Sharon Lewis Fatality Report

Report to the Minister of Justice Fatality Inquiries Act
and Solicitor General

ALBERTA Public Fatality Inquiry
WHEREAS a Public Inquiry was held at the Law Courts
in the City of Edmonton , in the Province of Alberta,

(City, Town or Village) (Name of City, Town, Village)
on the 30th day of May , 2016 , through

Year
to the 10th day of June , 2016 , (inclusive)

Year
before Janet L. Dixon , a Provincial Court Judge,
into the death of Sharon Grace Lewis 35

(Name in Full) (Age)
of Edmonton, Alberta and the following findings were made:

(Residence)
Date and Time of Death: December 28, 2009 at 3:50pm
Place: Royal Alexandra Hospital, Edmonton, Alberta
Medical Cause of Death:

("cause of death" means the medical cause of death according to the International Statistical Classification of
Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose
and published by the World Health Organization The Fatality Inquires Act, Section 1(d)).
Acute ethanol and drug toxicity
Manner of Death:
(manner of death means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable
or undeterminable The Fatality Inquiries Act, Section 1(h)).
Unclassifiable
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Overview:
1. The purpose of a fatality inquiry is set out in section 53 of the Fatality Inquiries Act (Act).
A judge is appointed to conduct the inquiry in public and must make the following findings:
Identity of the deceased;
The date, time and place of death;
The circumstances under which the death occurred;
The cause of death; and
The manner of death.
2. The Act permits the judge conducting an inquiry to make recommendations as to the
prevention of similar deaths, subject to the following limitations:
No finding may be made regarding legal responsibility;
No conclusions in law may be reached; and
Any recommendations must be related to the death.
3. The design of the Act is to undertake the inquiry after all other processes arising from the
death, other than civil matters, are complete.
4. The Act provides standing to the next of kin and the personal representative of the
deceased to cross-examine witnesses and present arguments and submissions. Section
49(2)(d) of the Act permits other parties who claim to have a direct and substantial
interest in the subject matter of the inquiry to appear with leave of the judge. The parents
of Ms. Lewis and the Public Trustee, as personal representative of the estate of Ms.
Lewis, participated in the inquiry as a matter of right. In addition the following parties
were granted leave to participate, having established they had a direct and substantial
interest in the subject matter:
Alberta Health Services

Dr. Allen Shustack
Dr. Jonathan Davidow
Dr. Jennifer Pritchard
Dr. Naureen Kasamali
Dr Taiebeh Orujy Jukar
Inquiry Process:
5. The Fatality Review Board reviewed the Medical Examiners Case file in this matter and
recommended that a public fatality inquiry be held in order to determine if similar deaths
can be prevented.
6. This inquiry was delayed in its commencement and completion due to many factors,
including other investigations and reviews which flowed from the circumstances of the
death of Sharon Lewis.
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7. The Public Security Division of the Ministry of Justice and Solicitor General conducted a
review of the circumstances of the death of Ms. Lewis pursuant to Section 19(2) of the
Peace Officers Act . The recommendations resulting from that review were provided to
Alberta Health Services by letter dated January 27, 2011 and entered as an exhibit in this
Inquiry.
8. During the pre-inquiry conferences counsel for Alberta Health Services disclosed that a
Quality Assurance Committee at the Royal Alexandra Hospital undertook a review of the
death of Ms. Lewis. Counsel for Alberta Health Services explained the quality assurance
process conducts a full and frank investigation after critical incidents of this nature with
the objective of enhancing health care. Due to the provisions of the Alberta Evidence Act
every aspect of the proceedings before the Quality Assurance Committee was privileged
including who was called as a witness, the testimony of the witnesses, any documents
tendered to the Committee and any quality assurance record including the findings and
recommendations of the Quality Assurance Committee. The commencement date and
duration of this process was also privileged. The proceedings were concluded prior to the
commencement of this inquiry.
9. This inquiry was ultimately ordered in 2013 and the initial pre-inquiry conference was held
in September 2013. At that time the family of Ms. Lewis had not been provided notice of
the inquiry. Counsel for the Minister of Justice was directed to provide notice to the family
and matters were adjourned to ensure the family received notice and had an opportunity
to retain and instruct counsel. By September of 2014 all parties had been identified and
counsel were directed to set dates for the inquiry for a three week duration. Delays in
disclosure and congestion of counsel schedules delayed the inquiry; all parties agreed to
a three week block for the inquiry commencing October 2015.
10. An application for an adjournment of the October 2015 date was brought by the family in
September 2015 because a member of the family of Ms. Lewis had suffered a serious
medical incident. The adjournment was granted to permit them to deal with the family
issue. By late October the family of Ms. Lewis was prepared to proceed with the inquiry
and dates were set commencing May 2016.
11. The inquiry commenced hearing evidence May 30. Twenty-five witnesses were called
and over three thousand pages of exhibits were entered. Final argument was completed
in late June 2016.
Circumstances under which Death occurred:
12. Initially counsel for the Attorney General proposed to focus the inquiry on a narrow time
period immediately prior to the death of Ms. Lewis. Ms. Lewis died at 3:50pm on
December 28, 2009 in the emergency department of the Royal Alexandra Hospital (RAH)
in Edmonton. Two hours prior to her death Ms. Lewis was found collapsed on the floor of
a patient care unit in the RAH. She was not a patient on the unit. Security staff was
called. The security staff placed Ms. Lewis in a wheelchair to transport her because she
could not stand due to intoxication from consuming Microsan, a hospital hand cleaner
which contains 70% alcohol. Once in the wheelchair Ms. Lewis kept slipping out so the
security staff tied her to the wheelchair with a cloth restraint. They then took Ms. Lewis to
the ambulance bay area outside the emergency department where they left her tied to the
wheelchair to sober up supervising her by video monitoring and perhaps in person. The
evidence was inconsistent regarding the nature of supervision by the security staff. It was
the intention of the security staff to issue a trespass summons to Ms. Lewis and escort
her off the property when she was sober enough. Ms. Lewis was checked in person by a
security staff at 3:15pm who decided to take her to be seen by the triage unit in the
emergency department as Ms. Lewis was non-responsive. Ms. Lewis was admitted to
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emergency at 3:39pm and died a few minutes later.
13. These narrow circumstances of death lead to many questions. 1
Given her condition, why was Ms. Lewis not taken to emergency by security staff prior
to 3:15pm?
Why did security staff feel a trespass summons was appropriate?
How did Ms. Lewis become so intoxicated on hospital property?
Were the RAH staff aware of the use of Microsan as an intoxicant by individuals?
What safeguards were in place to prevent this use?
The answers to those questions raised many more questions which required the inquiry to
expand the time frame of circumstances of death to commence December 25, 2009, the
start of a series of interactions between Ms. Lewis and professional staff or security staff
of the RAH that culminated in her death just over 72 hours later.
December 25, 2009 12:50pm - Emergency admission
