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Ms. Kayfish's letter was released as part of an effort by the families of those dismissed to push for a public inquiry into the firings. The government has repeatedly said a public inquiry would be too costly and slow. Instead, the province said last week it would hand the matter to B.C.'s Ombudsman for review. Neither Health Minister Terry Lake nor the Premier were available for an interview Tuesday regarding Ms. Kayfish's allegations. But Mr. Lake's spokeswoman said in an e-mailed statement that the minister is confident the Ombudsman would complete a "thorough" investigation in "a timely and cost-effective way." Mr. MacIsaac, a doctoral candidate, had only three days left in his research placement when he and seven other health-ministry workers and contractors were fired in late 2012.

At the time, the B.C. government said the workers were dismissed due to inappropriate conduct related to the private medical information of millions of British Columbians. The minister at the time suggested the RCMP were investigating, but access-to-information documents uncovered last month showed the RCMP never began a probe. The province has apologized for firing Mr. MacIsaac and rehired or settled out of court with most of the employees. Lawsuits involving two others are ongoing.

Ms. Kayfish's letter says the family found out about the suicide note shortly after Mr. MacIsaac's death, but the B.C. Coroners Service refused to release it until their investigation was complete. After months of asking, Ms. Kayfish's letter says the coroners service agreed to read the note to the family over the telephone, while keeping any names mentioned in the document anonymous. Ms. Kayfish's letter says the coroners service responded to the family's request for the note with links to the province's access-toinformation laws. By October of 2013, the coroners' final report into the death had been completed and Mr. MacIsaac's computer was released to his family. Ms. Kayfish maintains someone had deleted the document from his computer.

he coroners service said in its statement that a police officer uncovered the note and forwarded the printed version to their investigators several days after the computer was recovered from Mr. MacIsaac's home. The service said it never had an electronic version of the note. Mr. MacIsaac's note does not mention his work or have any personal messages for his family, but it is "clear and concise" and "reflects his frustration with the public dismissals at the Ministry of Health," Ms. Kayfish says in her letter. She said later she would release the note to a public inquiry or the Ombudsman.

Shepter's story illustrates a problem that extends far beyond a single California nursing home. ProPublica and PBS "Frontline" have identified more than three-dozen cases in which the alleged neglect, abuse or even murder of seniors eluded authorities.

For more than a year, ProPublica, in concert with other news organizations, has scrutinized the nation's coroner and medical examiner offices [1], which are responsible for probing sudden and unusual fatalities. We found that these agencies -- hampered by chronic underfunding, a shortage of trained doctors and a lack of national standards -- have sometimes helped to send innocent people to prison and allowed killers to walk free.

If a senior like Shepter dies under suspicious circumstances, there's no guarantee anyone will ever investigate.

"a hidden national scandal."

Because of gaps in government data, it's impossible to say how many suspicious cases have been written off as natural fatalities.

In one 2008 study, nearly half the doctors surveyed failed to identify the correct cause of death for an elderly patient with a brain injury caused by a fall.

Autopsies of seniors have become increasingly rare even as the population age 65 or older has grown. Between 1972 and 2007, a government analysis [2] found, the share of U.S. autopsies performed on seniors dropped from 37 percent to 17 percent.

"father was lying in a hospital bed essentially dying of thirst, unable to express himself -- so people could have a nice, quiet cup of tea."

"We're where child abuse was 30 years ago," said Dr. Kathryn Locatell, a geriatrician who specializes in diagnosing elder abuse. "I think it's ageism -- I think it boils down to that one word. We don't value old people. We don't want to think about ourselves getting old."

A study published last year in The American Journal of Forensic Medicine and Pathology found that nearly half of 371 Florida death certificates surveyed had errors in them.

Doctors without training in forensics often have trouble determining which cases should be referred to a coroner or medical examiner.

State officials in Washington and Maryland routinely check the veracity of death certificates, but most states rarely do so

there has to be a professional, independent review process

a public, 74-bed facility

Some counties have formed elder death review teams that bring special expertise to cases of possible abuse or neglect. In Arkansas, thanks to one crusading coroner, state law requires the review of all nursing-home fatalities, including those blamed on natural causes.

Of the 1.8 million seniors who died in 2008, post-mortem exams were performed on just 2 percent. The rate is even lower -- less than 1 percent -- for elders who passed away in nursing homes or care facilities.

As the chief medical examiner for King County, Harruff launched a program in 2008 to double-check fatalities listed as natural on county death certificates. By 2010, the program had caught 347 serious misdiagnoses.

