WARNING: This story discusses suicide and suicidal ideation.
An Alberta judge has issued recommendations to safeguard patients who may be struggling with thoughts of suicide after examining the death of a 25-year-old woman at an Edmonton psychiatric hospital.
The recommendations come more than two years after a fatality inquiry was held into the death of Kaitlind Credgeur, who took her own life in 2018 at Alberta Hospital Edmonton (AHE).
Fatality inquiries are held to help clarify the circumstances of a death and can lead to recommendations for preventing similar deaths but they are not meant to determine legal responsibility.
Two of Credgeur’s family members told CBC News it was difficult listening to her death being discussed in detail during the inquiry but they believe the judge’s recommendations, if implemented, will help prevent future tragedies.
“It doesn’t bring closure but it brings some comfort that maybe someone else could be saved,” said Tina Credgeur, Kaitlind’s mother.
Three nurses, a psychiatrist and an AHS executive director for addiction and mental health testified at the two-day fatality inquiry, held in July 2021.
According to the inquiry report, which was recently published, Credgeur had been transferred to AHE from the Royal Alexandra Hospital on June 21, 2018, after an intentional drug overdose. When she was admitted to the psychiatric hospital, she had some personal belongings in a plastic bag.
The psychiatrist who assessed Credgeur shortly after she arrived at AHE testified that she expressed a willingness to remain in the hospital and to accept help.
He determined she should be observed every 15 minutes by a nurse or psychiatric aide.
One of the nurses who had been working on Credgeur’s unit testified that Credgeur was very pleasant when they spoke. When questioned about her suicidal thoughts, she said they were there but she had no plans or means to act on them.
Another nurse testified that he saw Credgeur sleeping at 7 a.m. the next morning.
At 8:20 a.m., Credgeur’s roommate banged on the nurses’ station door and told them there was a plastic bag over the 25-year-old’s head.
The report says Credgeur died that morning. The medical cause of her death was determined to be plastic bag asphyxia.
The psychiatrist testified that he estimated Credgeur had been dead for between one and four hours when she was discovered.
Gaps in notes
The fatality report says there were two gaps in the observation notes — one at 11:50 p.m. and another at 6:45 a.m.
The AHS executive director of addiction and mental health testified that gaps in notes were not uncommon. He said nurses making night observations must hear and see at least three respirations and they balance the need for safety with the patient’s need for sleep by making observations in the least intrusive way.
He testified that it is impossible to have an in-patient unit free of all risks and that, in his opinion, a plastic bag would not be withheld as it is no more dangerous than a pair of socks or a pillowcase.
Credgeur’s mother, who said she had stepped out of the courtroom when that comment was made in person, said she was disappointed to read that remark in the report.
Carl Erich-Nilsson, Kaitlind Credgeur’s common-law partner, said he believes staff did the best they could with the resources they had but he still thinks errors were made.
Nilsson said he had given Credgeur a mesh bag, since he knew her struggles and wanted to do everything possible to prevent another suicide attempt.
He said he was preparing to visit her in the hospital that morning and was feeling optimistic because he felt she was in a safe place.
“As we were getting ready to go, I got the phone call explaining that she was dead and my entire world just fell apart,” he said.
Credgeur and Nilsson met when they were students at MacEwan University and they had two children together.
Nilsson said their four years together were magical and they were planning to get married.
Credgeur’s mother, who lives in Wetaskiwin, described her daughter as beautiful, playful and full of love.
In her recommendations to prevent similar deaths, Carrie Sharpe with the Alberta Court of Justice said plastic bags should immediately and permanently be removed from new AHE patients.
She wrote that more staff should be required on the units, specifically at night, that nurses and psychiatric aides should have ongoing training as to how to conduct observations, that the observations should occur as directed and that newly admitted patients should be placed in single rooms, close to the nurses’ station.
The judge also recommended AHS regularly review technology that could help with completing observations.
Nilsson said he likes the recommendations, especially the one calling for more staff at the hospital.
“These recommendations will help others be safe, especially when they are seeking help,” he said.
Added Tina Credgeur: “I’m just really hoping they take it seriously and follow through.”
AHS improving protocols
AHS and the hospital have taken steps to improve protocols and address the recommendations, said AHS spokesperson Kristi Bland in an emailed statement.
“This was a tragedy, and our thoughts and sympathies remain with the family and friends of Kaitlind Credgeur,” Bland added.
Steps that have been taken include:
- A strategy to educate staff on procedures when searching patients, and the practice of removing items that could be used for self-harm
- Using Connect Care to enter real-time observations about patients directly into their health records
- Evaluating tools and processes for patient unit orientation and the subsequent implementation of a standard process for educating patients on night observation rounds.
- Admitting patients at night, when possible, into rooms that allow for easier observation by staff
If you or someone you know is struggling, here’s where to get help:
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