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Recommended renovations to HSC PsychHealth unit never completed

The shower room where a 22-year-old psychiatric patient managed to hang himself at Health Sciences Centre almost four years ago hasn t been renovated to stop other potential suicides, an inquest report has concluded. Michael Winsor died on Sept. 10, 2013 at HSC s PsychHealth unit, according to the report by provincial court Judge Rocky Pollack. Pollack, who presided over a lengthy and long-delayed inquest into the death, made renovations to protect patients from themselves his number one recommendation.

“WRHA has a working group on mental health bathroom safety. Its May 20, 2015 report indicates that its purpose is to review ligature points in patient bathrooms and to provide an analysis and recommendations related to the priorities to be addressed.

“Regardless of the progress made by the working group, the shower room in which Winsor was able to complete his suicide is still in the same state as he found it,” Pollack wrote.

Pollack noted the apprentice electrician from Cambridge, Ont., was an involuntary patient, a man barely 5 6″ tall, who somehow made a lethal ligature out of a wet towel attached to a towel bar mounted barely three feet off the floor. Winsor called 911 for help when his bus stopped in Winnipeg; he was on his way home to Ontario from Lloydminster, Alta. He also had a long history of mental illness, including suicide attempts. In the days leading up to his death, he’d been admitted for suicide attempts in Lloydminster and North Battleford, Sask., in between using an open ticket to board buses and make it back home to Cambridge. His last stop was Winnipeg.

The report put the most scrutiny on Winsor’s 34-hour wait in HSC s ER with a peace officer — not a trained hospital security official — as a minder. There was no psychiatric bed open to admit the man and the judge described the 22-year-old’s growing paranoia in detail, using it to underpin the report’s strongest recommendation: to overhaul both the Mental Health Act and the Police Services Act. Pollack recommended Manitoba s lawmakers review both laws “and take all necessary steps, to introduce amendments if necessary, to permit a police officer who has brought an involuntary mental health patient to a health care facility to transfer custody of the patient to a peace officer employed by that health care facility.”

The ER was under construction in early September 2013, which added to Winsor’s torment, the report said.

“All day long, the noises of power tools, including jack hammers were heard in the ER. Patients like Winsor do not respond well to that sort of thing. At one point, he complained he felt the walls were going to cave in on him,” Pollack wrote.

“While Mr. Winsor was not subject to what has become known as hallway medicine, he was certainly unable to escape the cacophony.”

During that wait, Winsor tried to choke himself, tying the drawstring of his hoodie around his neck. Later, he tried to escape the ER, managing to get outside clad only in his underwear where a security guard brought him to the ground. By the time Winsor was admitted to the PsychHealth Unit, his paranoia prompted the psychiatrist who assessed him to change his admission from voluntary to involuntary, outside his control. Later, he attacked another patient. The morning afterward, Winsor was noticablely calmer but still under suicide watch. An overworked unit assistant pulling a double shift took a break, leaving the locked unit where Winsor had been placed. By the time Winsor s absence was noted, it was too late. He was found in the shower room partially suspended by the neck, the wet towel encircling his neck.

Despite a series of measures to save his life, Winsor died that night.

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