Thogmartin said "95 percent" of the elder abuse allegations he comes across "are completely false," and that many of the claims originate with personal injury attorneys.

Decubitus ulcers, better known as pressure sores or bed sores, are a possible indication of abuse or neglect. If a person remains in one position for too long, pressure on the skin can cause it to break down. Left untreated, the sores will expand, causing surrounding flesh to die and spreading infection throughout the body.

Federal data show that more than 7 percent of long-term nursing-home residents have pressure ulcers.

"Very often, that is the way these folks die," he said. "It is a preventable mechanism of death that we're missing."

"Occasionally, there are elderly people who are being assaulted. But this issue of pressure ulcers is a far, far bigger issue, and really nationwide."

a new state law requiring nursing homes to report all deaths, including those believed to be natural, to the local coroner. The law, enacted in 1999, authorizes coroners to probe all nursing-home deaths, and requires them to alert law enforcement and state regulators if they think maltreatment may have contributed to a death.

"It was a horrible place,"

A 2004 review of Malcolm's efforts by the U.S. Government Accountability Office concluded that the "serious, undetected care problems identified by the Pulaski County coroner are likely a national problem not limited to Arkansas."

prompted Medicare inspectors to start citing nursing homes for care-related deaths and to undergo additional elder-abuse training.

Still, nursing homes inspections are not designed to identify problem deaths. The federal government relies on state death-reporting laws and local coroners and medical examiners to root out suspicious cases

They found such problems repeatedly at Riley's Oak Hill Manor North in North Little Rock.

investigations led state regulators to shut down the facility, in part because of the home's failure to prevent and treat pressure sores

staffing in homes is a constant challenge. Being a caregiver is a low-paying, thankless kind of job. (at one time you could make more money flipping burgers than caring for our elderly- priorities anyone??) With all the new Medicare cuts, pharmacy companies who continue to overcharge facilities for services, insurance companies who won’t be regulated, our long-term facilities are in for a world of hurt- which will affect the loved ones we care for. Medicare cuts mean staffing cuts- there are no nurse/patient ratios here- meaning you may have one nurse for up to 50 residents. Scary? You bet it is!!  Better staffing, better care, everyone wins.

Lets not just blame the caregivers. Healthcare and business do not mix. When a business is trying to make money, they will not put the needs of patients and people first. To provide actual staffing (good-competant care with proper patient to caregiver ratios) the facilities would not make money.

There's no guarantee that a coroner's investigation would have uncovered the alleged medication murders of eight elderly residents in Woodstock and London. Ontario Provincial Police announced this week that 49-year-old registered nurse Elizabeth Wettlaufer is facing eight first-degree murder charges related to deaths in homes from 2007 to 2014. Cheryl Mahyr, spokesperson for the coroner's office, said the requirement for an investigation in every 10 deaths was added in the mid-1990s because government oversight was lax. It was dropped in 2013 after the office concluded that the 2010 long-term care legislation had "robust investigation requirements." Ministry inspections do expose problems. The issue, say critics, is that Ontario's long-term care system is so cash-strapped and short-staffed that systemic failures - filthy unchanged diapers, resident-on-resident violence - are never really fixed. For the past two days, Premier Kathleen Wynne and Health Minister Eric Hoskins have been grilled in the legislature on the issue. NDP leader Andrea Horwath asked "exactly what's being done by the premier to ensure that something this horrific and heartbreaking never happens again?"

In response, Wynne said the government might conduct an independent review "at some point not because of political pressure from the NDP, but because we all need to have the answers." Wynne committed to improvements on Sept. 23 - six days before Wettlaufer's arrest - when she sent Hoskins his new "mandate letter." Long-term-care goals were to include: "Increased safety (and) an ongoing commitment to annual inspections." Earlier this year, the ministry said its inspections - which were supposed to include private interviews with roughly 40 residents and families - will be done every three years, instead of annually as promised around the time when the coroner's office made its changes. (The ministry continues to do shorter inspections every year.)

By law, all deaths in nursing homes must be reported to the local coroner, who can decide whether further investigation is needed. The number of coroner investigations has fallen by more than half since it dropped the one-in-ten-deaths requirement - in 2013, there were 2,027 investigations, followed by 890 in 2014.

But stress is not the sole explanation. As both the coroner and the ombudsman note in their reports, the medical classroom and workplace are brutal: Bullying and psychological harassment are commonplace in hospitals, and the stigma about mental illness is pervasive in the medical profession. In short, medical education is too often imbued with a macho attitude that learners have to be broken down and toughened up and that those who can't take it are weak and unworthy.

