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 Provincial Court of Alberta in the City of Calgary, in the Province of Alberta, (City, Town or Village) (Name of City, Town, Village) on the 29th day of October, 2013, (and by adjournment year on the 30 th and 31 st day of October, 2013 ), year before S. L. Van de Veen, a Provincial Court Judge, into the death of Diane Susan Linder 42 (Name in Full) (Age) of Calgary, Alberta and the following findings were made: (Residence) Date and Time of Death: Place: June 22, 2011 at 10:45 a.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)). 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)).
Report Page 2 of 2 Circumstances under which Death occurred: Recommendations for the prevention of similar deaths: DATED March 21, 2014 at Calgary, Alberta. Original signed by S. L. Van de Veen A Judge of the Provincial Court of Alberta
Fatality Inquiry Report, October 29-October 31, 2013 The Identity of the Deceased and the Date, Time and Place of Death On June 22, 2011, Diane Susan Linder died at the Foothills Medical Centre in Calgary, Alberta. Circumstances, Medical Cause of Death, and Manner of Death 1) The circumstances under which the death of Diane Susan Linder occurred are that she climbed over a balcony railing and fell approximately 15 to 16 feet to the ground. The railing was approximately six feet high and the balcony was one level above ground at the Bethany Care Centre in Calgary, where Ms. Linder lived. She sustained significant internal injuries and only compassionate medical care was instituted. In the result, Ms. Linder died several hours later. 2) Ms. Linder was 42 years old and had lived at the Bethany Care Centre since 2005. At the age of 17, she sustained a very severe traumatic brain injury as a result of a fall while hiking. Since then, she had lived largely in institutional care, both in acute care facilities and hospital. When she came to live in the Bethany Care Centre, she was in fact transferred from an acute care hospital. 3) The brain injury diagnosis included left side hemiparesis, depression, and a seizure disorder. At Bethany she exhibited a number of problematic behaviours, all of which were consistent with the severe traumatic brain injury she had sustained, including poor insight into both her condition, its effects and impairments on her functioning, as well as her need for extra support. In particular, she had poor insight into the need for her to live in institutional care. She had poor problem-solving and decision-making abilities, impaired impulse control, and exhibited aggressive behaviour. The impaired impulse control could be sexually impulsive and disinhibited. She had difficulty regulating her mood and emotional expressions, including anger. 4) At the time Ms. Linder was admitted to the Bethany Care Centre, her condition was static in nature, meaning that her condition was likely permanent. There was little likelihood of improvement in the basic diagnosis and the challenge for the institution was to manage the condition and try to help provide adaptive strategies or reduction strategies. The static nature of Ms. Linder s condition was in contrast to the other generally older residents of the Bethany Care Centre, whose conditions could be expected to change and deteriorate with age. 5) The Bethany Care Centre generally houses older residents, but it was unfortunately the best option available to her parents since Ms. Linder required an institutional residence. As a much younger resident of the Bethany Care Centre, Ms. Linder was not a good fit, and she was well aware of the fact that she did not belong in the senior environment in which she had been placed. She constantly tried to escape and her brain injury caused significant behavioural, emotional and physical issues, all of which were difficult to manage and which were aggravated by her living in a residence primarily serving the elderly. 6) Significant efforts were made by the Bethany Care Centre to accommodate the age difference issue impacting Ms. Linder, but this issue could only be managed to some degree. For instance, Ms. Linder was placed on Level Six at the facility, because she could have her own room in that particular secure treatment area of the centre. Although Level Seven had a more secure railing and balcony design, and thus may have been more secure in terms of efforts to escape, Ms. Linder would not have had her own
Report Page 2 of 4 room had she been placed in Level Seven. Given her age and other issues, Level Six was a better fit for her. 7) It was the opinion of Dr. Quickfall that Ms. Linder struggled psychologically with significant frustration over having to live some place she didn t believe she needed to live and likely had some degree of boredom. She was on a unit with primarily older patients who were medically frailer and who had most likely progressive conditions like Alzheimer s disease. Although there were activities, some designed for younger patients at the facility, such added activities clearly did not make up for a full complement of daily activities directed at younger, physically capable individuals suffering from traumatic brain injury, such as Ms. Linder. Dr. Quickfall also testified that this frustration with her living arrangement would amplify exhibited behaviours arising from her brain injury. 8) Dr. Quickfall also testified that Ms. Linder frequently did not take her anti-seizure medications, as a result of which she would have more seizures which in turn typically caused deterioration in behaviour. Such patients can become, in turn, more difficult to manage and even less likely to take their medication. As a result, further seizures are produced which in turn further deteriorate behaviour. This vicious cycle is difficult to break and Ms. Linder s condition was characterized by this issue. 9) On June 21, 2011, Ms. Linder was alone on the balcony just after breakfast. From June 1st, 2011 to June 14, 2011, she had been the subject of one-on-one care, but this was discontinued when the behavioural issues requiring such care decreased. On June 21, 2011, Ms. Linder pulled a plastic patio table to the railing, climbed onto the table and over the railing. She fell one level to the ground, the distance being about 15 to 16 feet. She was quickly found flailing around on the ground and taken to hospital. No one saw the incident occur. Medical Cause of Death 10) The immediate medical cause of death was multiple blunt injuries. Her internal injuries were severe enough that her parents, her legal guardians, requested compassionate care only. Medical evidence at the Inquiry confirms this decision as being a reasonable one, given the quality of life Ms. Linder could expect if intrusive medical procedures were undertaken. There was a possibility she could have been returned to the same condition which she endured prior to the June 21, 2011 incident, but there was also the possibility her condition could have been worsened. Ms. Linder s parents were well aware of the difficult life their daughter endured and the intensive care physicians agreed with their decision to apply compassionate care only. As a result, Ms. Linder s condition gradually deteriorated and she died the morning of June 22, 2011. Manner of Death 11) The evidence at the Inquiry is such that the manner of death is best described as accidental. Ms. Linder was trying to escape when she climbed over the railing. Her ongoing efforts to escape had been known to some of the witnesses but not others. She had tried to climb over the balcony to escape twice in 2009, for instance, and this was known to some but not all of the staff. What was in evidence, however, is that generally speaking her repeated efforts to escape were a characteristic of her stay at the Bethany Care Centre.
