Policy changes have already been made at the Centennial Centre in Ponoka after a resident with a history of suicide attempts hung himself, but a judge recommended further changes after a fatality inquiry.
Aldo Digiacomo, 48, of Calgary was found hanging from a tree branch on the grounds of the Centennial Centre for Mental Health and Brain Injury in July 2015.
A daylong public fatality inquiry into the events surrounding his death was held on Nov. 22, 2017 at the Ponoka Courthouse before judge Gordon Yake. His final report was released on Monday.
Kerry Bales, Chief Zone Officer for Alberta Health Services Central Zone, said in an emailed statement that a comprehensive review was conducted following the incident.
“As a result of our review, there have been a number of changes undertaken at the Centennial Centre for Mental Health and Brain injury to enhance patient safety and our response plans in the event a patient goes missing.”
Among those changes are improvements to the response plans in the event of a missing person, more education for staff involved in search efforts, more detailed maps of the external grounds and emergency response backups and an infared camera on site to aid searchers. More security cameras were also installed on the exterior of the building in the patient courtyard for 24-hour monitoring and recording and more security personnel were hired.
“We are committed to continuing exploring ways to further enhance the safety of the facility through the recommendations from this inquiry.”
Yake recommended a comprehensive closed-circuit television system to monitor the grounds, more lighting of the exterior grounds, a regular schedule of security patrols of the grounds and search and rescue training for staff involved in searches.
Digiacomo was admitted to the Centennial Centre in January 2015, after an almost three year period of continuous admission as a psychiatric inpatient to the Calgary Foothills Medical Centre. He suffered from obsessive-compulsive disorder with comorbid depression and suicidal ideation.
According to the review, when Digiacomo was admitted it was apparent he presented a significant risk of suicide.
In his six months at the Centennial Centre, Digiacomo experienced a range of privileges. At times he was allowed unaccompanied walks around the Centennial Centre and its grounds for 30 minutes at a time, while at other times he was put in seclusion and had a staff member check on him every 15 minutes.
About a week before he died, Digiacomo was allowed an overnight leave of absence to visit his wife, son and brother. The day before, he was seen pacing the dining hall and was unwilling to participate in activities. He was noted by a doctor to be anxious, intensely staring and expressing fleeting suicidal thoughts.
On July 5, at 6:30 p.m. he used his privileges to go for a walk around the exterior grounds. By 7:05 p.m., he had not returned and a search began. By 8 p.m., staff had not located Digiacomo and Ponoka RCMP were notified. At 8:10 p.m., he was found handing from a tree with a ligature around his neck.