Perversely, many physicians take pride in this boot-camp mentality. When efforts were made to eliminate the insane 100-hour workweeks of residents, old-timers quietly (and sometimes not so quietly) dismissed the younger generation as wimps. Even Quebec Health Minister Dr. Gaetan Barrette, when asked about medical-school suicides, reacted dismissively, saying: "The pressure they are dealing with is a lot less than it was 15 years ago." In fact, what's different today is not that young people are weaker, it is that expectations are so much higher and isolation is so much greater, in spite of (or perhaps because of) so-called social media. Medical students and residents are also headed into a world of uncertainty, not one in which they are guaranteed a life of privilege.

There is also an open recognition of the problem; when residents and doctors killed themselves before, it was hushed up - now it is at least talked about. But while the system has become adept at collecting data on depression and suicide, it has done little concrete to offer help and invest in prevention. Emilie Marchand, like all her classmates, had stellar marks and, from the time she was in high school, dedicated herself heart and soul to the goal of becoming a doctor - in her case a specialist in internal medicine. When she was in medical school she was diagnosed with a personality disorder and, in residency, suffered from bouts of depression so severe that she had to be hospitalized. She also had a previous suicide attempt, using the same drug, hydromorphone. But Ms. Marchand continued her studies full bore and - her friends testified later - lived in mortal fear that her illness would be exposed and her career derailed.

Increasingly, research is showing that so-called superperformers (such as those attracted to medical school) are particularly vulnerable. Paradoxically, the very qualities that make someone a good doctor - empathy, caring, perfectionism - make them vulnerable to burnout, depression and suicide. The students attracted to medical school are among the best and brightest of their generation. They are smart, talented and driven. But many are also anxious, overwhelmed and lost - sick, not weak.

We cannot simply respond to the wounded healers with the age-old admonishment, Cura te ipsum (Physician, heal thyself). We must create an environment in which our future doctors can learn to heal, beginning with caring for themselves.

Why were these deaths not investigated? "While all nursing home deaths are reported to the coroner, an autopsy is not scheduled except in specific circumstances, including those that are considered suspicious.

This painful issue should not become a political football. The crimes of a rogue nurse, if that is indeed what is involved here, cannot be blamed on any particular party or government. No one will respect a politician who tries to score cheap points on the backs of murdered seniors. But neither should Ontarians be expected to wait silently for months before hearing more specifics of what went on, whether any weaknesses in the system can be identified, and what steps might be taken to reduce the likelihood of anything remotely similar from happening again. The stakes are too high for that.

In that light, Health Minister Eric Hoskins' blanket assurance that there is no danger to any care home resident and his assertion that Ontario has one of the best oversight systems for nursing homes "in the world," fall short of what is needed. There are legitimate questions that can and should be addressed without getting into the details of the Woodstock case or interfering with the police and judicial processes. For example: Does the province need to take another look at how often coroner's inquests are held into the deaths of people in care homes? As recently as three years ago the provincial coroner's office automatically investigated every tenth death in every care home. It was intended as a way of identifying any problematic patterns in the deaths of residents.

But in 2013 that was stopped on the grounds that it turned up no useful information. At the time, critics said it was a short-sighted move. In light of the Wettlaufer case, should that be re-visited? And are there any gaps in the system for reporting residents' deaths to the province or local coroners? Are there gaps in the system for making sure drugs are accounted for in nursing homes? According to police, the eight seniors who died were given fatal overdoses of a drug.

There are supposed to be fail-safe systems for ensuring that drugs cannot go unaccounted for in care homes. How exactly do they work, and can improvements be made following this tragedy? Are there adequate systems to monitor the stability and mental health of medical professionals? Wettlaufer apparently had problems with addiction and she was reportedly identified by police when she shared information about the deaths with staff at the Centre for Addiction and Mental Health in Toronto. Were there measures in place that might have picked up earlier on any problems she was experiencing?

There are much broader concerns, too, about the general condition and funding of the long-term-care system. There's no question that the needs are enormous and growing and more robust staffing would improve service all around. But for now, the focus should be on reassuring care home residents and their families.

Premier Kathleen Wynne says the government is prepared to conduct an independent review or inquiry into safety procedures in nursing homes "at some point, if there is a need." In the meantime, her government would do everyone a service by more clearly addressing specific points directly relevant to the sickening allegations in Woodstock and London.

