Lorraine Johnson, foreground, holds a photo of her son, Brian David Geisheimer, 30, as Deb Nolet, with a photo of her daughter, Sarah Louise Charles, talks to Kim Young outside the B.C. Coroner’s Service in Burnaby, B.C., on Wednesday.John Lehmann/The Globe and Mail
British Columbia's top health officials need to guide a shift toward a structured, measurable and deliberate approach to suicide prevention, a coroner's inquest has heard.
Suicide prevention expert Johnny Morris took the stand in Burnaby on Friday, the final day of a two-week inquest into the deaths of three people who died by suicide shortly after leaving Abbotsford Regional Hospital, where they were admitted separately for mental-health reasons.
Brian David Geisheimer, 30; Sebastien Pavit Abdi, 19; and Sarah Louise Charles, 41, died between December, 2014 and April, 2015. The BC Coroners Service grouped the deaths for their similarities; the inquest aimed to determine the facts of what happened and prevent similar deaths from occurring.
The five-person jury was expected to deliver recommendations late Friday.
Drawing on his 18 years of experience in the field, Mr. Morris spoke of the need to systematize risk assessment and suicide prevention within the context of health care.
"We've heard testimony from the doctors that there's an array of techniques and strategies that they use as clinicians to assess suicide," Mr. Morris told the inquest.
"Given that there is often a chance for idiosyncrasy, or for gaps in our system of care, I think the … way to think about suicide prevention is to think through a systematic lens: How can we place more checks and balances around suicide, in risk assessment and prevention, to reduce errors in health care, to reduce the likelihood that mistakes or made or that there is an error in judgment?"
A systematic approach could include the collaborative development of a safety plan between patient, family and physician, for example, and the screening for suicide risk at multiple points in care.
Mr. Morris called for leadership from the top, building a culture around ready access to training in suicide risk assessment and management.
"If I'm compelled to do something – there's a culture from the chief executive to do that, my employment depends on it – then I try to do that," he testified.
"When we're working within complicated systems of care and we see leadership – directors, chief executives, right up to ministers of health – taking this on as a priority, I think things start to filter down."
Mr. Morris also spoke of the need to balance patient privacy rights and safety, and the "privacy paralysis" that health-care providers can feel when adult patients do not want to share information with well-meaning family members.
"Because of sometimes a lack of understanding, or perhaps a lack of confidence or comfort with privacy legislation … nothing gets shared," he said.
"The wall goes up and it's game over. [But] there have been clear directives that privacy legislation absolutely allows for the transmission of information when there is risk of deaths, suicide."
Presiding coroner Donita Kuzma provided the jury with 23 suggested recommendations, which included annual training and retraining on health information privacy law, increasing resources for community mental-health teams and the development of a national strategy for suicide prevention.
In a Globe and Mail report on this subject last spring, B.C.'s Ministry of Health acknowledged that the province's health information privacy law, currently guided by nine separate pieces of legislation and many regulations, "can be confusing and difficult to navigate."
The ministry says it is developing a single policy aimed at streamlining how health information is managed, protected and stored.
Andrea Woo