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.
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.
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Sherwood Park is a large hamlet in Alberta, Canada within Strathcona County that is recognized as an urban service area. It is located adjacent to the City of Edmonton’s eastern boundary, generally south of Highway 16 (Yellowhead Trail), west of Highway 21 and north of Highway 630 (Wye Road). Other portions of Sherwood Park extend beyond Yellowhead Trail and Wye Road, while Anthony Henday Drive (Highway 216) separates Refinery Row to the west from the balance of the hamlet to the east.
Sherwood Park was established in 1955 on farmland of the Smeltzer family, east of Edmonton. With a population of 70,618 in 2016, Sherwood Park has enough people to be Alberta’s seventh largest city, but technically retains the status of a hamlet. The Government of Alberta recognizes the Sherwood Park Urban Service Area as equivalent to a city.
Sherwood Park, originally named Campbelltown, was founded by John Hook Campbell and John Mitchell in 1953 when the Municipal District of Strathcona No. 83 approved their proposed development of a bedroom community east of Edmonton. The first homes within the community were marketed to the public in 1955. Canada Post intervened on the name of Campbelltown due to the existence of several other communities in Canada within the same name, so the community’s name was changed to Sherwood Park in 1956.
The Sherwood Park Urban Service Area is located in the Edmonton Capital Region along the western edge of central Strathcona County adjacent to the City of Edmonton. The majority of the community is bound by Highway 16 (Yellowhead Highway) to the north, Highway 21 to the east, Highway 630 (Wye Road) to the south, and Anthony Henday Drive (Highway 216) to the west. The Refinery Row portion of Sherwood Park is located across Anthony Henday Drive to the west, between Sherwood Park Freeway and Highway 16. Numerous developments fronting the south side of Wye Road, including Wye Gardens, Wye Crossing, Salisbury Village and the Estates of Sherwood Park, are also within the community. Lands north of Highway 16 and south of Township Road 534/Oldman Creek between Range Road 232 (Sherwood Drive) to the west and Highway 21 to the east are also within the Sherwood Park urban service area.