14. According to admission records Ms. Lewis was found on patient station 44 at the RAH.
She was not a patient. Security staff brought her to the emergency department by
wheelchair. The concern at the time of Ms. Lewiss admission was the compromise of her
airway due to her level of intoxication. She was supported in her breathing by a manual
bag and then a tube was put down her airway (intubated) to protect against her choking
and maintain a clear airway. She was put on a ventilator to assist her breathing. Due to
her condition she was transferred to the intensive care unit (ICU). The final diagnosis in
the emergency department documentation was alcohol intoxication.
December 25, 2009 3:35pm Intensive Care Unit (ICU)
15. Ms. Lewis was transferred to ICU and remained intubated until 8:00am on December 26.
According to her attending physician in ICU the purpose of the transfer to ICU was to
monitor Ms. Lewis as the alcohol in her system was metabolized and then to have her
seen by psychiatry as soon as she was awake and could talk clearly. Ms. Lewis was
seen by a resident in psychiatry at 12:20pm on December 26. Ms. Lewis refused to
answer questions and was irritable and angry. The resident was unable to complete a full
assessment, including an assessment of Ms. Lewiss safety. Ms. Lewis walked off ICU at
12:30pm. The resident discussed the history and case with ICU staff after Ms. Lewis left
and recommended they consider completing a Form 1 and Form 3 under the Mental
Health Act in order to have Ms. Lewis apprehended and returned to the hospital for a
proper assessment. According to the patient care record ICU staff called security staff to
locate Ms. Lewis and escort her out of the building. No steps were taken to complete a
Form 1 and Form 3 under the Mental Health Act.
December 26, 2009 1:17pm Ms. Lewis is found and returned to ICU
16. Ms. Lewis was returned to ICU by a staff member from Unit 51, another patient care unit
at the RAH. She was confused, drooling and sleepy. She was swaying and unbalanced.
Due to her condition Ms. Lewis was transferred to a wheelchair. ICU staff called security
staff to escort Ms. Lewis out of ICU. ICU staff did not assess Ms. Lewis. In the 47
1
Throughout this report, questions arising from the chronology are set out in bullets and italics.
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minutes since Ms. Lewis walked away from ICU the staff had coded her as discharged
against medical advice in the computer system. Given Ms. Lewis was discharged from
ICU the unit was unable to provide her any treatment, even if staff had been prepared to
do so. The last entry in the handwritten patient care record at 2:15pm indicates ICU staff
met the security staff in the hallway outside ICU and handed over Ms. Lewis.
Why did the ICU staff treat Ms. Lewiss departure as a discharge? The psychiatric
resident had been unable to complete an assessment of Ms. Lewiss safety and had
raised issues about Ms. Lewis's mental health. What other response could have
occurred in the circumstances?
Why did the ICU staff call security for the purpose of escorting Ms. Lewis out of the
building when the psychiatric resident had recommended steps under the Mental
Health Act?
What steps did the ICU staff take in response to the psychiatric residents
recommendation that a Form 3 and Form 1 under the Mental Health Act be
considered?
December 26, 2009 1:30pm security response
17. Upon being handed over to security by the ICU staff Ms. Lewis was arrested for
trespassing. Security took her to emergency to have her triaged and she was again
admitted as a patient. Ms. Lewis was given a ticket for public intoxication.
Why did security treat Ms. Lewis as a trespasser given she was a person in need of
medical care at a hospital and she was admitted to emergency?
December 26, 2009 1:50pm admission to emergency department
18. When security presented Ms. Lewis to the emergency department they advised triage that
Ms. Lewis had consumed Microsan. Ms. Lewis was again intubated and attached to a
ventilator. At 7:30pm the attending physician completed a Form 1 Admission Certificate
pursuant to the Mental Health Act. He recommended Ms. Lewis be discharged to the
George Spady Centre when she was able. The Nurses Record from the emergency
department indicates that Ms. Lewis had a difficult night in emergency, thrashing and
crying out. Her breathing tube was removed shortly after 5:00am on December 27, 2009.
December 27, 2009 continued emergency department admission
19. After the tube was removed Ms. Lewis continued to create security concerns. A patient
constant was assigned to her and she was restrained on her stretcher. A patient
constant is a member of the security staff who is typically assigned to a patient admitted
under a Form 1 Admission Certificate for the duration of the Certificate for the purpose of
providing constant care and supervision.
20. At 6:00am the nurse charted that Ms. Lewis was a danger to herself. Ms. Lewis
continued to display similar behaviours throughout the day. Ms. Lewis was seen by a
psychiatrist at 6:30pm. During the interview Ms. Lewis was focused on seeing her mother
and was asking to be discharged home. Ms. Lewis kept asking to see or speak to her
mother so on two occasions during the interview she was offered the opportunity to phone
her mother. Ms. Lewis could not remember her mothers phone number so she was
brought back to the interview room with the psychiatrist. The psychiatrist had no
recollection of checking the chart which identified Ms. Lewiss mother as a contact and
emergency notification person and listed her phone number. Ms. Lewis was not given
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any further opportunity to telephone her mother or any assistance with making the
telephone call, nor did anyone call Ms. Lewiss mother regarding the situation.
Why was Ms. Lewis not provided additional assistance to speak to her mother?
Why was Ms. Lewiss mother, the emergency contact, not notified of the
circumstances, including the decision to detain Ms. Lewis under a Form 1 under
the Mental Health Act?
21. At the conclusion of the interview Ms. Lewis was discharged. Times of discharge vary on
the documentation from 7:30pm (written record) to 8:03pm (electronic record). The
nurses record from that evening shows a single chart note entered at 7:50pm. The
author of that note could not be identified so no witness was available to the inquiry who
had personal knowledge of the discharge circumstances.
22. The 7:50pm nurses record note indicates the George Spady Centre was contacted and
advised of the plan to discharge Ms. Lewis to their facility. Ms. Lewis was noted to have
refused a taxi chit or bus pass to get to the Centre. The patient constant assigned to Ms.
Lewis accompanied her to the waiting room and then left her there with her personal
belongings, apparently when the Form 1 Certificate expired at 7:30pm, 24 hours after the
initial certification. Ms. Lewiss intravenous port (saline lock) had not yet been removed.
Ms. Lewis then left the waiting room without advising anyone. The nurses record notes
Ms. Lewis left her personal belongings on a chair in the waiting room. When her absence
was noted the emergency department area was searched but Ms. Lewis was not found.
According to the nurses note, security was involved either in the search for Ms. Lewis or
dealing with the property left behind.
23. This note is not consistent with the discharge practice described by the emergency
department unit manager. Normal practice would be to leave Ms. Lewis in the examining
room until all pre-discharge steps were completed, including removal of the intravenous
port. After those steps Ms. Lewis would have been discharged and offered the taxi chit or
bus pass. Social workers were not available after 5:00pm on weekends so nursing staff
were responsible for ensuring the implementation of the discharge plan.
Was there adequate discharge support for Ms. Lewis given her diagnosis and
recent history at the RAH?
Were there adequate resources in RAH emergency department to implement this

