Secure unit would have saved dementia patient killed in traffic: fatality report
A dementia patient who was run over in the street after he wandered away from the Royal Alexandra Hospital in 2015 should have been protected on a secure unit, a fatality inquiry has found.
Robert Earl Wright, 84, was a patient in the hospital's geriatric unit for more than two weeks in the summer of 2015, and walked away three times.
The third time he left the hospital, on Aug. 21, he stepped into traffic and was hit by a vehicle.
He was seriously injured and died in hospital three days later.
A fatality inquiry into his death was held over four days in June 2017. Six witnesses were called and Wright's medical records were entered as exhibits.
A report on the inquiry findings, released Thursday, said that if Wright had been held on a secure unit, or on a unit with a functioning locked door, "his unfortunate death would not have occurred."
After Wright first wandered away, on Aug. 8, 2015, a physician issued an order saying that a nursing assistant had to constantly stay with the patient.
But there was a "significant disconnect" among staff in the understanding of what the order meant, provincial court Judge D'Arcy DePoe wrote in the fatality report.
Three days later, however, Wright "eloped" from the hospital again and was found downtown by police officers. He was taken back to the unit.
The supervision order on his chart was later renewed, but he tried to walk off the unit again on Aug. 13. Security was called and he was given medication to calm him down.
On Aug. 20, the day before he died, Wright left again and was found one floor below the unit.
'Major recommendation'
A registered nurse who was working on the evening of Aug. 21 testified that staff expected an extra nursing assistant to be on duty be to supervise Wright. But that night the unit did not get an additional nursing assistant, so there was only one on duty.
Decisions about supervision orders should be made in consultation with a patient's doctor, and should not be changed or discontinued without similar consultation, DePoe wrote in the fatality report.
"Rules to this effect ought to be implemented," the judge wrote. "This is the major recommendation I make arising out of this inquiry."
In Wright's case, a change was made to the supervision order on Aug. 15 that added the letters PRN — a medical term meaning "as needed" — without the consent or knowledge of his physician, the report said.
PRN was "far too vague a term to deal with the complex issues facing Mr. Wright," DePoe wrote.
The fatality inquiry was told that on the night Wright left the hospital, it appeared he walked through a rear fire door that was equipped with an alarm, but the alarm did not function. The report said the alarm was repaired the next day.
Changes have been made
The hospital has made numerous changes since August 2015, DePoe noted in the report.
The unit where Wright was a patient is now a secure locked unit and WanderGuard technology, which includes ankle monitoring bracelets, is now being used. Staff communication is now more structured and better documented.
"It is highly unlikely that such an incident could happen again on this unit," DePoe wrote.
The fatality inquiry was told Wright was on the unit temporarily. His name had been placed on a wait list for a bed in a secure unit. The hearing was told patients can wait months for placement but the median wait at the time was 48 days.
"Every acute-care hospital in this province should have a secure unit in order to transition patients," the judge wrote, though he noted it was "beyond the scope" of the inquiry to provide meaningful input on that subject.
"Once a patient has been assessed as requiring a secure unit, if at all possible simple common sense would dictate he should get it," DePoe wrote.