In 2007, the Quebec coroner faulted hospital administrators for failing to spend enough money on measures known to contain the spread of the superbug.

the Ontario government’s new Retirement Homes Act has created a regulatory authority to impose rules that will fix the problems

But seniors’ advocates warn that the complaints system is currently toothless because the government still hasn’t passed the regulations that allow it to remove licenses from problem homes.

The authority has investigated about 30 complaints about neglect but cannot take away licenses until that part of the act is in force

Judith Wahl, executive director of the Advocacy Centre for the Elderly, said the coroner’s investigation shows the office will shine a light on retirement home deaths in the future. But, Wahl said, relying on new legislation will not help the most vulnerable. Retirement homes, she said, are private rental accommodations that will charge medically fragile residents for each medical service they need. The authority, she said, still does not have the powers needed to fully investigate homes.

hree weeks later, Shippobotham died due to complications from his injuries, his family said.

Susan Eng, vice-president of advocacy for the Canadian Association of Retired Persons, said she’s troubled by the spate of fatal attacks on residents at nursing homes by other residents, usually suffering from dementia.

Just weeks after that incident, William May, an 85-year-old resident at the Polson Residential Care facility in Vernon, B.C., died after allegedly being assaulted by his 94-year-old roommate.

oth cases are now being reviewed to see if they warrant an inquest or deeper examination by a death review panel, says the British Columbia Coroners Service. A pair of attacks in the Toronto area last year triggered similar alarms. Francisco DaSilva, 87, was found dead at the Castleview Wychwood Towers nursing home in November with “obvious injuries to the head,” police said. His roommate, 81-year-old Francesco Greco, was charged with second-degree murder. Earlier in March, 72-year-old Joycelyn Dickson was found dead at the Wexford Residence long-term care facility, allegedly beaten with a cane. Another resident, 72-year-old Peter Brooks, was charged with second-degree murder.

The homicides prompted the Ontario Nurses’ Association to call on the province to act on key recommendations from a previous inquest – held in 2005 into the deaths of two residents at the Casa Verde nursing home in Toronto.

The Star's analysis shows that at least one patient is seriously injured attempting suicide every three days, and 13 patients take their own lives every year. The hospital suicide rate is too high for psychiatrist Dr. Ian Dawe. "We are committed to making in-hospital suicides a 'never event,'" he said, noting that many hospitals in the United States are in the process of adopting what is known as a "zero suicide" strategy. Last May, after the Star started investigating this story, the government created a task force to develop standards on suicide prevention in hospitals and appointed Dawe as chair.

Suicides and attempts occur in all hospital departments, from maternity to neuro-clinical, emergency, medical and psychiatry. Methods range from strangulation and suffocation to drowning, overdose and electrocution, according to the data. Records show that a 12-year-old patient attempted to hang herself with her nightgown in the Sault Area Hospital, a 71-year-old woman went missing from Homewood Health Centre and jumped to her death from a parking garage and a patient at Alexandra Marine and General Hospital used a broken vase to slit his or her wrists. The three hospitals declined to comment on these incidents. Secrecy is a big part of the problem, the Star found.

Following an in-patient suicide, hospitals hold reviews behind closed doors to identify what went wrong and what can be done to prevent further deaths. But hospitals are not required to share these results publicly, or even with other institutions, under Ontario's health secrecy legislation - the Quality of Care Information Protection Act.

Details about deaths have even been withheld from grieving families. The family of Prashant Tiwari, 20, had to fight Brampton Civic Hospital for basic details about how he died by suicide last year. Tiwari was taken to the hospital after stabbing himself and placed under 15-minute suicide watch. His family eventually learned he had hanged himself in a bathroom after he was not checked for three hours. (Earlier this month, the health minister introduced changes to the protection act to address the problem of families being left in the dark.) Brampton Civic Hospital has refused to comment publicly on the Tiwari case, other than expressing its condolences, but in a letter to the family it said three staff members have not worked at the hospital since the day of his death. The Star's investigation found significant inconsistencies in how hospitals approach suicides: Some hospitals use only clothing and shoes without drawstrings, ties and shoelaces. Others don't take such precautions. Some confiscate personal medication from patients to prevent overdoses. Others don't.