kind of discharge plan when no social worker was on duty?
Is there any special care taken upon the expiry of a Form 1 Certificate, or is all
supervision and support withdrawn immediately upon the expiry?
24. Ms. Lewis was observed by security to be walking towards the emergency department
entrance. In his statement given January 13, 2010 the security officer indicated he
encountered Ms. Lewis shortly after 7:30pm on December 27, 2009 walking towards the
hospital carrying three bags and a suitcase. Security notes of the incident indicate the
officer knew Ms. Lewis had previously been banned from RAH property so he approached
her and asked her to leave the property. He assessed her as sober and cooperative.
Why is the recollection of the security officer in his statement given 15 days after
the death of Ms. Lewis inconsistent with the nursing notes and recorded discharge
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time?
Was Ms. Lewis actually removed from the property by security prior to the nursing
staff noticing she was missing from the waiting room and prior to her discharge
from emergency?
What policies or procedures are in place to inform security of the status of patients
who have been previously banned from the RAH who are in the process of
discharge?
25. Staff from Unit 44 at RAH contacted security to have Ms. Lewis removed from a
washroom. She had locked herself in the washroom and was suspected of drinking
Microsan. Ms. Lewis was escorted from Unit 44 to the security office located outside of
the emergency department in the ambulance bay.
26. Security decided to issue two more summons to Ms. Lewis; for trespass and for being
intoxicated in a public place. Security staff concluded Ms. Lewis was too intoxicated to
care for herself so she was detained in the ambulance bay area until she was sober
enough to leave on her own. Ms. Lewis had a small suitcase with her at the time of her
detention. Some security staff on the overnight shift recalled Ms. Lewis to have been
sobering up on a bench in the ambulance bay and noted she slid or fell off the bench
numerous times during the night and had to be placed back on the bench. Ms. Lewis may
have been handcuffed to the bench overnight. Another security staff recalled Ms. Lewis
told him that night she was banned from shelters and had nowhere to go. He did not
check with shelters, Edmonton Police Service or the emergency department regarding
options. On at least one occasion a member of the public raised a concern regarding Ms.
Lewiss condition to the security staff.
Why did security treat Ms. Lewis as a trespasser?
Given Ms. Lewiss condition, why was she not taken to be triaged at the
emergency department?
Was security aware of the significant medical interventions with Ms. Lewis over
the prior 60 hours? If not, why not?
How does security staff work with RAH staff? How is information shared?
27. The emergency department was located immediately adjacent to the ambulance bay. At
all times at least one registered nurse (RN) was on shift as a triage nurse who was
responsible for assessing admissions to emergency. The shifts in emergency changed at
11:00pm and 7:00am. In total Ms. Lewis was detained in the ambulance bay for 12 hours
so two shifts of triage RNs were on duty during her detention.
December 27 - 28, 2009 night shift
28. The night triage RN was on shift from 11:00pm to 7:00am. Her recollection of the
evening was unreliable. In the course of direct and cross examination the night triage RN
contradicted herself. Her evidence was also inconsistent with a statement she gave in
January 2010 during an internal investigation. In the 2010 statement she advised she
received a report from the prior shift triage RN that a previously discharged patient was in
the garage and may still be intoxicated. She advised she had no contact with Ms. Lewis
but saw her through the window of the emergency department. She stated she was never
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asked by security to see Ms. Lewis.
29. In her testimony before the inquiry the night triage RN reiterated some aspects of her
2010 statement but also stated said she was aware the discharge plan had not been
implemented and assumed Ms. Lewis was waiting until 9:00am when social work arrived
at the hospital for the social worker to deal with any issues. The night triage RN said she
was not advised that Ms. Lewis had gone missing, been searched for, left her property
behind and was not located and was not aware Ms. Lewis had walked away from
emergency and was in the ambulance bay detained by security staff for trespassing and
being intoxicated in a public place. The night triage RN recalled on one occasion during
her shift the security staff brought Ms. Lewis between the doors from the ambulance bay
to emergency. Another nurse on shift asked the triage nurse if Ms. Lewis needed to be
triaged and she told her not to triage Ms. Lewis as she had already been discharged. The
triage nurse surmised it might have been appropriate to re-triage Ms. Lewis after 9:00am
when a social worker came on duty, but she did not pass on that thought to the triage
nurse who replaced her on shift at 7:00am.
30. The data management systems of Alberta Health Services only permit charting after a
patient is admitted. Given Ms. Lewis was not admitted there was no RAH documentation
regarding triage involvement between 8:03pm December 27 and 3:39pm December 28
(her next admission). The weakness of the evidence of the night triage RN may have
been due to the passage of time, the lack of reliable records or some other cause. In any
event it was clear from her evidence that she regarded Ms. Lewis as a discharged patient
throughout her shift and she thwarted at least one effort by others to have Ms. Lewis re-
triaged based on her discharged status.
Why did the night triage RN take no steps to confirm the discharge history of Ms.
Lewis given Ms. Lewis was in the ambulance bay due to her level of intoxication
for the entirety of the RNs shift?
Why did the night triage RN not re-triage Ms. Lewis during her shift when other
nursing staff made inquiries about her condition?
December 28, 2009 morning shift
31. At 7:00am December 28, 2009 two triage RNs came on shift. At morning report morning
triage RN #1 recalled being told Ms. Lewis was in the ambulance bay waiting to go home.
She had seen Ms. Lewis many times before and heard stories about her but was not
aware of the December 26 admission to emergency and ICU. Morning triage RN #1
recalled going into the ambulance bay at 8:00am but could not find Ms. Lewis. She made
no further efforts to check on her.
32. Morning triage RN #2 recalled seeing Ms. Lewis as she walked up the ambulance bay
ramp on her way into work. She saw a person crawling on the floor near the door. She
started to go to check on the person but a security staff got to the person first and said it
was okay so she proceeded into emergency on the assumption the security staff had
matters in hand. Morning triage RN #2 checked with the evening triage RN about the
person and was told she was Ms. Lewis; she was told not to worry about it because Ms.
Lewis was not a patient; security was taking care of it. She was told Ms. Lewis had been
discharged and was waiting to be picked up by the George Spady Centre. This is
inconsistent with the evidence of the evening triage RN. Morning triage RN #2 knew Ms.
Lewis from before.
33. Morning triage RN #2 continued to discuss Ms. Lewis with the other triage RN for the first
hour of their shift. This led to the check made at 8:00am when Ms. Lewis was not found.
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34. When asked about general triage practice at the time, morning triage RN #2 was adamant
that anybody in the ambulance bay should have been triaged. She also noted the
emergency department was very busy so the triage nurses did not have time to go into
the ambulance bay. Security staff was responsible for anyone in the ambulance bay.
35. When asked about her expectations whether security should get an intoxicated person
triaged, morning triage RN #2 indicated that the assessment of Ms. Lewis needed to be
made by security staff. She noted however that for her to assess whether an intoxicated
person required medical attention she would speak to the patient, ask questions, evaluate
the responses and take vital signs as part of her assessment.
If an RN needed to undertake the described assessment to decide whether an

