Coroner, jury make 15 recommendations in suicide inquest

Patricia Borthwick says her daughter can finally rest in peace after a coroner and jury issued 15 recommendations following an inquest into her suicide death.

Hillary Hooper, 27, died by suicide on Dec. 9, 2020, following a weeks-long hospitalization in the Saint John Regional Hospital’s 4D North ward.

A public inquest heard testimonies from 16 people, including Horizon Health leadership, law enforcement and mental health professionals, recounting in graphic details of the Charlotte County woman’s final moments in an effort to prevent future deaths under similar circumstances.

The jury recommended the hospital’s psychiatric unit use bedding which tears easily and wouldn’t be able to support the weight of a grown adult, along with bolting hospital beds to the floor so they can’t be moved to barricade a room.

The jury also recommended “any time a patient door is blocked, that attention be given to the room immediately” and also said Horizon Health should consider increasing overnight staffing levels on the psychiatric ward.

The jury also recommended installing security cameras in rooms on the psychiatric ward, “recognizing there are issues pertaining to patient privacy that require consideration in that regard.”

Hooper had been staying in the Saint John Regional Hospital for nearly three weeks when she made her final suicide attempt on Dec. 2, 2020.

During the 11 p.m. hourly round of bed checks, psychiatric nurse Karen Wood testified she found Hooper’s door had been barricaded by a hospital bed.

Wood said she continued her round of the ward and then returned to Hooper’s room, eventually pushing open the door with the help of another nurse. They found the room was empty.

The pair noticed the light was on in the bathroom and the door was jammed. When the nurses opened the door after “four or five” tries, they found Hooper, who had attempted suicide.

Hooper had a light pulse when they found her, and the nurses performed CPR until the hospital’s “code blue” team arrived to continue the resuscitation efforts. Hooper was then moved to the hospital’s intensive care unit where she was put on life support for a week, where she had “continuous seizures.”

She was put into palliative care on Dec. 9 and died just a few short moments later.

Hooper had been in the psychiatric ward since a suicide attempt on Nov. 13, 2020, when she overdosed on prescription medication. Lauren Oulton, a mental health nurse who assessed Hooper in the emergency room that day, described the 27-year-old as “unshakeable” in her resolve to end her life.

Hooper had been diagnosed with borderline personality disorder, which included attention-seeking behaviour, self-harm and other maladaptive coping strategies, as well as vast fluctuation in emotions and intense moods, among others.

The jury also recommended a “short-stay” unit be added to the hospital as a part of their psychiatric services, which Horizon Health also recommended after its own internal review.

Renée Fournier, director of addictions and mental health services for Horizon’s greater Saint John region, said the health network ultimately recommended a “crisis stabilization unit” for short-term mental-health related stays separate from the hospital’s psychiatric wing.

The unit would be intended for people with borderline personality disorder and similar mental health afflictions, in order to “stabilize” people in crisis and help them with coping mechanisms for their daily lives.

Dr. Alan Fostey testified Hooper had expressed reservations about returning home because she was “really comfortable” in 4D North. She’d been there for longer than normal as they were tweaking her medication, which is a lengthy process, he said.

Provincial coroner Emily Caissy, who presided over the inquest, also recommended the short-stay unit be implemented.

She also recommended Horizon provide information sessions for local physicians on local resources available for borderline personality disorder, and “adopt or make a continuous assessment of suicide urgency” via standardized forms in emergency departments and other clinical settings.

Caissy also recommended the Department of Justice and Public Safety support the Office of the Chief Coroner establish a suicide fatality review committee.

The recommendations will be brought before Horizon Health and the Department of Justice and Public Safety, and the response will be summarized in the chief coroner’s annual review.

“It is through this process the death has not been overlooked, concealed or ignored,” Caissy told the jury. “From the bottom of my heart, I thank you.”

Borthwick, Hooper’s mother, has been looking for answers in her daughter’s death for 27 months now. She said the jury’s recommendations were everything the family had been hoping for.

“I know it’s been hard to hear what you’ve heard,” she told the jury. “I wanted to say sorry you had to come here for this. I think we can let my girl rest in peace now, because of your help,”

For those experiencing a mental health crisis, the Saint John Mobile crisis line is 1-888-811-3664 and the Chimo Help-Line is 506-450-4357. The Kids Help Phone is 1-800-668-6868.

Marlo Glass, Local Journalism Initiative Reporter, Telegraph-Journal