. 48. Timothy Lowe, the Acting Director of an agency called Persons With Developmental Disabilities Central Region Community Board ( PDD ) testified at this Inquiry. PDD is the agency that provided funding for Mr. Mr. Jacknife s residential placement and support. 49. Mr. Lowe testified that on behalf of PDD and commencing November 26, 2010 he conducted a review of the circumstances surrounding the death of Mr. Jacknife. He is a co-author of the PDD Report reproduced at Tab 56 of Exhibit The following recommendations appear at page 7 of the PDD Report: (a) PCLASS needs to develop and implement a formal risk assessment process that identifies potential risk and proved risk mitigation strategies; (b) PCLASS should undertake a review of any policies or practices that relate to the use of restrictive procedures or practices; (c) PCLASS should develop a system to make sure that all staff working in a home are aware of and understand any restrictive procedures and practices that are in place within any given project; (d) PCLASS should ensure that PCLASS staff sign off on Restrictive Practices and Procedures, acknowledging that they have read them and understand them; (e) Restrictive Practices and Procedures should be reviewed and updated as required before a PCLASS client is moved from one group Home to a different group Home; (f) PCLASS should ensure regular and frequent monitoring in order to attempt to determine the effectiveness of each Restrictive Practice and in order to allow staff to report failures to consistently follow Restrictive Practices; (g) installation of automatic locking doors should be considered by PCLASS, particularly when a person receiving PCLASS services is either directly or indirectly responsible to lock a door; and (h) doors at PCLASS group homes should be monitored to ensure they are fully closed.

8 Report Page 8 of The PDD Report states that PCLASS was cooperative with the PDD review, and it notes that PCLASS has installed self-locking mechanisms on all interior basement doors in its group homes. 52. PCLASS CEO David Verstraete testified at this Inquiry. His evidence was that the Restrictive Practice that required locking of the basement door was developed in August of 2010 after an assessment by PCLASS of the risks resulting from Mr. Jacknife s penchant to wander in his wheelchair and to open cupboards and doors in the Group Home. The Restrictive Practice was designed to reduce or eliminate the risks of injury to Mr. Jacknife and other residents of the Group Home. 53. Mr. Verstraete testified that following of the death of Mr. Jacknife PCLASS conducted a review of its policies, practices and procedures in order to prevent the recurrence of similar accidental death or injury in its group homes. 54. I am satisfied by the evidence presented at this Inquiry that PCLASS has accepted and followed the recommendations listed at page 7 of the PDD Report including, but not limited to, the installation of automatic locks on basement doors, as depicted at Tab 32 of Exhibit 1. Once locked, those basement doors can only be opened from the main floor by use of a key, and access to that key is restricted to PCLASS staff. 55. Further, PCLASS now requires its staff to record in writing on a daily log each use of the basement stairways. Pages 1 and 2 of Tab K to Exhibit 2 are copies of the documents developed by PCLASS in this regard. 56. PCLASS has also: (a) eliminated pony walls that abut stairways in its group homes (see Tab 34 in Exhibit 1); (b) posted signs on basement doors directing that such doors be kept closed at all times (see Tab 33 in Exhibit 1); (c) developed an individual in-service checklist with house specific orientations including a direction that basement doors be kept locked (see Tab 31 in Exhibit 1); (d) installed additional stairway lighting (see Tab 41 in Exhibit 1); and (e) installed double hand rails on all the basement stairways in its group homes (see Tab 40 in Exhibit 1). 57. Some evidence was given by Mr. Verstraete about the prospect of installing auditory alarm systems in its residential facilities, so that PCLASS staff and facility residents would hear an alarm when basement doors were open or ajar, and that alarm would sound until the basement door was completely closed. Mr. Verstraete expressed some concern that auditory alarms might cause distress to some PCLASS residential clients. 58. Mr. Verstraete also expressed concern with the suggestion that self-closing basement doors be installed in PCLASS residential facilities. He testified that self-closing doors pose a hazard to some people who have mobility impairment, as they may not be able to move through the doorway before the door closes upon them. 59. Alicia Congdon testified at this inquiry. She is a behavioral consultant and she was a member of the PCLASS Service Management Team that developed the Restrictive Practice that required that the basement door in the Group Home be locked. Her evidence corroborated Mr. Verstraete s evidence that the Restrictive Practice was developed in