intoxicated person required medical attention, did security staff have the
appropriate training to make a decision regarding the need for triage?
36. Morning triage RN #2 was asked to comment on acts of compassion towards inner city
patients she had seen as a member of the emergency department at RAH. She
described instances when she and her colleagues had provided meals, clothing, gifts and
haircuts to patients. They would put on rubber boots and raincoats to help patients in the
shower. They even held a memorial service for a long time patient who had died.
37. Morning triage RN #2 stated she did not provide any care to Ms. Lewis because she was
not a patient and because the triage RN on the prior shift told her security staff was taking
care of the discharge.
38. According to evidence from security staff, by the time of their shift change the morning of
December 28 Ms. Lewis was sitting in a wheelchair. From 7:00 to 7:30am Ms. Lewis
wheeled herself into the emergency department at least five times. She was advised by
security staff she was not permitted to go into the emergency department. After the fifth
time the security staff re-arrested Ms. Lewis for being intoxicated in public and handcuffed
her to a bench in the garage area. On at least one occasion a member of the public
inquired about the welfare of Ms. Lewis based on her appearance in the ambulance bay.
By 11:00am on December 28, the security staff deemed Ms. Lewis to be sober enough to
be released, removed her handcuffs, provided her with her suitcase and released her
from the ambulance bay.
Why did security staff prevent Ms. Lewis from presenting herself as a patient to
the emergency department when she was able to move herself?
Why did security staff interpret the efforts by Ms. Lewis to present herself to
emergency as grounds to arrest her for public intoxication? Given Ms. Lewis had
been detained by security staff since 11:00pm the prior night did he consider her
actions might be associated with something other than intoxication?
Why did the evening triage RN think security staff was taking care of Ms. Lewiss
discharge plan? How could such a fundamental miscommunication occur?
39. At approximately 1:15pm Ms. Lewis was found intoxicated and unconscious by nursing
staff on Unit 28. Security staff was called. A member of nursing staff on Unit 28 checked
Ms. Lewiss vital signs and released her to security. The security staff lifted Ms. Lewis
into a wheelchair. She continued to slip out of the chair so they tied a cloth restraint
around her waist and behind the wheelchair to hold her in place. Ms. Lewis was taken
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back to the ambulance bay area to sober up. It was the intention of security staff to issue
a trespass notice to Ms. Lewis and escort her off the property when she was sober
enough. Security staff gave evidence that they did not have Ms. Lewis triaged by
emergency because they thought the check made on Unit 28 was sufficient. Security
staff monitored Ms. Lewis by video camera from the security office. Ms. Lewis was
personally checked by an officer at 3:15 pm who decided to take her to be seen by the
triage unit in the emergency department as Ms. Lewis was non-responsive. Ms. Lewis
was admitted to emergency at 3:39 pm and died a few minutes later.
Reviews flowing from the death of Ms. Lewis
RAH Security Department
40. The inquiry heard evidence the management of the security department (also known as
Protective Services) at RAH has not changed since the death of Ms. Lewis. It is managed
through a program that blends Alberta Health Services staff and an independent
company. The independent company providing services has changed since 2009.
41. Community peace officers (CPOs) are direct employees of Alberta Health Services.
Security officers (SOs) are employed through the independent company. The CPOs were
required to take provincially mandated training offered by the Solicitor General; once
completed the CPOs were peace officers for the purpose of the Mental Health Act and the
Gaming and Liquor Act. All security staff acted as an agent of the RAH in applying the
Petty Trespass Act.
42. In 2009 the RAH had a manager of the security department and four teams of security
staff, each headed by a CPO. Each team had mixed membership of CPOs and SOs, with
at least one CPO on each shift. Only CPOs had the authority to detain and arrest under
the two acts.
43. RAH security operations had a computer database for recording incidents. The policy
regarding record keeping was not clear; however some incidents related to Ms. Lewis
were entered in the database. The incident log was available to any security staff on duty
and was primarily intended to assist security staff in dealing with individuals at the RAH.
The incidents related to Ms. Lewis could be identified in the database simply by entering
her name into the search field.
44. Security staff had no access to any patient care records maintained by the RAH.
45. The relationship between Alberta Health Services and the Edmonton Police Service
(EPS) was set out in a formal Memorandum of Understanding (MOU) dated August 21,
2009. The MOU was required by the Alberta Solicitor General given Alberta Health
Services was permitted to directly employ CPOs who were peace officers under the
Peace Officer Act. A Working Agreement was negotiated under the MOU which detailed
the steps CPOs should take regarding complaints, either related to a suspected breach of
the Criminal Code or provincial legislation. The Working Agreement dealt only with the
CPOs obligations to the EPS when acting as peace officers under the Gaming and Liquor
Act. The Working Agreement tendered as evidence in the inquiry was dated January
2010.
46. Evidence of security staff indicated there was a general understanding that they were to
call EPS when they detained someone, however on a practical basis the security staff
stated EPS rarely had the resources to respond given the nature of the call and the low
priority it had for service. Over time the step of calling EPS was often left out of the
security steps when someone was detained under the Gaming and Liquor Act based on
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the expectation EPS would not attend.
Internal RAH Security Review
47. The Director of Corporate Security for Alberta Health Services undertook a review of the
RAH security department immediately following the death of Ms. Lewis.
48. As part of his review the Director looked at incidents in the security incident log involving
Ms. Lewis. The log disclosed Ms. Lewis was known by security to consume Microsan on
the premises of the RAH as early as July of 2005 and that on repeated occasions she had
been detained and handcuffed in the ambulance bay until she was deemed sober enough
by security to be released. According to the log, on several occasions Ms. Lewis was not
triaged while detained in the ambulance bay even though she was suspected to have
recently consumed Microsan and was too intoxicated to be released. The pattern of Ms.
Lewis becoming intoxicated by consuming Microsan on RAH premises, being arrested,
ticketed, detained and then released when sober was repeated several times from July of
2005 to the time of her death. Security was also involved in at least two prior detentions
of Ms. Lewis under the Mental Health Act. The entries in the incident log make it
apparent Ms. Lewis had a significant and uncontrolled addiction to alcohol, often drank
Microsan she obtained from the RAH and became so intoxicated she could not care for
herself.
49. The Director interviewed several CPOs and SOs on staff. By January 13, 2010 it was
clear several security staff gave statements that they believed either nursing or social
work would have been notified about Ms. Lewiss situation during her detention in the
ambulance bay overnight from December 27 to December 28. Some security staff
indicated requests were made to have Ms. Lewis triaged through the shift of the night
triage RN but the requests were refused.
50. By January 13, 2010, the Director of Corporate Security recognized his investigation was
overlapping an investigation being undertaken by Human Resources at RAH about the
same incident. From that point, interviews for both investigations were integrated and the
investigations were coordinated.
51. Ultimately the investigation by Human Resources found there were no breaches of
Policies or Acts; the actions of RAH employees, while not ideal, were not uncommon
practice in the various departments. No action was taken.
52. It emerged from the interviews of security staff conducted by the Director of Corporate
Security, and from the evidence given by security staff before this inquiry that much of the
information relied upon by security staff in making decisions about how to deal with a
person they encountered was based on stories they had been told by colleagues and
personal history with an individual. There was no indication from any security staff that
any reliance was placed on the incident log or other documentary sources of information
in making decisions. For example one security staff indicated he felt the use of Microsan
by Ms. Lewis was relatively new, when the incident log clearly indicated the use went
back over 4 years. Another indicated it was his experience that many incidents involving
Microsan were not documented or reported by security unless there was something more
serious about the conduct. The term frequent flyer was used by at least one security
staff in his evidence in reference to Ms. Lewis which appeared intended to denote her
behaviours as habitual and annoying to security. The view of Ms. Lewis as a nuisance
was evident in the comments of many security staff.
53. It appeared from the evidence heard in this inquiry that decisions about detaining or
releasing an individual who was intoxicated was based on complying with the provisions
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of the Gaming and Liquor Act and managing risk and liability. The policies and
procedures developed for RAH security operations are consistent with that focus. Once a
person who was detained pursuant to section 115 of the Gaming and Liquor Act had
recovered to a point where he could be released, he would be banned from the RAH
property and escorted off the premises, or if previously banned, typically charged with
trespassing and escorted off the premises.
54. Security staff was not directed to provide any assistance to an individual to address the
root cause of his addiction and offending cycle. Intoxicated individuals were viewed as
nuisances who needed to be expelled from the property to protect other users of the RAH.
This focus had the effect of intercepting intoxicated or banned individuals who may have
been seeking medical attention from ever getting to the emergency department.
55. The report of the Director of Corporate Security concluded Ms. Lewis was not being
detained when she was kept in the ambulance bay from the evening of December 27 to
11:00am on December 28, but rather was allowed to sleep in the ambulance bay until she
had sobered up enough to be safely escorted off RAH property. The Director also noted
that EPS did not respond to calls from RAH security staff when an individual was taken
into custody under the Gaming and Liquor Act for suspected intoxication.
56. This conclusion highlights the conundrum faced by RAH security staff when dealing with
intoxicated individuals:
Security staff are focused on removing nuisance visitors from the RAH property
because these nuisance visitors interfere with other visitors, patients and staff.
Some individuals addicted to alcohol may be attracted to the RAH property

