WARNING: This story contains distressing details.

Some of the details were difficult to hear, but a Charlotte County mother is pleased with the results of a coroner's inquest into the death of her daughter in the secure psychiatric unit of the Saint John Regional Hospital.

"I think we can let my girl rest in peace now," Patty Borthwick told the five members of the coroner's jury on Wednesday afternoon after they delivered 11 recommendations to try to prevent similar deaths.

Hillary Hooper, 27, was a patient in the psychiatric unit after trying to end her life on Nov. 13, 2020. After 19 days in 4D North, Hooper hanged herself in the bathroom of her room. She spent a week on life support, before her family made the decision to remove her on Dec. 9, 2020.

The jury recommended that the psychiatric unit use "bedding that tears easily and will not support a person's weight."

It also recommended that the hospital consider installing security cameras in patient rooms, and that patients be searched for "potential weapons, drugs, mobile phone, etc." before they're admitted to 4D North.

Other recommendations included increasing staffing overnight, positioning a "code blue crash cart" on 4D North, and implementing a "short-stay unit" at the Regional that would include a special therapy component — something that was recommended in Hooper's case but not provided while she was a patient.

Presiding coroner Emily Caissy added an additional four recommendations to the jury's list, including that Horizon Health Network provide information to physicians "on local resources available for people with borderline personality disorder."

She also recommended the Department of Justice and Public Safety "support the office of the chief coroner in establishing a suicide fatality review committee."

After the jury foreperson read out their 11 recommendations, Borthwick was given an opportunity to address the five-member panel. She thanked them and told them they "got everything right" and "nailed" the recommendations.

Speaking to reporters outside the courtroom, Borthwick said she was grateful to jurors.

"They got everything that we wanted to get, you know, the doors, the bedding — all the things that should make it impossible for someone to do what she did again," said Borthwick.

Her final message was for officials with Horizon Health to put themselves in the position of a grieving parent desperate for answers about how and why their child died while in the health-care system.

"As a mom — anyone that has kids — they want to know what happened to their child, right? … It might not be important to anyone else. What was she wearing? What did she eat? How was her hair? But it was important to me, and although it was very hard to hear what happened, I needed to know what happened. I needed to find out the actual truth."

Borthwick said she wished an inquest hadn't been necessary. She wished she didn't have to fight so hard to get the answers in an inquest — and she hopes to help other parents not have to go through that fight for information.

She's working with her MLA on "Hillary's law," as she calls it. They're trying to get changes to the Coroner's Act that would automatically require an inquest when a patient dies by suicide.

A face to the issue

Borthwick wanted to make sure that everyone who participated in the inquest remembered that the process was about a human being.

"So I put her picture there at the end of the aisle," she said. "So any witness going by [would see it]. You have thousands of patients. I have one daughter.

"I want you to know she lived. She had a great life. She mattered. And I want you to remember her beautiful face. If you want to go up there and not tell me what really happened, I want you to remember her. Because she's not going to die in vain. There are going to be changes and there's going to be a reason that this happened and she's going to save lives. I honestly believe that."

16 witnesses in 3 days

Sixteen witnesses testified during the three-day inquest, nearly every one of them a health-care professional who had been involved in Hooper's care.

The jury heard that Hooper had a history of mental health issues and had previously tried to take her own life.

On Nov. 13, 2020, she had an appointment with a community-based mental health counsellor. That social worker said Hooper arrived as a "high priority" case, in part because of her "suicidal ideation."

Hooper drove from that appointment to the parking lot of the Saint John Regional Hospital. She took about 50 pills, for which she had prescriptions, and walked into the emergency room with a suicide note in her hand. The note said she wanted to die and asked that her organs be donated.

Hooper remained in the department until her condition stabilized enough to transfer her to the hospital's psychiatric unit, 4D North, where she remained for 19 days on a voluntary admission.

Her psychiatrist, Dr. Alan Fostey, said the goal of her stay was to stabilize her mood and her medications, which had been troubling her. She complained that they were giving her nightmares and making her feel drowsy, according to evidence from witnesses, including Fostey.

Several witnesses testified that Hooper had been improving, and Fostey said she appeared happy and "stabilized" and that he was preparing to discharge her, although not for another few days.

He said that's why he was so surprised to hear what happened.

The inquest also heard from the nurse who found Hooper during routine hourly rounds.

Registered nurse Karen Wood said Hooper had a pulse when she was first discovered, but it soon weakened. Another nurse began CPR, while a third nurse called a "code blue."

A team from 4C North, internal medicine, arrived at 11:15 p.m. Respiratory therapist Michael Kennedy, who was part of that team, testified about changes in Hooper's pulse during the resuscitation efforts.

At 11:44, Hooper was moved to the ICU and placed on life support.

IF YOU NEED HELP:

CHIMO hotline: 1-800-667-5005  / http://www.chimohelpline.ca

Kids Help Phone: 1-800-668-6868

Canada Suicide Prevention Service: 1-833-456-4566