Some lock the windows of mental health units and remove the window handles. Others don't. It's not surprising then that there is confusion about the exact number of in-patient suicides province-wide. While the Star's investigation found more than 96 patients had taken their own lives in half of Ontario's hospitals since 2007, the coroner's office, to which all hospitals must report suicides by law, says there have been only 60. "(I) cannot account for the reasons why our data differs from that offered by the specific hospitals," Chief Coroner Dirk Huyer said. There hasn't been a single coroner's inquest into a hospital suicide in the past nine years because, Huyer said, it is not the coroner's role "to raise issues that are already known." In the previous decade, the coroner's office held six inquests into in-patient suicides resulting in numerous recommendations aimed at preventing these deaths, including the establishment of task forces targeted toward the most at-risk patients. But little has been done and the problem continues.

A few weeks before Ken Coyne committed suicide at Providence Healthcare in Scarborough, he told his sister, Jean Brewster, that he wanted to die because the stroke had left him with only "half a body." She says the doctors knew of his suicidal intent and that she will never understand how he managed to hang himself while he was bed-bound and under 15-minute suicide watch. She recalls exactly what she said to the police officer who delivered the news: "I remember saying to the officer: 'Hang on, how did he do that in a hospital?'" Providence Healthcare said staff members continued to be deeply affected by Coyne's "tragic" death.

Just last week, two major Canadian health organizations identified suicides in hospitals as "preventable" incidents. Health Quality Ontario and the Canadian Patient Safety Institute released a report, "Never Events for Hospital Care in Canada," which said suicides in hospitals "should never happen" when patients are under suicide watch.

"Whether you're in a healthcare facility, a manufacturing facility, driving a vehicle - if you're tired, the risks of mistakes are going to go up." Two studies comparing eightand 12-hour schedules during day and night shifts found that 12hour night shifts were associated with more physical fatigue, smoking or alcohol use, according to a 2004 report from the U.S. Centers for Disease Control and Prevention. "It's the law of diminishing returns," said Liane Davey, vicepresident of team solutions with Lee Hecht Harrison Knightsbridge, which specializes in talent recruitment and development.

"We think that we're staying and doing more and being more productive; but the negative outcome of doing that actually means our core quality suffers." Irregular schedules - such as switching from a block of night shifts to day shifts - can result in sleep disturbance which can become chronic, Mustard noted. "If you build up a period of disturbed sleep ... this is somewhat different from fatigue, although in a sense the consequence is kind of the same. "If we can't rest, we're not renewing our cognitive and physical capacities."

German-born Moritz Erhardt was a week from completing a work placement at Bank of America Merrill Lynch in London when he died in 2013. A British coroner said the 21-year-old intern died of an epileptic seizure that may have been triggered by fatigue. Erhardt's case sparked widespread speculation that the notorious long working hours and competitive environment at top investment banks were to blame for his death. Matt Ferguson said his 22-yearold brother, Andy, died in a headon collision in 2011 after logging excessive hours as an unpaid intern at an Edmonton radio station.

When Jeff and Andrea Archibald launched their design agency, the couple initially worked from home and logged significant extra time to establish their business. "We definitely hit 60-hour work weeks mainly because when there's two of you, you have to do all the billable work," recalled Jeff Archibald. "When you're starting out, your rate's a little lower, and then you have to balance out with all the business side of things, like invoicing. You don't have anybody on staff that can do those kinds of things, so you're basically wearing all of the hats," he said. "What ends up happening is you have all your meetings and your phone calls ... during the day and you do your production work at night - and that's not just us. A lot of our friends are in similar situations."

The Archibalds are now part of a team of seven at their Edmonton custom Web and branding firm, Paper Leaf. Weekly meetings help assess key tasks to accomplish within a given day and week - and avoid overbooking. "One of the singularly biggest concerns I think we all have is balancing the amount of workload so that we can have a profitable company - but also not overwork people," Jeff Archibald said.

"When you overwork, you're staring down the barrel of burnout. It's a real short-term gain." Mustard said employees logging overtime should be aware of the pace of their work and ensure they are taking breaks. "Being thoughtful about nutrition, making sure that you're not missing meals is very important. And then rest. Not shortening your chance to have sleep."

Iqaluit resident Joanasie Akumalik hopes sharing his family's story at this month's inquest into high suicide rates in Nunavut will help prevent other Nunavummiut from sharing the same pain. 

Since Nunavut was created in 1999, 486 people have died by suicide. But it wasn't until a record-breaking 45 people took their lives in 2013 that Nunavut's coroner was driven to call for an inquest.