because Microsan was and is readily available and it has a high alcohol content.
Other individuals may come to the RAH property when already intoxicated,
perhaps for help or perhaps to access Microsan.
When security staff encounter visitors who they know to be subject to a ban they
are focused on removing the trespasser. If the security staff suspect the person is
intoxicated then pursuant to practice and the MOU Working Agreement they were
to issue a violation ticket or take the person into custody and contact EPS to be
advised of the appropriate course of action. Pursuant to the Gaming and Liquor
Act if a person is taken into custody he may only be released from custody if he
has recovered sufficient capacity that if released he is unlikely to injure himself or
be a danger, nuisance or disturbance to others or can be released to another
person who undertakes to care for him.
By a memorandum dated December 8, 2006, security staff were directed to cease

use of the holding rooms in the emergency department of the RAH for detaining
individuals under the Gaming and Liquor Act because section 53(3) of the Police
Act states that if a special constable requires the use of a lock up facility they are
directed to use the lock up facility of the police service jurisdictions. Security staff
were directed to secure suspects in the emergency department ambulance bay
until police took over the arrest.
EPS was not responding to calls for assistance so ultimately the practice of
security staff evolved to discontinue calling the EPS when a person was taken into
custody due to intoxication.
The practice of holding someone in custody until they were safe to be released
under section 115 of the Gaming and Liquor Act began to be characterized as
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letting someone sleep in the ambulance bay whether or not restraints were
used.
It was effectively impossible to comply with the MOU Working Agreement, section
115 of the Gaming and Liquor Act and section 53(3) of the Police Act given EPS
did not have the resources to respond to calls about intoxicated individuals at the
RAH.
57. The provisions of section 115 of the Gaming and Liquor Act and section 53(3) of the
Police Act have not been changed since the death of Ms. Lewis.
Review by and direction from the Solicitor General
58. The Public Security Division of the Ministry of Justice and Solicitor General conducted a
review of the circumstances of the death of Ms. Lewis pursuant to Section 19(2) of the
Peace Officers Act. The recommendations resulting from that review were provided to
Alberta Health Services by letter dated January 27, 2011 and entered as an exhibit in this
Inquiry. The recommendations imposed terms and conditions on Alberta Health Services
authority to maintain peace officer designation for CPOs, including the following:
The practice of arresting a person under the Gaming and Liquor Act for
intoxication and housing them until sober, without involving the police service
shall cease forthwith.
Alberta Health Services shall implement policy with respect to the management of
intoxicated persons who have not been arrested and are not being detained.
59. Alberta Health Services developed a Department Standard regarding Gaming and Liquor
Apprehensions dated June 24, 2011. That policy meets the direction of the Solicitor
General but does not solve the inherent conundrum arising from the provisions of the
Gaming and Liquor Act, the Police Act and the Memorandum of Understanding described
in paragraph 56.
60. The new policy adds a requirement that security staff must request an assessment of a
person taken into custody under section 115 of the Gaming and Liquor Act. While that
requirement appears responsive to one of the issues related to the death of Ms. Lewis, it
likely has little practical impact considering the following:
Nursing triage RNs were all of the view that anyone held in the ambulance bay
ought to have been presented for triage for assessment in 2009.
Some security staff expressed the view that nursing staff did not care for security
staff and viewed them as goons or thugs. Several nursing witnesses were highly
critical of the security staff practice of detaining individuals in the ambulance bay.
The evidence before this inquiry indicated a tension between the two groups which
may have had an impact on communication.
Microsan is a highly concentrated intoxicant. The evidence before this inquiry was
that the level of intoxication of a person who consumed Microsan could increase
very rapidly depending on the time of consumption. It is also foreseeable that a
person being held in custody by security could get access to Microsan or another
intoxicant during his detention. A single requirement that a detained individual be
assessed does not address these contingencies.
61. This new policy still leaves security staff in the position that they are responsible for the
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supervision of intoxicated persons in custody after being assessed by medical staff and
until the EPS respond. The anecdotal evidence before the inquiry from some current
security staff is the situation during that period of time has not materially changed since
2009: these intoxicated persons are still kept somewhere in the hospital, sitting up on
benches or in wheelchairs while they become sober enough to be released.
62. The inquiry was provided with a Use of Force policy in place at the RAH. While undated it
was apparently drafted or revised in response to the circumstances of Ms. Lewiss death
and other factors. Significantly the policy identifies positional asphyxia as one of two
conditions that accounts for the majority of custody related deaths. It is discussed in the
context of restraints. There was no evidence before the inquiry that the concern of
positional asphyxia has been flagged as a risk associated with detention. Evidence of
security staff is that intoxicated individuals continue to be placed on benches, chairs or in
wheelchairs while in custody awaiting the response of EPS.
Review of use of Microsan at RAH
63. The inquiry heard from the Executive Director of the Emergency Program in the
Edmonton Zone of Alberta Health Services. She gave evidence the RAH started using
Microsan in 2007; no policies were in place regarding its risks at the time of Ms. Lewiss
death. As a consequence of her death, a review was undertaken and steps taken. The
Executive Director indicated the death caused the RAH to be extremely vigilant.
64. A review of literature was also undertaken, which disclosed studies and papers as early
as 2007 recommending precautions be taken to reduce availability of alcohol based hand
sanitizers to high risk populations in hospitals. The two seminal documents reviewed by
the RAH in 2010 both offered several recommendations to address the misuse of
Microsan, including more secure dispensers, removing dispensers from more public areas
and issuing staff personal pocket dispensers rather than using wall dispensers in high risk
areas.
65. The inquiry was advised RAH has acted on most of the recommendations from the
document, however the consumption of Microsan as an intoxicant is a continuing
challenge at the hospital.
66. A February 2010 report by Alberta Health Services indicated only twenty incidents of
Microsan ingestion had been reported province wide in the health incident reporting
system, eleven of which were in the Capital region. The eleven incidents involving
ingestion of hand sanitizer in Edmonton were reported in the netSAFE system, an
Edmonton based reporting system implemented in 2005. NetSAFE documented that
seven of the incidents involved a bottle dispenser, one involved a wall dispenser and
three could not be determined.
67. The records of Alberta Health Services are in contrast to the findings of the Director of
Corporate Security in his report in March 2010. He concluded the misuse of Microsan by
Ms. Lewis and others had been evident at the RAH for a considerable period of time. The
security incident log related to Ms. Lewis alone indicated five incidents of her drinking
Microsan as early as July 15, 2005, not including the consumption during the 72 hours
preceding her death.
68. On January 14, 2010 a Memorandum was sent to all staff and physicians alerting them to
increased supply and availability of Microsan at the RAH. The action staff and physicians
were directed to take was as follows:
Immediately notify Protective Services [security] staff of any concern regarding a patient
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or visitor consuming Microsan.
69. Notwithstanding the steps taken by RAH, Microsan continues to be available at the
hospital and continues to be abused by individuals. While staff has a heightened
awareness of the concern, they are to report any concerns to security staff.
Other initiatives of RAH
70. The Executive Director of the Emergency Program in the Edmonton Zone of Alberta
Health Services described projects being undertaken to better serve patients who are
identified as high risk. While these initiatives seem promising, a pre-condition for
participation through referral by RAH, is being admitted as a patient.
71. In her evidence the Executive Director described the challenge in dealing with at risk
individuals as a difficult balance, striving to help these individuals move forward in dealing
with their addictions, but recognizing some may choose to live unhealthy lifestyles. The
identified goal for these individuals is to provide support, either in their recovery or by
helping them to manage their addiction in a safe way.
72. The Executive Director noted that health care is one piece of an integrated program
delivery to achieve better outcomes for high risk individuals.
73. The Executive Director acknowledged that discharge transportation has been an historical
difficulty in implementing discharge plans. In the past few years the Hope Mission, a local
not for profit society, has purchased an old ambulance and converted it into a van to
deliver programs on the street to the inner city community. The RAH sometimes utilizes
the Hope Mission van to support transportation of individuals being discharged to other
facilities.
Review by Medical Examiner
74. An autopsy was conducted on Ms. Lewis immediately after her death. The Autopsy
Report was entered as an exhibit. Dr. Graham Jones, Chief Toxicologist of the Office of
the Chief Medical Examiner gave evidence before the inquiry.
75. Dr. Jones indicated the concentration of alcohol in Ms. Lewiss body after her death was
480 mg/100ml of blood; he considered any level over 350 mg/100ml to be life threatening.
76. Dr. Jones indicated Microsan has a concentration of 70% alcohol. A person consuming
Microsan would be affected quickly given its concentration, and would be affected by
smaller amounts of product consumed, compared to traditional liquor. The impact is on a
persons central nervous system; the higher the concentration of alcohol, the bigger the
impact.
77. Dr. Jones noted the presence of other medications in Ms. Lewiss blood. Upon reviewing
her medical chart he identified these substances as having been administered during her
hospital admissions prior to her death. He indicated the presence of these other
medications could intensify the impact of the Microsan.
78. Dr. Jones indicated the effect of the alcohol would make Ms. Lewis hypoxic; as her supply
of oxygen reduced she would go into a slow decline to the point she died. It was his
opinion this condition could easily have been determined by measuring Ms. Lewiss vital
signs respiration rate, blood oxygen level, heart function which he described as
straight forward observations for a medical professional.
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Witnesses called by the Inquiry
Proper care for intoxicated persons
79. The evidence before this inquiry indicated a recognized risk of alcohol intoxication is the
inability of a person to protect his or her airway. The opinion of Dr. Jones was described
differently by other professionals. One described the risk that the tongue of an intoxicated
person may collapse to the back of the mouth obstructing the airway or a person may
vomit and aspirate. If a person was sitting up with his or her head on her chest that
should signal a concern that the airway may be obstructed. It was explained that any
drug, including alcohol, that is a sedative dulls ones senses and reduces the ability of a
person to respond to breathing obstructions.
80. Given this evidence the inquiry sought evidence from other agencies as to how these
risks were managed.
81. The Executive Director of the George Spady Society gave evidence regarding the
protocols in place at the George Spady Centre to ensure the safety of a client who is
intoxicated. The person would never be kept sitting up, but rather would lie down on a
mat in the recovery position. The person would be required to hydrate regularly and
encouraged to go to the washroom. Staff would regularly try to engage the person in
conversation to ensure the persons condition is not deteriorating and if deteriorating
would seek medical assistance. The Executive Director indicated medical interventions
were common in dealing with their clients; Emergency Medical Services (EMS) was on
site frequently and clients were assessed and removed for medical care three to five
times a week.
82. An Inspector from the Edmonton Police Service (EPS) responsible for management of
all detainees gave evidence regarding the Detainee Wellbeing Procedure of the EPS.
The policy provides If there are any doubts as to whether a detainee may require medical
attention, members must always resolve all doubts in favour of the detainees wellbeing.
The policy further requires the detainees medical condition and all medical care provided
or not provided to the detainee is documented on the detainees detention report. The
Inspector gave evidence that in the case of a grossly intoxicated person EMS would be
called and the police would rely on the EMS recommendation. The Inspector noted that
intoxicated detainees were to be physically checked every 10 minutes. For example if
EMS recommended no need to transport the detainee, but 10 minute checks showed a
deterioration in condition, the policy required EMS to be called back.
Certification under the Mental Health Act
83. The inquiry heard a range of explanations for the failure of staff at RAH to follow up on the
psychiatry residents suggestion that a Form 1 and Form 3 be issued for Ms. Lewis on
December 26, 2009.
84. The Executive Director of the Emergency Program for the Edmonton Zone gave evidence
that it was very difficult for clinicians to use the Forms under the Mental Health Act. She
also expressed the concern that use of the Forms is monitored by the Mental Health
Advocate and the RAH may be challenged if it issued too many Forms. She indicated the
Mental Health Advocate had expressed a concern to the RAH that patients were certified
too quickly or without their knowledge.
85. Carol Robertson Baker, the Mental Health Advocate in Alberta, provided evidence to the
inquiry. Ms. Robertson Baker was the assistant Mental Health Advocate since 2004 and
took over her current position in 2013. She explained the role of the Mental Health
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Advocate is to investigate complaints received from or relating to a patient. While the

Regulations permit the Mental Health Advocate to initiate investigations on her own
motion, Ms. Robertson Baker indicated that such a step had never occurred to her
knowledge.
86. The Mental Health Advocate does not perform an audit function of certificates issued and
has no authority to reverse any clinical or administrative decisions related to the
certification process. The primary role of the Advocate is to explain to patients the
procedure to appeal or review a certificate issued under the Mental Health Act.
87. Ms. Robertson Baker specifically denied her office had voiced a concern regarding the
number of certificates being issued or potential abuse by any facility. She indicated the
Mental Health Advocate respects the physicians decision and is focused entirely on
educating the patient about his or her rights.
Concerns raised by circumstances:
88. The following concerns arise from the evidence:
Culture of security operations at RAH
Intolerance by security and professional staff at RAH of individuals struggling with

addictions and mental health issues
Professional response to individuals presenting in the emergency department at

