Fatality inquiry into falling death wraps up

The inquiry into the falling death of a wheelchair-bound group home resident wrapped up with testimony from employees of the Red Deer group home and provincial staff.

The inquiry into the falling death of a wheelchair-bound group home resident wrapped up with testimony from employees of the Red Deer group home and provincial staff.

Anne Graham, a Parkland Community Living and Supports Society supervisor, was working in the group home at the time that Richard David Jacknife died. Jacknife, 47, of Red Deer died of injuries he suffered from falling down about 20 steps on Nov. 4, 2010. He died a week later at the Foothills Medical Centre.

A fatality inquiry into the circumstances surrounding his death and the subsequent action taken by Parkland to mitigate or prevent future incidents started on Wednesday.

Graham said Nov. 4, 2010, was an unusually busy morning. She had to take a resident who lived in the basement of the group home to a medical appointment before dropping that resident off at their volunteer position. A second employee, Shelley Elliott, had worked the night before and stayed until Graham returned from the morning errands at about 9 a.m.

When Graham returned, Jacknife had gotten up. After Graham completed a few tasks, she was set to take Jacknife on their daily walk. As she was checking on the laundry, she heard a loud noise coming from the stairwell to the basement.

When she got to the stairs, she saw Jacknife had fallen down the stairs, still strapped into his wheelchair. She unbuckled him from the wheelchair and called 911. When EMS arrived, they performed CPR and took Jacknife to hospital.

Central to the inquiry is the lock on the door to the basement.

When Jacknife moved into the residence, a special lock was put on the door that allowed the basement resident to get upstairs without having to unlock the door. However, the other side of the door required people to unlock it to open it. It took a small coat hanger to unlock the door. To relock the door, staff had to ensure it was locked. It was not Parkland policy to rely on the basement resident to lock the door. Instead, staff practice was to check on it when it was used. On the day of the Jacknife fall, Graham said she must have forgot because it was so busy.

After the incident, Parkland made changes to the lock, making it automatic, as well as policy changes requiring documented door checks and changes to their orientation and safety manuals.

The afternoon of testimony focused on Persons with Developmental Disabilities and an occupational therapist. They were asked to interpret the action taken by Parkland in light of the incident. Tim Lowe, the acting director of community resources for PDD Central Region, said Parkland had gone above and beyond in their action after the incident.

Judge Gordon Yake asked Lowe and occupational therapist Elizabeth Edwards if there was a way to alert the staff at the group home to the door being open without installing an audio-alarm or an auto-closing door.

The inquiry wrapped up with closing remarks from Parkland’s counsel Gillian Holowisky saying Parkland had done more than either PDD or the Protection of Person and Care Association recommended in their respective reports on the incident.

Yake has 90 days to file a written report and may include recommendations for future action in light of Jacknife’s death.