It was also a trauma his family would face again, a coroner’s inquest into the 45 suicides in Nunavut in 2013 was told when the inquest began Sept. 14. Three months after Rex’s death, yet another brother — 15-year-old Peter — killed himself. Rex was living with as many as 23 family members in his grandmother’s four-bedroom house in Naujaat, a community of about 1000 people. The family shared eight beds and one bathroom while they waited for subsidized housing.

The evening before he died, Rex played with his cousins and stayed overnight at their home. His aunt and uncle found him and tried to revive him. His family reported not knowing the immediate triggers for Rex’s decision to hang himself. “I don’t know what was wrong with him,” Martha Uttak, Rex’s mother, testified. “He was my baby and he hugged me all the time.”

Five years ago, four partner organizations came together and released a suicide prevention strategy that was visionary and evidence-based in its design. The Government of Nunavut, the Embrace Life Council, the Royal Canadian Mounted Police and Nunavut Tunngavik Inc.’s goal was to reduce the territory’s suicide rate to one commensurate with, or lower than, the rest of the country.

But as the inquest heard, Rex was living with many of the risk factors for suicide that researchers have identified, including repeated exposure to the suicide of others. From 1999 until 2014, Nunavummiut took their lives at a rate of 111.4/100 000 population — nearly 10 times the rate of other Canadians, which stands at 11.4/100 000 according to the most recent Statistics Canada data (2000–2011).

The widespread unresolved grief surfaced again when testimony from Shuvinai Mike, a senior government official who was called to talk about her department’s involvement in cultural activities, devolved into a description of the impact of her own daughter’s suicide. When someone kills oneself, the news spreads rapidly, often via social media, throughout this vast territory of only 36 000 people. Parents live with the constant fear that one of their children will be next

The inquest, which ran Sept. 14 to 25 and included testimony from about 30 witnesses, touched on many underlying issues: poverty, high rates of child sexual and physical abuse, housing shortages, unemployment, educational deficiencies, food insecurity and historical trauma that are the reality for too many Inuit families. It is also exposed the deep divisions among the territorial government and organizations coping with the population-wide damage that suicide inflicts.

Nunavut coroner Padma Suramala, a registered nurse who presides over death investigations in Canada’s newest territory, called the inquest to examine the rate of suicide that has seemingly left no one here untouched. “Nunavummiut are soaked in unresolved grief,” testified Jack Hicks, an expert witness at the inquiry and Nunavut’s former suicide prevention advisor. Hicks helped with a landmark follow-back study interviewing the families and friends of 120 people who committed suicide in Nunavut from 2003–2006 and 120 control subjects.

A year later, in 2011, the territory released and began to implement an action plan with specific goals, assigned responsibilities and time frames in eight different areas. Those areas, including early childhood education and school curriculum programs, gatekeeper prevention training, and mental health and addiction supports, are intended to address the root causes or risk factors that trigger suicide. The need for a strategy is undeniable. Between 1999 and 2014, 436 Inuit completed suicide. Like Rex, 22 of them were children between the ages of 10 and 14.

Before the implementation plan was tabled in the legislature, however, the territorial government stripped out the column stipulating the financial resources required to implement each item, Hicks testified at the inquiry. None of the other partners was consulted. Not only did the Government of Nunavut never allocate a specific pocket of resources, it never asked the federal government for money to tackle this critical public health issue. As a result, “we’ve had to cobble together funding from various sources,” Natan Obed, Nunavut Tunngavik’s director of social and cultural development, testified.

Nunavut has made progress on implementing pieces of the strategy, according to an independent evaluation. The government’s lack of capacity, poor communication with the other partners and inadequate resources have retarded success, the evaluation states. Nunavut has not yet achieved its overall vision for decreasing suicide rates, denormalizing suicide and keeping children — like Rex — safe.

As I have since learned, drug diversion can occur in most, if not all, hospitals, nursing homes and other medical facilities where highly addictive narcotics like morphine are dispensed.

The overdose death of a care aide at Vancouver General Hospital proves the need for better methods to detect and prevent theft and abuse of hospital medications, coroner Timothy Wiles said in his report Wednesday.

Wiles said Kerri O’Keefe, 36, who had worked in the emergency room for about 15 years, died in her Surrey condo last summer from respiratory failure after injecting a stolen hospital anesthesia drug.

As well, nurses and doctors will be expected to squirt leftover medications into a slush pail that’s a mixture of all drug residuals instead of using sharps containers. “We are looking to make these (remaining) drugs un-usable,” she said. Drug wasting is the term used in health care for discarding partly used medications. Some medical centres squirt leftovers into a bin filled with Kitty Litter to deter anyone from stealing the contents.