How suicide inquest, required under P.E.I. law, fell through the cracks

By the time the inquest into the death of Catherine Shirley Gillis begins in the fall of 2017, it will have been more than seven years since she took her own life while a patient at Hillsborough Hospital, P.E.I.'s main psychiatric care facility.

Gillis died Feb. 14, 2010, at the age of 69.

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According to P.E.I.'s current chief coroner Dr. Des Colohan (who was not chief coroner back in 2010), Gillis was an involuntary inpatient at Hillsborough at the time of her death.

"An inquest into this case was required under the Coroners Act," said Colohan.

Under the Coroner's Act, the P.E.I. Department of Justice is required to hold an inquest into such cases, with one of the possible goals listed in the legislation being to "bring dangerous practices or conditions to light and facilitate the making of recommendations to avoid preventable deaths."

More than three years after Gillis died, another patient at Hillsborough Hospital, Sherry Ball, also took her own life.

The inquest into Ball's death took place in Feb. 2016, with the jury coming up with 14 recommendations to try to prevent similar deaths from occurring at the facility in the future.

Health PEI says it conducted an internal review following Gillis' death in 2010, but that review was never released to the public.

Inquest discussion never took place, says chief coroner

Colohan says he knew nothing of the 2010 death until contacted by CBC News in the spring of 2016. At that point he looked back at the case, concluding an inquest was still required to be held.

"To the best of my knowledge, the coroner who was investigating this case left Canada in 2010 and emigrated back to his native country before completing his report," Colohan said. "Consequently a recommendation to conduct an inquest was never discussed with the chief coroner."

"It wasn't because somebody was deliberately trying to avoid doing an inquest. It's just that the discussion did not occur, as far as I can tell, and because of that no inquest was ever held."

Patient under increased scrutiny for suicide risk

Colohan said Gillis, "was being monitored for potential suicide risk, as all patients are at Hillsborough Hospital, but was under high-level scrutiny for this. The question is, as it was in the Ball inquiry, are there ways that people can find to kill themselves despite the best of precautions put into place? That's always the challenge and the issue."

Colohan said he wasn't aware of any other similarities between the two suicide deaths, "but that's the purpose of an inquest is to look at that."

Sophia Ball, the daughter of Sherry Ball, raised questions this week, wondering if an inquest into Gillis' death had happened sooner, whether it may have led to changes which might have prevented her mother's suicide.

"That's perfectly understandable," said Colohan. "The purpose of a public inquest is that that information be made available so that everybody understands what has been considered."

Colohan said it's his understanding that the changes made by Health PEI following its review of Gillis' death were implemented before Ball's death, but neither he nor Health PEI have provided that timeline thus far, or a list of the changes made.

Seven years later, inquest could be more challenging

Colohan admitted it may be more challenging to delve into the circumstances surrounding Gillis' death more than seven years after it occurred — more difficult to track down staff involved in her care, and harder for them to recall all the details around her care.

But he said it's important the inquest take place to "maintain the integrity of the process … so those involved are assured that everything has been done fairly."

He also said the original mandate of a coroner's inquest still applies — to examine the circumstances around one death, in the hopes of preventing another.

"It maintains the accountability of the professionals working in the system to provide the very best care they can under what are usually difficult circumstances," he said. "And if challenges are identified by this process and changes can be made that decrease the risk that somebody else goes through this in the future, then we'll have done what we can do."

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