Eastern Health releases investigation called after Waterford patient suicide

Eastern Health released an external review Thursday that highlights changes that need to be made to a unit of the Waterford Hospital where a suicidal patient took his own life in March.  

• Suicidal man not checked, inaccurate records at Waterford hospital: report
• Grieving mother says she warned Waterford staff her son was suicidal
• Eastern Health fires 3 workers, starts external review after Waterford Hospital death

The Centre for Addiction and Mental Health, based out of Toronto, was brought in to review the forensic unit at the St. John's psychiatric hospital after Kerry Murray, 39, was found hanged to death at the St. John's psychiatric hospital. 

Three employees had already been fired over the incident. 

On Thursday, Eastern Health released the external review. It includes five recommendations that, according to president and CEO David Diamond, involve policies that were not followed properly, opposed to new policies that need to be created.

The five recommendations that the external committee made were:

• "Resume the operation of the forensic steering committee
• "Develop a culture that considers the assessment and management of risk while safeguarding the recovery and dignity of forensic clients
• "Improve team communication through structured processes
• "Intentionally seek out opportunities to facilitate a shared understanding of inter-disciplinary roles and responsibilities
• "Improve the physical environment of the inpatient unit and surrounding area."

At the press event on Thursday, Diamond said the recommendations are not intended to be a major overhaul of the policies that are in place at the Waterford, but are meant to be a way to strengthen current policies to make sure they are followed more closely.

"If you have policies and they're not followed, that leads to the kind of outcome that we had," he said.

"The crux of the issue in the spring was really that the policies we had were not followed, what this does however is give us a blueprint to improve."

In March, Diamond said the patient did not receive the surveillance that was ordered.

He said at the time that he thought the "system failed the client."

Eastern Health did not confirm the cause of death, but Bob Buckingham, who represented Murray, said it was in fact a suicide.

An internal report showed that Murray had not been checked on for over an hour, despite being listed on close surveillance that called for checks every 15 minutes.

Joanne Calhoun, Murray's mother, earlier told CBC News that the health system failed her son and that he didn't receive the care he needed.

Following her son's death, Calhoun said this spring that the incident could have been avoided and that her son would still be alive if someone listened to the warnings.