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Coroner’s Inquest into the Deaths of Three People at Abbotsford Regional Hospital

Coroner’s Inquest into the Deaths of Three People at Abbotsford Regional Hospital

By Andrew Kerr, CD, RSW

A coroner’s inquest was held in September 2016 related to the suicide deaths of three people who were patients at Abbotsford Regional Hospital shortly before their deaths.  At the completion of the proceedings, the verdict at inquest made recommendations to many different agencies, including the BC College of Social Workers.  The jury findings of this inquest can be found at

The recommendations for the BCCSW were:
#11 Consider enhancing the standards of documentation to require specific evidence (including chronology) of the care provider’s assessment of suicide risk and development of a collaborative safety plan.

#12 Consider mandating annual suicide risk assessment and management re-training for health care and behavioral health professionals in order to maintain registration.

#13 Consider creating an education program designed to educate all health care staff on the practical application of all the privacy laws regarding the sharing of health care information and mandate annual training and retraining as part of maintaining professional registration.

In responding to the jury recommendations, the College and Board considered how these recommendations intersect with the current Standards of Practice, the College mandate of public protection, and the annual Continuing Professional Development (CPD) requirements of registrants.  While the recommendations seem to be targeted towards clinicians who work in acute or community mental health and/or substance use services in health care settings, the BCCSW Standards of Practice have to equitably apply to Registrants working in all different areas of practice.

Our existing Standards of Practice on documentation contain specific requirements about client records (see Principle 4: The Social Work Record).  BCCSW considers that the existing practice standards sufficiently address the concerns identified in the verdict.  The practice standards and accompanying practice guidelines are currently undergoing revision, and this jury recommendation will be reviewed by the Quality Assurance Committee and the Board as part of the revision process.

In considering the recommendation about annual suicide risk assessment and management re-training, Registrants who engage in suicide risk assessment in their practice are encouraged to consider how the annual self-directed CPD program could be used to augment or reinforce clinical skills related to suicide assessment and suicide risk management.  The jury verdict noted that some of the professionals who gave evidence reported they had not engaged in any formal re-training on suicide risk management since graduating from their respective programs. Registrants are reminded that the Standards of Practice require Registrants to remain current with emerging social work knowledge, skills and abilities relevant to their area of practice.

The third recommendation to the BCCSW recommends the creation of an education program about the application of provincial privacy laws that would have to be completed annually in order to maintain registration.  Sharing of client information with family members was one of the central issues that was examined in depth at the inquest and a discrepancy was noted where involved staff members cited that privacy legislation prohibited the sharing of client information with family members, yet no specific training was provided to staff about the application of privacy laws.  While it is outside the public protection mandate of the BCCSW to implement such an education program, it is acknowledged that this is an issue that is applicable to all Registrants, and the BCCSW Quality Assurance Committee will investigate how this recommendation could be integrated within the BCCSW’s policies and annual CPD requirements.  BCCSW will also forward this recommendation to the BC Association of Social Workers for possible development of training opportunities.

The purpose of a coroner’s inquest is to examine the issues surrounding a death and then provide recommendations to the service providers and relevant agencies about how future deaths could be avoided.  Suicide deaths are especially tragic for the families and professionals involved, and almost always allow for reflections on practice and reviews of training, policies, and processes to see if there are ways to improve care for people who are at risk for suicide.

If suicide risk assessment and suicide risk management are part of your clinical practice, please take some time to reflect how the recommendations made to the BCCSW (and other recommendations in the verdict, if applicable) might apply to your own practice.  If you have concerns or ideas to improve services to clients and need support, consult with your clinical supervisors, other leaders in your organizations or the staff at the BCCSW.

On a personal note, I worked with two of the people who tragically took their lives and was asked to give evidence at this coroner’s inquest.  It is a great privilege for me to honour the memory of these three people and the loss that their families feel in providing this information, and the possible improvements we can reflect on in our respective practices.