Inquest urges independent reviews of unexpected hospital deaths

When Paul Spencer died following an altercation with security officers at Victoria's Royal Jubilee Hospital in 2019, his family says they were left searching for answers amid inconsistent reports.

One week out from the fifth anniversary of his death, a coroner's inquest has shed new light on the circumstances surrounding Spencer's death — and posted recommendations to the B.C. minister of health and to Island Health to improve accountability for investigations into similar deaths.

As a verdict of accidental death was read by the jury's foreman, Spencer's mother, Angela Spencer, sat in the front row of the gallery. Richard Neary, her lawyer, sat beside her with an arm around her shoulders. 

"I thank the jury for giving such deliberations and their nine recommendations, one that has struck my heart: to have independent inquiries into the death of anybody in the hospital," she said, speaking outside the courthouse after the verdict.

"The verdict is an accidental death, but my interpretation of an accident is … that people did not know how to conduct themselves to help my son."

The inquest jury's nine recommendations to Island Health and the minister of health call for measures to improve accountability and the investigatory process around unexpected deaths in health-care settings.  

Spencer, 43, who had schizophrenia, had been admitted to the hospital during a psychotic episode where he was hearing voices and thought someone was going to kill him. 

Five hours later, he was found unresponsive in a seclusion room in the psychiatric emergency unit — shortly after an interaction with three hospital security officers. He died in the early morning of September 27, 2019.

Testimony cast light on circumstances of Spencer's death

On the first day of testimony, Paul Spencer's mother, Angela, told the inquest that she had been in the dark during the five years since her son's death, unsure whether to trust reports from hospital staff she found inconsistent. It was not until weeks before the inquest began that she saw Spencer's autopsy and CCTV video from the minutes before he died.

Over the course of eight days, the jury heard testimony from 22 witnesses — including Spencer's mother, doctors and nurses who treated him, the four security officers who were working at the hospital that day, and other Island Health staff. 

Angela described her son as a friendly man who was kind to others, such as donating his food to people experiencing homelessness. She said he had an intellectual disability as well as schizophrenia. 

In her testimony, she described that the day before he died, Spencer started experiencing psychosis and left the family home because he believed people were trying to kill him. Worried for his safety, she called the police.

Saanich Police Const. Shauntelle Nichols took Spencer to the hospital, testifying that he was co-operative and came willingly.

After he was admitted into the psychiatric unit, a nurse reported he had become agitated. 

Giuseppe Moonie-Tkachuk, the security officer in the unit, asked him to go into a seclusion unit, but Spencer ignored him. Moonie-Tkachuk said he grabbed Spencer, and the two struggled. 

Two other officers arrived and joined in — kneeing Spencer once and punching him three times in what they say was an effort to get him lying face down and handcuffed. 

They then walked him to the seclusion room. 

CCTV footage played during the inquest showed the struggle but not the three minutes during which security was with Spencer in the seclusion room, or the seven minutes Spencer spent there alone afterwards. 

Nurses later found him unresponsive, and efforts to revive him failed. 

The autopsy report

An autopsy report showed Spencer was bruised, had fractured ribs and sternum, and a laceration of his liver. 

Dr. Elizabeth McKinnon, the forensic pathologist who conducted the autopsy, testified those injuries are consistent with someone who has received CPR.

She also added that sedating medications may have played a role — though the report did not specify whether it was the two sedatives administered at the hospital right around the time of his death or the antipsychotic drug Spencer took for schizophrenia, which also has a sedating effect. 

During the inquest, security officers agreed there were discrepancies between what they'd written in different officers' incident reports and what could be seen in CCTV footage, including the number of times Spencer was hit and how he was positioned in the seclusion room.

They said no one with Island Health contacted them to follow up on the inconsistencies or to further investigate the death. 

 The jury also heard that Island Health security officers get more training now than they did in 2019. 

At that time, they were mostly trained on the job — but now, they do three weeks of classroom work in addition to both on-the-job and online training. 

Kristopher Marquardt, an employee of Island Health's Protection Services department,  testified the topics range from de-escalation techniques to the use of force, as well as learning about mental health and trauma-informed practices. 

Jury rules death accidental

The jury ruled Spencer's death accidental due to a combination of physical restraint, cardiovascular disease, psychosis, the administration of sedatives, and the long-term use of an anti-psychotic medication.

The recommendations to Island Health include installing CCTV cameras in seclusion rooms such as the one Spencer died in, reviewing evidence in investigations for consistency and reliability, and reviewing policy to consider closely monitoring patients involved in altercations for 30 minutes afterwards.

To the minister of health, the jury recommended that unexpected deaths following "critical incidents" should be reviewed independently and that the Evidence Act should be reviewed to ensure public accountability in these investigations.

The jury's recommendations in a coroner's inquest are not binding.

In response to the verdict, Island Health President and CEO Kathy MacNeil expressed condolences to the Spencer family and said it would review the recommendations before issuing a public response and taking "appropriate action."

"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," wrote MacNeil. 

"This work will build upon work undertaken in recent years to improve training for Protection Services Officers, expand and improve patient safety investigation processes, and enhance the quality of Psychiatric Emergency Services at Island Health." 

In his statement to reporters, Neary, the family lawyer, thanked the jury and said that without the inquest into Spencer's death, "the true facts would still be completely hidden." 

"Now we hope and pray that there is actually some action in response to those recommendations," he wrote.