RAH is constrained by computer programs and admission and discharge policies
Lack of awareness by RAH staff of risks and impact of Microsan
Inconsistent approach to and lack of understanding of options under the Mental

Health Act by RAH staff
Ineffective and inadequate communication within professional staff and between

professional and security staff at RAH
Lack of adequate support at RAH for discharge plans of high risk individuals
Culture of security operations at RAH
89. The impact of the evidence from security staff witnesses and the review by the Director of
Corporate Security was that the security staff viewed their role as protecting the RAH from
nuisance visitors and trespassers. The common practice of security staff in 2009 and
continuing to the time of the inquiry was to intercept nuisance individuals, ban them from
the property, issue summons for provincial offences and escort them from the premises.
If the person was too intoxicated to care for him or herself they were detained until their
condition improved so they could be released.
90. While policies and procedures regarding detention of intoxicated persons were altered
following the death of Ms. Lewis, the evidence heard by the inquiry suggested no practical
changes had occurred.
91. The Executive Director of the Edmonton Zone Emergency Program felt there had been a
change in the demeanour of security staff, from that of the enforcer to partners in care,
however the examples relied upon all related to individuals who were admitted as patients
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at RAH.
92. Ironically, if an individual was found intoxicated to the same level off RAH property,
evidence of EPS and the Executive Director of the George Spady Society indicated EMS
would be called to assess the individual if there was any concern about well-being: an
intoxicated person on RAH property has less access to professional assessment than the
same person off RAH property. The gatekeepers to professional health assessments for
intoxicated individuals on RAH property were and continue to be security staff, who have
no training to make these assessments.
Intolerance by security and professional staff at RAH of individuals struggling with addictions and
mental health issues
93. There were repeated references in the charts and evidence about Ms. Lewis being well
known to professional staff and security staff at RAH unrelated to her health care history.
The purpose of these references was not apparent in the documents and was not
explained by the witnesses. For example there is a reference in emergency charts to Ms.
Lewis being well known to RAH security. A security officer referred to Ms. Lewis as a
frequent flyer in his evidence. Many witnesses made comments about knowing stories
about Ms. Lewis.
94. The evidence regarding the refusal by the evening triage RN to triage Ms. Lewis for her
entire shift the evening of December 28, 2009, notwithstanding a request by security staff,
is inexplicable.
95. The decision by the nursing staff on ICU to call security to have Ms. Lewis removed from
RAH premises when she walked out of ICU on December 26, 2009 is inexplicable.
96. The immediate decision by the security staff to eject Ms. Lewis from RAH property as she
walked on the ambulance ramp near emergency on December 27, 2009, was expressly
made based on knowledge of the past trespass ban issued to Ms. Lewis.
97. Throughout the 72 hours that preceded her death Ms. Lewis was treated as a nuisance
and viewed critically for her repeated episodes of intoxication by security staff and most
professional staff. Professional staff took positive steps to have her removed from RAH
property and made conscious decisions not to inquire as to her physical wellbeing when
she was detained in the ambulance bay. According to security staff Ms. Lewis presented
herself five times in the emergency area and was removed each time without being seen
by a triage RN.
98. This sentiment was in contrast to the philosophy described by the Executive Director of
the George Spady Society. Within that facility addiction is recognized as a complex issue.
Staff understands it is not easy to treat and recovery is difficult. There is a realization that
not everybody can stop using drugs and alcohol and that it is difficult for a person in the
throes of withdrawal to think straight or make rational decisions.
Professional response to individuals presenting in the emergency department at RAH is

constrained by computer programs and admission and discharge policies
99. The admissions and discharge policies and procedures of RAH are designed to ensure all
services provided by staff are accounted for to Alberta Health Services within various
applications and databases. This permits Alberta Health Services to measure its overall
performance, both quantitatively and qualitatively. Key transactions are coded and
entered into various computer screens. The time of the transactions are automatically
entered and programs are capable of generating reports to assist in managing operations.
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100. In order to ensure conformity in measurement various protocols have been developed.
For example, a person is not considered a patient until admitted in the computer program.
A person who sits in the waiting room in emergency without checking in with the triage
desk, for whatever reason, is not a patient. A person can only be admitted as a patient
after being triaged.
101. This inquiry frequently heard from Alberta Health Service managers and counsel that the
RAH had no obligation to and was prevented from providing care to a person who was not
admitted. The explanations for this prohibition were based on multiple concerns including
liability issues, lack of consent by the person, and the inability to comply with privacy
obligations. This explanation is legally sound, but appears to show the tail wagging the
dog in the interactions between emergency staff, security staff and Ms. Lewis; legal
concerns designed to protect an individuals rights become the reason for medical care
not being provided to an individual.
Lack of awareness by RAH staff of risks and impact of Microsan
102. The evidence before the inquiry was that Alberta Health Services was only aware of
twenty incidents involving Microsan in the entire province at the time of Ms. Lewiss death
based on reported incidents. Anecdotal evidence from professional staff and security
staff made it clear the abuse of Microsan was well known at the RAH. The security
incident log disclosed five incidents involving Ms. Lewis from 2005.
103. RAH acknowledges that the steps taken to reduce the risks associated with Microsan use
were only as a result of Ms. Lewiss death.
104. The risks and impact of Microsan were well known to the international research
community, with studies published as early as 2007 disclosed in the evidence before the
inquiry. In July of 2008 the National Reporting and Learning Systems maintained by the
National Patient Safety Agency in the United Kingdom undertook a review of incidents.
One of the cases reviewed resulted in a death and two incidents were graded as severe.
105. The Edmonton Zone of Alberta Health Services had a specific reporting system to
document risks of this nature; it appears clear from the evidence before the inquiry that
known incidents were not being recorded in the reporting system.
106. It is a concern that RAH management did not consider and/or understand the collateral
risks of introducing Microsan as part of its infection prevention and control program.
While it is clear that a strong argument can be made for the use of Microsan, it is equally
clear that the risks of Microsan were well documented prior to the death of Ms. Lewis.
107. An oversight of this nature cannot be cured by a recommendation from this inquiry. As
health programs are changed and improved to deal with specific concerns it is critical that
unintended consequences be carefully considered and managed.
108. Reliable tracking of incidents is critical to successfully responding to adverse