Report Page 3 of 4 12) The distance to the ground was not sufficient for suicide and the deceased was found flailing away on the ground, definitely alive. But for the quality of life she could expect, medical procedures may well have saved her life. 13) The Bethany Care Centre instituted changes to the Level Six balcony after the death of Ms. Linder. They installed a railing and balcony system similar to that in place on Level Seven, in order to ensure patients could not again climb over the railing. In addition, there is a clear policy that patients are not to be left alone on the balcony, a policy some staff strictly adhered to prior to the death of Ms. Linder, while others did not. Notably, the changes to the railing on Level Six may well pose a disappointment to patients who had previously enjoyed the openness of the balcony system on Level Six. Closing it in with glass or Plexiglas undoubtedly would diminish this enjoyment. 14) I am mindful that at least one staff member thought Ms. Linder had committed suicide. There is evidence her parents had recently told the facility to no longer call them for everything concerning their daughter, because they needed to retire and have some freedom from the constant degree of caring for her. They had been extremely involved in her care previous to this decision. The parents instructed Bethany, sometime close to the date of her death, that they should only be called when it was important. In the result, there would be less frequent communication with the parents than in the past. Ms. Linder s parents also told Ms. Linder of this decision. Nevertheless, the totality of the evidence does not support a suicide attempt. The evidence is that she had repeatedly tried to escape throughout her stay at Bethany and the June 21, 2011 incident is consistent with this characteristic of her behaviour. She had significant difficulty accepting the senior environment in which she had been placed and the distance she fell is not sufficient for a suicide attempt. Recommendations to Prevent Similar Deaths 15) Dr. Quickfall testified that there is a terrible deficit for appropriate resources, particularly residential resources, for people who have severe neurological injury at a young age and who are severely impaired. Dr. Quickfall travels between various hospitals and sees these individuals in acute care because there are no other places for them to go or because they are waiting on long waitlists for appropriate placement. It was his evidence that he sees more of these kinds of patients than any psychiatrist in the city and talks with facility staff and physicians in other places about the difficult kinds of patients and frustrations they are having. 16) It was the opinion of Dr. Quickfall that Bethany Care Centre did the things that they could do to manage the patient but the Bethany Care Centre is not an ideal place to manage people like Ms. Linder. People like Ms. Linder with chronic traumatic brain injury, at a young age, require a purposeful facility with specialized nursing and medical disciplines trained to deal with the unique population of younger adults with brain injuries. 17) Dr. Quickfall testified that the Brain Unit at the Southwood Care Centre in Calgary was set up to accommodate younger, more mobile patients who have traumatic brain injuries. These injuries can result in physical aggression among other behavioural issues which are difficult to manage. He testified that the staff level of comfort with those kinds of patients is much higher at Southwood than it is at other nursing homes because every patient there more or less has those kinds of problems and the environment is more suited to young, mobile brain injured people.
Report Page 4 of 4 18) In addition, Doctor Quickfall testified that the big difference between patients who have the profile of Ms. Linder versus typical nursing home patients who are generally more elderly and medically frail, is that Ms. Linder s condition is static. She would not decline as other nursing home patients are expected to do. Ms. Linder was younger and typically mobile and physically healthy so she would be expected to keep up the same kinds of behaviours (positive or negative) for decades. There is a very low turnover at the Southwood Care Centre Brain Unit, which has only had twenty some new patients since they opened. Patients residing at the Southwood Care Centre Brain Unit are often somewhere between 30 and 60 years old and other than their brain, their physical bodies are often relatively healthy. This means they will live a long time and are perfectly capable of doing many things that physically healthy adults can do. The Southwood Care Centre Brain Unit is accordingly staffed and designed to accommodate such younger, physically healthier patients. It is the only such facility in the City of Calgary and because of its limited capacity for brain injured young adults, many such patients are unable to access appropriate medical care. 19) The evidence at the Inquiry is that Ms. Linder suffered from traumatic brain injuries sustained in a fall while hiking at the age of seventeen. She was housed in hospitals and acute care facilities for several years and in 2005 was placed into the Bethany Care Centre, a residence primarily designed for senior citizens. The evidence at the Inquiry is such that generally speaking young adult patients suffering from traumatic brain injuries like Ms. Linder, are currently housed in inappropriate facilities, including such hospitals, acute care facilities and senior residences. In the result, patients who actually do require the medical services offered in such facilities may be waitlisted with significant adverse effects upon those patients such facilities are designed to serve. In addition, the young adult traumatic brain injury patients utilizing such facilities are not served well by inappropriate placements in such hospitals or other facilities. The young adult traumatic brain injury patients require specialized nursing and medical disciplines trained to deal with the unique population of younger adults with brain injuries. 20) Accordingly, it is the recommendation rising from this Inquiry that in order to prevent similar deaths in future, Alberta Health Services address the significant need for residential health facilities serving young adults who suffer from traumatic brain injuries, particularly those who maintain significant physical mobility.