Serena Perry inquest: Psychiatric unit security increased after death

Several changes have been made to control the movements of patients at the Saint John Regional Hospital's psychiatric unit since the 2012 death of Serena Perry, a coroner's inquest heard on Thursday.

For example, the doors in and out of the unit are now locked, there's a buzzer system, and there are cameras everywhere, psychiatric nurse Claudette Lammers testified.

"That's a really good thing," she said.

There are also hourly checks — "people going around constantly," said Lammers.

Patients can still sign out to go out for a cigarette, but they're checked every 30 minutes, she said.

In the past, the sign-in/sign-out sheets were not always adhered to by patients, said Lammers. "It was always going awry."

Earlier in the inquest, the jury heard that Perry, an involuntary patient who suffered from paranoid schizophrenia, had left the psychiatric unit twice with a fellow male patient on Feb. 14, 2012.

But on the second occasion, they did not sign out and the male patient returned alone, the Saint John courtroom heard.

The body of Perry, 22, was later found in the amphitheatre, which is located in another part of the hospital. She was lying on the floor, clothed, with a blue garment wrapped loosely around her neck and all of the lights out.

The inquest is being held to determine the facts surrounding Perry's death. The five-member jury may also make recommendations aimed at preventing similar deaths.

Was sweet, not suicidal

"I think it's important for everyone to understand that this young lady was not suicidal," family lawyer John Gillis told reporters outside the courthouse.

In fact, she had never even mentioned having such thoughts, he said.

"In the litigation the family has commenced, they've alleged that … she was assaulted and killed. And so, at the end of the day that's what we believe happened."

Saint John police had treated Perry's death as a homicide. Although police had a suspect — a male patient also under the care of the psychiatric unit — a forensic examination could not determine the cause of her death, and no charges were ever laid.

Lammers told the jury about an incident that occurred the day before Perry's death. Perry punched a male nurse after he told her it was inappropriate to brush her body against a male fellow patient, she said.

Perry was put in a seclusion room following the attack, Lammers said.

Overall, however, Perry was "a sweetheart. Just a sweet kid," who was well-liked by staff, she said.

Marilyn Isaac, who was nurse-manager in the psychiatric unit in February 2012, but has since retired, agreed.

She said Perry was also vulnerable; a person who took everyone at face value.

Perry wanted to have a normal life — a husband, a baby and a house, said Isaac.

It was sad, she said, because Perry could never have that, due to her illness.

Scene not preserved for police

The inquest also heard from emergency room nurse Sandra McCavour, who was part of the code blue team that rushed to the amphitheatre to try to resuscitate Perry.

She testified no effort was made to preserve the scene for investigators. "We didn't know what happened, we were just there to resuscitate," she said.

Perry's body was put on a gurney and wheeled to the emergency department with the blue garment sitting on top, the courtroom heard.

McCavour said she gathered up packaging and other medical waste lying around the scene and took it back to the emergency department as well.

The inquest continues on Friday morning. Three weeks have been set aside.