consequences of program changes.
Inconsistent approach to and lack of understanding of options under the Mental Health Act by
RAH staff
109. The Executive Director of the Edmonton Zone Emergency Program was under a
misapprehension regarding the oversight role of the Mental Health Advocate in
certification procedures. Whatever the source, the evidence before this inquiry is that an
institutional reluctance exists about certifying a person who meets the criteria for
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certification under the Mental Health Act.
110. The staff of ICU also appeared to demonstrate a misunderstanding of the opportunities
under the Mental Health Act when they disregarded the advice of the resident in
psychiatry and sought assistance from security staff to remove Ms. Lewis from RAH
property.
Ineffective and inadequate communication within professional staff and between professional
and security staff at RAH
111. The evidence before this inquiry disclosed multiple incidents of ineffective or inaccurate
communication about Ms. Lewis. Some issues arose due to assumptions by staff, some
issues arose due to the failure to inquire about Ms. Lewiss status, some incidents arose
due to the inability of departments to access information about Ms. Lewis which was
entered in various databases.
112. The inquiry heard evidence the emergency department maintains an admission and
discharge database which is separate from Netcare, the patient health information
database. There is a delay in entering information on Netcare. All departments continue
to maintain paper files; not all chart information is documented electronically.
113. Security staff do not have access to Netcare or patient charts and information. They have
very limited access to the RAH emergency department admission and discharge
database; only the list of currently admitted patients is visible to security.
114. No person dealing with Ms. Lewis over the last 72 hours of her life had a complete picture
of the cycle in which she was involved. Security could not see the Netcare information.
The emergency database was not available to security, but in any event it did not include
the discharge plan. The paper on which the discharge notes had been filed was sitting in
a filing box to be added to Ms. Lewiss chart when there was time for filing. The
emergency triage nurses could not view the discharge information in the emergency
database.
Lack of adequate support at RAH for discharge plans of high risk individuals
115. The evidence before the inquiry is in conflict regarding the circumstances of Ms. Lewiss
final discharge from the emergency department. The nursing notes are inconsistent with
the security staff observations.
116. The evidence is consistent that the psychiatrist who discharged Ms. Lewis directed a
specific support plan be put in place. Ms. Lewis was to be discharged to the George
Spady Centre where she would receive support during her recovery from her cycle of
Microsan consumption.
117. This discharge occurred at the conclusion of the Form 1 admission, 24 hours after Ms.
Lewis was originally certified. The role of the patient constant was terminated and Ms.
Lewis was left alone in the waiting room.
118. The discharge occurred when the social worker was not on duty. Nursing staff was
responsible for implementing the discharge.
119. RAH has no formal transportation program. Ms. Lewis and others in her condition are
expected to take a bus or taxi to the discharge location and provided payment for the trip.
120. When Ms. Lewis went missing security staff were asked to assist, but whatever the
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communication was, it was insufficient to alert another security staff person at 7:30pm that
Ms. Lewis was missing in the course of discharge. As a result when he found Ms. Lewis
almost immediately after her leaving the emergency waiting room he ejected her from the
RAH premises instead of walking her back in to allow the nurse to complete the discharge
process.
121. The entire patient discharge process appeared very muddled from the evidence before
this inquiry. Security staff were not entitled to any information whatsoever. Probably the
evening triage RN was responsible because social work staff were not on duty, however
there was other evidence that a patient might be expected to wait until the next morning to
get help from social work in similar situations.
122. In this case, from 7:30pm on December 27 to 7:30pm on December 28, 2007, Ms. Lewis
was supervised by a patient constant and considered to be at risk. Immediately upon the
expiration of the Form 1 Certificate, the patient constant supervision was terminated and
all resources and support were removed from her.
123. Upon the triage RN deciding Ms. Lewis had rejected the discharge plan and left for good,
Ms. Lewis was entered in the computer as discharged at 8:03pm. That had the
consequence that the subsequent shift emergency triage RNs could not access any
information about Ms. Lewis, even though she was detained in the ambulance bay, and
chose not to assess her relying on a data entry at 8:03pm without knowing the
circumstances that caused Ms. Lewis to be back in the ambulance bay.
Recommendations for the prevention of similar deaths:
Recommendation 1:
That RAH management develop a policy or department standard that integrates Gaming and
Liquor Apprehensions (security policy standard) with a health standard to ensure security and
health staff work cooperatively to assess and respond to the social and health circumstances of
every individual apprehended by security for intoxication on RAH property throughout the period
the individual is held in custody or otherwise detained awaiting EPS response; these individuals
should be under some form of admission to the RAH during the period of custody to ensure dual
responsibility for the wellbeing of the individual. This will also enable a person in custody to be
assessed for participation in the various program initiatives introduced at RAH for high risk
individuals.
In our society a hospital is a place of safety, where a person can receive care. Hospitals have a
security staff in place to ensure that safety and professional staff to provide care.
Due to standards required to manage infectious diseases hospitals now use Microsan, a hand
sanitizer with a high percentage of alcohol which is known to be consumed by individuals with
severe addiction to alcohol.
Individuals with addictions go to hospitals, in some cases to seek care or assistance in the first
instance; perhaps in other cases to seek out alcohol contained in Microsan. In any event,
individuals with addictions find themselves in hospitals with ready access to highly concentrated
alcohol. If an individual becomes intoxicated on hospital property the most foreseeable result is
the person will be dealt with by security. Security protocols are built around enforcement
legislation, particularly the Gaming and Liquor Act. The security staff concern for wellbeing of the
individual is in accordance with section 115 of the Gaming and Liquor Act. Accordingly the
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response of the security staff is either to ticket the individual and ban them from hospital property
or take the person into custody and separate him from hospital services while awaiting EPS
response or until the person becomes sober; then remove him from hospital property.
Enforcement legislation does not contemplate discharge planning. Security staff are not trained
to conduct ongoing assessments of the health and wellbeing of individuals recovering from
intoxication. These individuals should be regularly assessed, including an assessment of their
vital statistics. The current RAH policy requires a medical assessment at the commencement of
the custody period but leaves it to security staff to conduct ongoing assessments. Security staff
are not going to call for EMS support for someone in custody at the RAH. Current policy and
procedures at the RAH prevent health staff from assessing or providing assistance to an
individual in custody because that individual is not a patient.
The RAH, where these individuals are being held in custody is uniquely positioned to provide
ongoing assessments and to design and implement discharge plans. It is most appropriate for
the RAH to have formal responsibility to provide ongoing assessment and care to individuals held
in custody on its premises.
Recommendation 2:
That RAH management, in conjunction with Alberta Health Services, develop a reliable database
to record incidents of Microsan misuse by patients, clients or visitors. This database should
integrate RAH incidents and security operation incidents of misuse. A manager should be
assigned to be responsible for reviewing each incident to assess how the Microsan was
accessed and to revise strategies for securing the Microsan to avoid future misuse.
The netSAFE reporting system was not being used to record all incidents of Microsan abuse
known to RAH staff. The evidence of emergency department staff made reference to a general
understanding of the prolific nature of the abuse on the premises. These incidents were far in
excess of the eleven reported incidents in Edmonton from 2005 to the time of Ms. Lewiss death.
Tracking incidents alone will not manage the risk associated with using this Microsan. It is
recommended that a designated manager have responsibility to review incidents, consider
international initiatives and implement appropriate changes to manage new and emerging risks
associated with Microsan, or any subsequent product introduced as a strategy to manage
infectious diseases at the RAH.
Recommendation 3:
That RAH management provide an ongoing program for all patient care units, including ICU and
emergency department, to educate professional staff on the challenges of addictions and the
importance of admitting individuals to ensure access to the enhanced supportive programs being
offered for these individuals.
Recommendation 4:
That RAH management develop strategies to implement the immediate assessment and
development of accelerated discharge plans for individuals who are patients by virtue of being in
custody under s. 115 of the Gaming and Liquor Act, assuming Recommendation A is
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implemented.
The challenge of recovery for someone struggling with a serious addiction coupled with mental
health issues is significant. Sometimes task driven public resources can lose sight of those
challenges.
The criminal justice system fell prey to that loss of vision. As a result the Supreme Court of
Canada gave specific direction to sentencing judges to be mindful of the significant challenges
faced by aboriginal offenders in arriving at fit and appropriate sentences. In R v. Gladue 2 the
Supreme Court of Canada made note of the following:
Years of dislocation and economic development have translated, for many

