Shower room where man died at mental health centre hasn't changed, inquest finds

The inquest into the death of a 22-year-old man in thePsychHealthunit of the Health Sciences Centre in 2013 has found that the room where he diedhasn't been changed to prevent other suicides.

MichaelWinsorwas an involuntary patient at the psych centre when he used a wet towel as a ligature, suspending himself from a towel bar in a shower room.

Winsor, an apprentice electrician, had a previous history with psychosis, suicide attempts and paranoia and had beenhospitalizedin Saskatchewan and Ontario.

• Mental health centre struggles to divert patients from ERs
• Discharged: Mental health patients raise alarms about care in Winnipeg

Provincial court Judge Rocky Pollack, who was in charge of reviewing the evidence, said that while actions by police and HSC staff werewell documented, he is concerned that the shower room has not changed sinceWinsor's death.

In Sept. 2013,Winsorarrived at the Winnipeg Bus Depot and called 911, making statements that demonstrated paranoia, the inquest report, released on Friday, said.

Two officers were called and he was brought to HSC where he was left in a private waiting room, which was "makeshift" because of ongoing renovations, the inquest said.

Winsorwas alone in the room but he was checked on by a physician and there was a window so he could be watched. But a few hours later, he was found trying to choke himself with the drawstring of hishoodie.

There were some marks on his neck, butWinsorsurvived the suicide attempt.

The following day, after spending time in the emergency room because of a lack of beds,Winsorwas taken into the psychiatric unit. After attacking another patient he was put in seclusion until he calmed down.

He was able to come out of seclusion the next day and was being checked on regularly. But at some point he made his way into a shower room where he used a wet towel and a towel bar, 81 centimetresabove the floor, to strangle himself.

Pollack said there is no evidence how or whenWinsorwas able to enter the shower room, which is locked on the outside when it is closed.

"A completed suicide like this has never taken place at HSC. Some witnesses did not think that it was possible for a patient to strangle himself using a normal towel bar mounted so low that only Mr.Winsor's torso was suspended," Pollack wrote in the inquest report.

"There are solutions to address this as well as other potential opportunities for self-harm."

• Mental-health services haven't matched demand, Manitoba minister says
• Self-harm behind 1 in 4 youth injury hospitalizations

Recommendations

Pollack wrote that since the death, theWinnipeg Regional Health Authority has created a working group on mental health bathroom safetybut wrote "regardless of the progress made by the working group, the shower room in which Mr.Winsorwas able to complete his suicide is still in the same state as he found it."

Pollack recommended that all Manitoba health authorities carry out the necessary renovations to remove ligature points and other protrusions that enable self-harm in facilities where mental health patients require privacy.

• Manitoba looks at cutting the number of mandatory inquests into deaths
• Mental health crisis centre to open in Winnipeg

The inquest report also recommended examining the Mental Health Act and the Police Services Act to allow police officers who have brought an involuntary mental health patient to a health care facility to transfer custody to a peace officer at the facility. He pointed to the amount of resources used by keeping officers on the scene for a long period of time whileWinsorwas being admitted.

"From 2011 to 2015 police responded to 18,202 suicide threat calls and 2,166 calls concerning a mental health issue. The average time spent on a suicide threat was over three and one half hours and the other mental health calls averaged over seven hours. During the same period, an average commercial robbery call only took five hours," Pollack wrote in the report.

The final recommendation was that when there is a death resulting in an inquest, all Manitoba health authorities involved ensure their staff are "aware that an inquest will be held at some time in the future and that it is desirable for them to make and to keep an account of their connection with the death to enable them to provide testimony."