MOOSOMIN — A six-person jury has filed its recommendations following the public inquest into the 2022 death of Karen Joy Ireland in Moosomin.
The inquiry was held from March 30-April 2 at the Canalta Hotel in Moosomin. According to a Government of Saskatchewan news release, Ireland was taken to the Moosomin Southeast Integrated Care Centre by the RCMP under the Mental Health Services Act on Nov. 22, 2022.
The news release adds she was admitted, placed in a secure room and allowed to go outside unsupervised. She was last seen by hospital staff while sitting in the building's front foyer at approximately 7 a.m. the following day.
A short time later, staff noticed she was not in her room or outside, and a missing person's report was issued. At approximately 2:30 p.m. on Nov. 23, 2022, she was found dead outside, about 550 meters from the care centre. She was 50 at the time of her death.
The inquest report said Ireland’s death was accidental from hypothermia due to environmental exposure.
According to a document posted on the Government of Saskatchewan's website, the jury made recommendations to both the Saskatchewan Health Authority (SHA) and the RCMP.
For the SHA, the jury recommends:
*Exterior cameras at all entrances to the hospital, and covering all main access roads and parking lots, within reason;
*Twenty-four-hour security personnel to monitor screens, with daily checks for camera date and time accuracy;
*Implement annual mandatory staff reviews and sign-off sheets for new and existing procedures for emergency codes. The full staff body should be included in reviews; and
*If possible, provide at least one registered psychiatric nurse within an area in rural regions, with the ability to travel between hospitals.
As for the RCMP, the jury recommended:
*All personnel should have body cameras and all police vehicles should have dash cameras and GPS recordings of vehicle travel, if not already in place;
*All personnel should take very descriptive notes of all instances while on duty, to ensure accuracy of report paperwork;
*Implement mandatory annual intensive training for handling mental health cases, and supply a manual for all personnel to have on hand while on duty;
*Implement a detailed transfer form for detainees under the Mental Health Act when transferring from RCMP custody to hospital care, including reason for transfer and description of behaviour;
*Implement an inter-provincial transfer program for RCMP members to ensure a full understanding of new jurisdiction laws and bylaws;
*Implement a search and rescue policy, ensuring all police searches include both foot and vehicle searches of the immediate area, and promptly contacting additional resources, such as fire departments, other detachments and/or other relevant services;
*All phone calls within the detachment should be recorded to have on file to ensure accuracy of reports;
*File jot notes from detachment service area calls for a minimum time period to ensure record accuracy.
The Saskatchewan Coroners Service is responsible for the investigation of all sudden, unexpected deaths. A news release states the purpose of an inquest is to establish who died, when and where that death occurred, and the medical cause and manner of death. The coroner's jury might make recommendations to prevent similar deaths.