aboriginal peoples, into low incomes, high unemployment, lack of opportunities
and options, lack or irrelevance of education, substance abuse, loneliness, and
community fragmentation.
Criminal courts were directed to take judicial notice of these factors in the hopes that the justice
system would arrive at more effective sentences.
Ms. Lewiss ethnicity was well known to all who dealt with her at the RAH. Her aboriginal
background was noted in both her health records and security records. It was a matter of record
that she was unemployed, frequently homeless, suffered from substance abuse, depression and
other mental illnesses. She was known to have a supportive family, who would always support
her, but could not always provide housing to her depending on her level of addictions.
In the case of Ms. Lewis it appears the health system lost sight of the context of Ms. Lewiss
struggles, responding to her with frustration and seeing her as a nuisance. An ongoing program
of education for RAH professional and security staff may provide that same reminder the
Supreme Court of Canada sought to give the criminal justice system about the importance of
considering the circumstances of every individual when making decisions that have a profound
impact on someones life.
Recommendation 5:
That RAH management develop a policy or standard, and supportive procedures to provide
guidance to and educate professional staff regarding the appropriate considerations in deciding
whether or not to issue a Form 1 and Form 3 under the Mental Health Act. Specific guidance
should be provided for circumstances where a patient leaves a unit during the course of an
assessment prior to the risk assessment being complete. In those circumstances the patient
should not be coded as discharged until the responsible physician has authorized the discharge.
Recommendation 6:
That RAH management review discharge policies and procedures for individuals who have been
certified during the course of their admission. Procedures should be revised to provide enhanced
care and support on discharge and to consult with a psychiatrist whether a patient should be re-
certified if the discharge plan is not successfully implemented.
The circumstances of discharge for Ms. Lewis on December 27, 2009 are difficult to piece
2
[1999] 1 S.C.R. 688
LS0338 (2014/05)
together from the evidence. The nurse who entered the nursing notes describing her
understanding of the discharge could not be identified. Her notes conflicted with the prior
statements and documentary evidence of security staff. It is not known whether the nurse who
entered those notes was available to the Quality Assurance Committee because those
proceedings are privileged.
It is clear Ms. Lewis was detained by a Form 1 Certificate under the Mental Health Act from
7:30pm on December 26 to 7:30pm on December 27, 2009. Ms. Lewis was under the
supervision of a patient constant for that period. The supervision of the patient constant
terminated abruptly at 7:30pm December 27 as the Certificate had expired.
The psychiatrist who developed the discharge plan for Ms. Lewis knew that Ms. Lewis had
expressed a desire to either go to a facility like the George Spady Centre or to go home to her
mother. Presumably a factor in the psychiatrists decision not to extend any Certificates under
the Mental Health Act was the expectation her discharge plan was being implemented.
Would the psychiatrist have extended the Certificate had she been aware Ms. Lewis did not go to
the George Spady Centre? Would she have altered the discharge plan to consider involving Ms.
Lewiss mother? Could the admission have been extended until social work staff arrived on shift
at 9:00am the next morning? Discharge policies and procedures should give guidance to
professional staff to ensure these options are considered prior to a patient in these circumstances
being discharged.
Recommendation 7:
That RAH management develop a shared database with security staff including admissions and
discharges for the prior seven days. Flags should be developed for discharged patients who
have not been transported to the discharge destination immediately upon discharge or whose
discharge plans have not been implemented.
Recommendation 8:
That the Minister of Health and the Minister of Justice conduct a review of section 9 of the Alberta
Evidence Act to consider permitting public fatality inquiries to have access to quality assurance
records, proceedings and recommendations.
The purpose of a public fatality inquiry under the Fatality Inquiries Act is to inquire into the cause
and manner of death of an individual and consider whether any recommendations may be
appropriate to prevent similar deaths. In this case section 9 of the Alberta Evidence Act
prevented this inquiry from even asking questions about the quality assurance review conducted
years earlier by RAH into the same death. The Fatality Inquiries Act contains provisions which
permit portions of the inquiry to be held in private. While section 45.1 of the Fatality Inquiries Act
makes it clear the limitation on a public inquiry fatality was deliberate, this inquiry agrees with the
following comments of Judge S.R. Creagh included in a Report she prepared following a Public
Fatality Inquiry in 2001 where she urged a reconsideration of this limitation:
it is ironic that the legislation has removed from my consideration a report which could
have greatly benefitted this inquiry. I urge that the interplay of these two sections be
reconsidered with a view to permitting this type of information to be available to an
LS0338 (2014/05)
Inquiry. 3
The delay in the presentation of evidence to this inquiry significantly affected the reliability of
much of the evidence. Many witnesses called before this inquiry likely provided evidence before
the Quality Assurance Committee convened to enable a full and frank investigation after critical
incidents of this nature with the objective of enhancing health care. Their recollections would
have been fresher and the evidence likely therefore more reliable.
The recommendations of the RAH Quality Assurance Committee would likely have been of
assistance to this inquiry, especially to the extent any recommendations addressed issues
around triage practice in emergency and the relationship between security operations and health
care delivery at the RAH.
Conclusion:
124. The successful implementation of all these recommendations may still be ineffective in
preventing future similar deaths at the RAH. Underlying all of the evidence heard in this
inquiry was a fragmentation of policies and procedures designed to meet various issues
that have arisen over time, without considering the collateral impact on the individual
involved.
125. The adherence to strict protocols on patient admission, treatment and documentation
makes imminent sense. The use of dynamic computer programs to permit entry of data
and measuring of outputs, outcome and performance is a very useful management tool.
126. Yet this inquiry heard evidence that a woman was left crawling in an ambulance bay
outside the emergency department by an RN starting her shift who relied on advice from
an RN on duty that the patient was discharged. Eight hours later that person crawling in
the ambulance bay was dead.
127. The RAH is an inner city hospital. Much of the evidence described the challenge for
professional staff in dealing with the demands of individuals coming to emergency while
intoxicated on drugs and alcohol, pan handling, looking for food or trying to get warm.
128. The attraction of the RAH was undoubtedly enhanced upon its introduction of Microsan, a
hand cleaner with a high concentration of alcohol, known to be abused by alcoholics in
studies that dated back to 2007.
129. Alberta Health Services is able to explain the need for an effective hand sanitizer; the risk
of bacteria being spread in a hospital environment is a serious public health concern. To
be accredited at an international level, steps of this nature are necessary.
130. After the introduction of Microsan its abuse by patients and visitors to the RAH was well
known. The evidence from security staff indicated numerous encounters with individuals
intoxicated by the substance. Emergency and ICU staff were also aware of its abuse.
131. Not surprisingly inner city residents addicted to alcohol were drawn to the RAH. Not
surprisingly they became intoxicated. Individuals suffering from severe addictions did not
have the insight or perhaps the support to take meaningful steps on their own to resist the
temptation of the alcohol.
3
Public Fatality Inquiry Report into the death of North Carter Tapp (page 18)
LS0338 (2014/05)
132. Are these individuals drawn to the RAH for care and then succumb to the temptation of
Microsan or are they drawn to the RAH for Microsan? Either way the culture of the RAH
in 2009 and at the time of this inquiry is generally to regard these individuals as
nuisances. They are banned, issued tickets for trespassing and public intoxication and
escorted off the premises to go home, even if they are homeless.
133. There was evidence before the inquiry of caring and compassion by some professional
staff. Community programs are being continually introduced to better respond to the
needs of high risk individuals in the vicinity of the RAH. However there appears to be little
recognition that the deliberate design of the security operations of the RAH builds an
invisible wall around the emergency department at RAH. Security policy compels security
staff to apprehend, ticket and expel or detain the very individuals these programs are
intended to serve. If a repeat visitor to the RAH is unable to get triaged in the emergency
department he will not be able to get access to community programs.
134. The inquiry heard evidence of exciting new community programs to respond to the needs
of these vulnerable inner city populations. But for these programs to be successful for the
most vulnerable, the invisible walls around the RAH must come down. Vulnerable
individuals suffering from addictions and other mental health issues should be assumed to
have a health purpose in coming to the RAH and not be treated as nuisances and
trespassers.
135. This attitudinal change does not lend itself to a recommendation, but it is critical to
ensuring the success of any programs being offered from or through the RAH.
DATED July 21, 2017 ,

Original signed by
at Edmonton , Alberta.
Janet L. Dixon
A Judge of the Provincial Court of Alberta
LS0338 (2014/05)

Sharon Lewis Fatality Report

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Sharon Lewis Fatality Report

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Report to the Minister of Justice Fatality Inquiries Act

and Solicitor General

WHEREAS a Public Inquiry was held at the Law Courts

in the City of Edmonton , in the Province of Alberta,

on the 30th day of May , 2016 , through

to the 10th day of June , 2016 , (inclusive)

before Janet L. Dixon , a Provincial Court Judge,

into the death of Sharon Grace Lewis 35

of Edmonton, Alberta and the following findings were made:

Date and Time of Death: December 28, 2009 at 3:50pm

Place: Royal Alexandra Hospital, Edmonton, Alberta

Medical Cause of Death:

Acute ethanol and drug toxicity

Identity of the deceased;

The date, time and place of death;

The circumstances under which the death occurred;

The cause of death; and

The manner of death.

No finding may be made regarding legal responsibility;

No conclusions in law may be reached; and

Any recommendations must be related to the death.

Alberta Health Services

Circumstances under which Death occurred:

emergency at 3:39pm and died a few minutes later.

13. These narrow circumstances of death lead to many questions. 1

Why did security staff feel a trespass summons was appropriate?

How did Ms. Lewis become so intoxicated on hospital property?

December 25, 2009 12:50pm - Emergency admission

December 25, 2009 3:35pm Intensive Care Unit (ICU)

December 26, 2009 1:30pm security response

December 26, 2009 1:50pm admission to emergency department

December 27, 2009 continued emergency department admission

Were there adequate resources in RAH emergency department to implement this

December 27, 2009 7:30pm security response

December 27, 2009 11:00pm security response

Why did security treat Ms. Lewis as a trespasser?

December 27 - 28, 2009 night shift

asked by security to see Ms. Lewis.

December 28, 2009 morning shift

If an RN needed to undertake the described assessment to decide whether an

December 28, 2009 1:15pm security response

Reviews flowing from the death of Ms. Lewis

RAH Security Department

the expectation EPS would not attend.

Internal RAH Security Review

Some individuals addicted to alcohol may be attracted to the RAH property

By a memorandum dated December 8, 2006, security staff were directed to cease

Review by and direction from the Solicitor General

Review of use of Microsan at RAH

or visitor consuming Microsan.

Other initiatives of RAH

Review by Medical Examiner

Witnesses called by the Inquiry

Proper care for intoxicated persons

Certification under the Mental Health Act

Advocate is to investigate complaints received from or relating to a patient. While the

Concerns raised by circumstances:

88. The following concerns arise from the evidence:

Culture of security operations at RAH

Intolerance by security and professional staff at RAH of individuals struggling with

Professional response to individuals presenting in the emergency department at

Lack of awareness by RAH staff of risks and impact of Microsan

Inconsistent approach to and lack of understanding of options under the Mental

Ineffective and inadequate communication within professional staff and between