April 11, 2013
The Province’s Chief Medical Examiner, Dr. A. Thambirajah Balachandra, has called an inquest into the death of JAMES LIVINGSTON, age 68 years, of Winnipeg, Manitoba, who died on April 19, 2012 at the Health Sciences Centre (HSC) where he was being held under The Mental Health Act.
Mr. Livingston was initially brought to the Emergency Department at the HSC by ambulance on March 21, 2012 after he called “911” and told the dispatcher that he was going to have a cardiac arrest. However when the Winnipeg Fire Paramedic Service arrived, he denied having chest pain, shortness of breath, or dizziness. On March 22, 2012, following further assessment in Emergency, Mr. Livingston was admitted with a diagnosis of organic brain syndrome. Over the next few days, his behavior became more agitated and manic, and, he began refusing medication and treatment. On March 27, 2012, Mr. Livingston was seen by a psychiatrist; and, the following day, his status was changed to involuntary admission under The Mental Health Act (Form 6).
During his course in hospital, Mr. Livingston was treated for multiple medical problems and was also diagnosed with dementia. On April 18, 2012, his status as an involuntary patient was renewed under The Mental Health Act (Form 7). As there were concerns regarding Mr. Livingston’s ability to manage his own affairs, his physician applied to the Chief Provincial Psychiatrist, Manitoba Health, for an Order of Committeeship, which would allow The Public Trustee of Manitoba to assist Mr. Livingston. The Order was to be issued on April 23, 2012.
On April 15, 2012 Mr. Livingston was observed on a video monitor placing a belt around his neck and then entering the bathroom in his room. The belt, as well as a chair, was removed by medical staff. However, on April 19, 2012, when a nurse attempted to enter his room she pushed the door against resistance and found Mr. Livingston on the floor with a belt around his neck. A “code blue” was called. However, resuscitation was unsuccessful and Mr. Livingston was declared dead at 19:42 hours on April 19, 2012.
The Office of the Chief Medical Examiner and the Winnipeg Police Service were notified of the death on April 20, 2012. A medicolegal autopsy was authorized by the medical examiner. The cause of death was confirmed as hanging. The manner of death was suicide.
The inquest was called in accordance with The Fatality Inquiries Act for the following reasons:
1) to fulfil the requirement for an inquest as defined in section 19(3)(a) of The Fatality Inquiries Act;
__________________________
Inquest mandatory
19(3) Where, as a result of an investigation, there are reasonable grounds to believe
3) to determine what, if anything, can be done to prevent similar deaths from occurring in the future.
Information as to the date, time, and location of the inquest will be determined by the Chief Judge of the Provincial Court of Manitoba and released at a later date.
INQUEST CALLED INTO THE DEATH OF JAMES LIVINGSTON
Mr. Livingston was initially brought to the Emergency Department at the HSC by ambulance on March 21, 2012 after he called “911” and told the dispatcher that he was going to have a cardiac arrest. However when the Winnipeg Fire Paramedic Service arrived, he denied having chest pain, shortness of breath, or dizziness. On March 22, 2012, following further assessment in Emergency, Mr. Livingston was admitted with a diagnosis of organic brain syndrome. Over the next few days, his behavior became more agitated and manic, and, he began refusing medication and treatment. On March 27, 2012, Mr. Livingston was seen by a psychiatrist; and, the following day, his status was changed to involuntary admission under The Mental Health Act (Form 6).
During his course in hospital, Mr. Livingston was treated for multiple medical problems and was also diagnosed with dementia. On April 18, 2012, his status as an involuntary patient was renewed under The Mental Health Act (Form 7). As there were concerns regarding Mr. Livingston’s ability to manage his own affairs, his physician applied to the Chief Provincial Psychiatrist, Manitoba Health, for an Order of Committeeship, which would allow The Public Trustee of Manitoba to assist Mr. Livingston. The Order was to be issued on April 23, 2012.
On April 15, 2012 Mr. Livingston was observed on a video monitor placing a belt around his neck and then entering the bathroom in his room. The belt, as well as a chair, was removed by medical staff. However, on April 19, 2012, when a nurse attempted to enter his room she pushed the door against resistance and found Mr. Livingston on the floor with a belt around his neck. A “code blue” was called. However, resuscitation was unsuccessful and Mr. Livingston was declared dead at 19:42 hours on April 19, 2012.
The Office of the Chief Medical Examiner and the Winnipeg Police Service were notified of the death on April 20, 2012. A medicolegal autopsy was authorized by the medical examiner. The cause of death was confirmed as hanging. The manner of death was suicide.
The inquest was called in accordance with The Fatality Inquiries Act for the following reasons:
1) to fulfil the requirement for an inquest as defined in section 19(3)(a) of The Fatality Inquiries Act;
__________________________
Inquest mandatory
19(3) Where, as a result of an investigation, there are reasonable grounds to believe
(a) that a person while a resident in a correctional institution, jail or prison or while an involuntary resident in a psychiatric facility as defined in The Mental Health Act, or while a resident in a developmental centre as defined in The Vulnerable Persons Living with a Mental Disability Act, died as a result of a violent act, undue means or negligence or in an unexpected or unexplained manner or suddenly of unknown cause; or (b) that a person died as a result of an act or omission of a peace officer in the course of duty; the chief medical examiner shall direct a provincial judge to hold an inquest with respect to the death.
2) to determine the circumstances relating to Mr. Livingston’s death; and,3) to determine what, if anything, can be done to prevent similar deaths from occurring in the future.
Information as to the date, time, and location of the inquest will be determined by the Chief Judge of the Provincial Court of Manitoba and released at a later date.
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