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Disabled woman strangled by wheelchair seatbelt should have been watched: report

WINNIPEG - A judge says vague and confusing care instructions were partly to blame for the death of a severely disabled woman who was strangled by her wheelchair's seatbelt.

Staff at the Manitoba Development Centre were not given clear direction on how Ann Hickey, 51, should have been monitored, provincial court Judge Rocky Pollack said in an inquest report released Thursday.

"The use of the verb 'to monitor' at MDC was never an exercise in precision," Pollack wrote in the 26-page report.

Staff on duty the night Hickey died "certainly did not understand that she was in danger of strangling herself in a strange wheelchair."

Hickey was born with severe mental and physical disabilities. She had lived at the centre since she was 10 along with others who need round-the-clock care. She suffered seizures and was prone to falling, the inquest was told.

On March 25, 2011, she was left unattended for about 10 minutes in a hallway. Three psychiatric nursing assistants were assigned to the section of the centre in Portage la Prairie, Man., where Hickey was, but one of them was reassigned that night because of a staff shortage in another area.

At around 11:30 p.m., one of the assistants rushed to another patient's room because an alarm had gone off indicating the patient may have fallen out of bed. The other worker was answering a phone call.

Hickey was in the hallway in a wheelchair — not her usual one. She slipped down and was strangled by the seatbelt.

Pollack found that Hickey's patient care guide said she should be watched for sliding in her wheelchair, but there were no specific instructions on how frequent that monitoring should be.

"The monitor instruction ... is in the 19th line of the single-spaced (instruction) box. It is not capitalized or otherwise emphasized and it is found among contradictory information," Pollack wrote.

The judge also found that clear instructions were lacking when Hickey was transferred from another section, which houses 200 residents.

Recommendations in the inquest report include clearer instructions for patient care and allowing staff to carry electronic devices such as tablets to give them quicker access to care guides.

The report also recommends there should be a special tag for a wheelchairs that is not a patient's usual one and explicit instructions on whether a resident needs constant monitoring while in a wheelchair.

Pollack noted in his report that the centre has already moved to implement many improvements.

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