St. Paul’s negligent in man’s attempted suicide — (24 Hours Vancouver)

SSRI Ed note: Man on antidepressants drinks, taken to hospital for threatening suicide, not monitored, attempts to die by hanging, permanent damage, wins lawsuit.

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24 Hours Vancouver

By Michael Mui, 24 Hours Vancouver

Wednesday, September 23, 2015 2:21:16 PDT PM

A man who hanged himself in St. Paul’s Hospital after being involuntarily admitted for professing suicidal thoughts was awarded nearly $400,000 by the B.C. Supreme Court.

A court ruling said Providence Health Care was negligent for failing to monitor the man before he locked himself in a washroom for the attempt.

Michael Jason Paur did not die from his suicide attempt, but rather suffered a permanent brain injury that resulted in him losing all memory of his recent past, including that of his wife or his wedding. He has lost his ability to function at a high level.

He was 36 in 2011 when he was admitted to St. Paul’s after a fight with his then-wife. According to the court decision, police apprehended Paur under the Mental Health Act after he told his wife “bye” and threw his phone off a high floor in a hotel room.

Police found him at the hotel after he’d consumed a two-litre bottle of cider, several shots of hard liquor and clonazepam, and took him to the hospital, where he appeared normal, being jovial with officers, and telling the doctor he had no wish to kill himself. They later found his blood alcohol content was four times over the legal driving limit.

In fact, upon admission, he seemed more concerned that he had to stay the night at the hospital and would miss work in the morning. But there were also old cuts on his arms — indicators he had previously attempted suicide — and his PharmaNET records indicated he was taking medication for depression.

Paur was admitted to a ward known as the Comox Unit so he could be assessed when he sobered up. The unit was designed for close monitoring — there were suicide-resistant “seclusion rooms” with cameras, patients weren’t allowed to close curtains, and nurses made routine checks.

Paur, however, was given a regular bed somewhat out of view from the nurses’ station. More than once, the nurses there saw Paur heading to the washroom, which wasn’t suicide resistant, had a lock and was also out of view of the nursing station. But they didn’t think much of it as they knew how much Paur had to drink.

There was no detailed evidence how long Paur spent in the washroom by himself each time — the nurses didn’t make accurate notes, Judge Susan Griffin said — but one nurse noticed he wasn’t in his bed and finally checked the bathroom, which was locked.

By the time they got in — the first nurse didn’t know how to unlock the door — Paur was already purple. The crash cart also couldn’t fit through the door, adding time to the critical window before someone gets permanent injury or dies from lack of oxygen to the brain.

“I find that the two nurses on duty at the time of the hanging incident failed to meet nursing standards of care for observing Mr. Paur,” the judge said, though she also credited the nurses with saving the man’s life.

Griffin added that the hospital should’ve known the washroom was unsafe, should’ve known how quickly a patient who attempts hanging can die or suffer permanent injury, and should’ve monitored the patient better.