9 Report Page 9 of 10 order to mitigate the risks posed by Mr. Jacknife s habit of wandering around the Group Home in his wheelchair and trying to open doors and cupboards. 60. The final witness called to testify at this Inquiry was Elizabeth Edwards. She is an Occupational Therapist hired by PCLASS to review the changes made after November 4, 2010 to PCLASS group homes and to PCLASS policies, practices and procedures. She was qualified by the Court to give expert opinion evidence in the area of occupational therapy. Her statement of qualifications was entered as Exhibit 3. Her written report was entered as Exhibit Ms. Edwards testified that PCLASS has met or exceeded all of the recommendations listed at page 7 of the PDD Report. In addition to the PDD Report recommendations, Ms. Edwards recommended that: (a) there should be regular maintenance of the automatic locking doors; (b) there should be no throw rugs or other obstructions placed on the floors in proximity of the automatic locking doors; (c) a risk assessment specific to each PCLASS facility resident and each PCLASS group home should be completed, particularly when a PCLASS client is moved from one group home into a new PCLASS group home; (d) consideration should be given to the installation of an auditory alarm system that emits a constant auditory signal designed to notify staff when a basement door is open or ajar. (Ms. Edwards notes that PCLASS clients with Autism Spectrum Disorder cannot accept intrusive sound, and therefore an auditory alarm system that can be heard by those clients is not recommended for group homes in which people with that disorder reside). 62. With regard to the prospect of installing self-closing basement doors, Ms. Edwards opinion is: Doors that automatically close would eliminate human error but would only be effective if all of the individuals living in that home were safely and independently ambulatory, but should not be allowed to wander for other reasons (such as dementia). For individuals with any form of mobility impairment, self-closing doors can be a hazard since the door may close onto an unstable individual. The individual with the impairment doesn t necessarily have to be the person using the door for it to be a hazard. 63. At the conclusion of her report Ms. Edwards states: There is no one device or combination of devices that would be appropriate for all group homes. This is a grey area and each person residing in the home needs to be considered thus making each home a unique situation which will require a unique solution for a similar concern.

10 Report Page 10 of 10 Recommendations for the Prevention of Similar Deaths 64. The Fatality Review Board recommended that a public fatality inquiry be held pursuant to section 33(2)(a) of the Fatalities Inquiry Act to determine if adequate care and services are available in group homes for a person of this nature, referring to Mr. Jacknife. 65. In light of the changes made by PCLASS to its policies, practices and group home facilities I find that adequate care and services are available at PCLASS group homes for persons suffering from mental, developmental and physical disabilities of the nature and to the degree that afflicted Mr. Jacknife. 66. In addition to the recommendations of the PDD Report that have been accepted and acted upon, I recommend that: (1) CCTV cameras should be installed and should operate continually to monitor doors leading to basement stairways in group homes where staff occupying group home offices do not have a direct and unobstructed view of those doors. A CCTV screen should be located in the main floor staff office and that screen should be activated whenever group home employees occupy those offices. (2) An auditory alarm system should be installed in group homes to notify staff if a basement door is left open or ajar, excepting group homes housing client(s) that suffer from Autism Spectrum Disorder or other disorders that render auditory alarms unacceptable. In those group homes a visual alarm system incorporating flashing warning lights at strategic locations in the group home should be installed. (3) A policy requiring that staff check to ensure that basement doors are locked at the start and at the end of each work shift and at regular intervals during the course of each work shift should be instituted. (4) Records of group home staff attendance at Restrictive Practice training sessions should be created and maintained. (5) A policy requiring regular and timely maintenance of the self-locking basement doors should be instituted and records of that maintenance should be created and maintained. (6) There should be no throw rugs or other obstructions placed on the floors in proximity to self-locking basement doors. (7) If not already established, a policy should be instituted requiring a risk assessment specific to each group home resident be completed, particularly when a group home resident is moved from one group home into a different group home.