Jury at N.B. inquest makes recommendations to improve mental health services

The jury at a coroner’s inquest into the death of a New Brunswick woman has made five recommendations to improve mental health services.

The inquest for Kaytlyn Hemsworth began Monday and wrapped up Wednesday. The 19-year-old died in the psychiatric facility of the Dr. Georges-L.-Dumont University Hospital Centre in Moncton, N.B., on April 11, 2023.

Coroners and juries can classify a death as homicide, suicide, accident, natural causes or manner undetermined. The province said the inquest found Hemsworth’s death was the result of suicide.

Over the course of three days, the five-member jury heard from nine witnesses. They made the following recommendations:

-Staff should be assigned solely to conduct required patient checks to eliminate lapses caused by multi-tasking or staff shortages and to reduce the burden on nursing staff, allowing them to focus on patient care.

-Continuous monitoring with wearable devices that track vital signs, such as heart rate, oxygen saturation and movement, should be introduced, ensuring early detection of physiological distress and allowing for timely intervention and harm prevention.

-The patient-to-nurse ratio should be reduced.

-Doors and windows should be kept clear of obstructions, and the possibility of removing curtains should be evaluated to improve visual access.

-The new guidelines and changes from this incident should be implemented across all psychiatric units in the province.

Additionally, deputy chief coroner Emily Caissie, who presided over the inquest, which was conducted in French, made two recommendations:

-Vitalité Health Network should equip all nursing stations on psychiatric units with a “J-knife” to facilitate rescue in the event of a hanging situation.

-Vitalité Health Network should put in place a policy to accompany its “documentation of surveillance” form to ensure proper implementation, compliance and quality assurance in its use.

The province said the chief coroner will forward these recommendations to the “appropriate agencies” for consideration and response.

An inquest is a formal court proceeding with the purpose of making recommendations to prevent deaths under similar circumstances in the future. It does not make any finding of legal responsibility, nor does it assign blame.

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