Inquiry finds death at the Royal Jubilee accidental, calls for increased monitoring of psychiatric patients

After nearly two weeks of hearing witness testimonies and reviewing video footage of the events leading to Paul Spencer’s death in the hospital’s psychiatric unit, the jury made recommendations to Island Health and the Ministry of Health to improve care for people experiencing mental-health crises.

Spencer was involuntarily admitted to the Jubilee’s Psychiatric Emergency Services (PES) late at night under the Mental Health Act after he was picked up by Saanich police who said he was exhibiting erratic behaviour. Spencer was on medication for psychosis and had a history of schizophrenia, among other health issues. Spencer’s doctor described him as a generally stable, “nice guy” who had a couple of psychotic episodes a year.

According to video footage shown at the hearing, Spencer attempted to leave the unit upon his arrival and was apprehended by three security officers, who, following the procedure, uncuffed and wrapped him in a blanket to restrict his arms before placing him in a seclusion room where he could unwrap himself.

When a nurse entered the seclusion room to administer medication, Spencer’s breathing became shallow and stopped—eight minutes after the altercation with security, he was dead.

Last Fri., the jury found Spencer’s death had been accidental and had been caused by a combination of physical restraint, hypertensive cardiovascular disease, psychosis, and the long-term use of risperidone, an antipsychotic medication.

Along with their findings, it released the following recommendations for Island Health:

1. Increase representation of mental-health workers in the PES
2. Following a critical incident resulting in unexpected death, consider ways of improving collecting evidence and ensure all evidence is reviewed for reliability and consistency
3. Review policies and training regarding health risks to patients in mental-health distress after being in a physical altercation or under physical restraint
4. Patients should be monitored closely for 30 minutes after an altercation
5. Interview all persons involved in an incident resulting in an unexpected death
6. Record security footage in PES seclusion rooms
7. Record audio from all security cameras in the PES
8. Ensure individuals are not left unattended in a prone position following physical restraint

For the Ministry of Health:

1. Consider how to investigate critical incidents via an independent party
2. Consider reviewing Sect. 51 of the Evidence Act to ensure public accountability regarding investigations into critical incidents resulting in unexpected deaths

Island Health said in a statement that it would review each recommendation to understand what action needs to be taken before issuing a public response.

"As care providers, it is our obligation to learn from cases like this and take accountability to enhance the care experiences of our patients, clients, residents and their loved ones," Kathy MacNeil, Island Health CEO and president wrote.