Serena Perry's death deemed homicide by jury at coroner's inquest

The jury in the Serena Perry coroner's inquest has deemed her death a homicide and presented 11 recommendations aimed at preventing similar deaths, including the implementation of community treatment order legislation in New Brunswick.

The body of Perry, who was an involuntary psychiatric patient at the Saint John Regional Hospital, was discovered in the hospital's amphitheatre on Feb. 14, 2012, with a blue hospital gown wrapped loosely around her neck.

A young male psychiatric patient, who was the last seen with Perry, 22, was considered a suspect in the case, but no charges were ever laid. Perry's exact cause of death could not be determined, police had said.

After deliberating for about four hours on Tuesday, the jury concluded Perry died from asphyxia due to strangulation.

The New Brunswick Coroner Service is an independent fact-finding agency. It does not make any findings of legal responsibility.

The verdict came as a relief to Perry's family, who has maintained from the beginning that she was the victim of foul play.

"It feels great," her mother, Rose Perry, told reporters outside the courthouse.

"There's not going to be another mother suffering the way I did for the last three years. It will never go away, but now the province has got to do that they say they've got to do."

Coroner John Evans had previously told the five jurors their options for her cause of death were homicide, suicide, accident or undetermined.

Natural causes had already been ruled out, he had said.

'Serena's law' proposed

Among the jury's 11 recommendations are that the province introduce community treatment order legislation and that it be called Serena's law.

New Brunswick and the territories are the only governments in Canada that don't have community treatment legislation to ensure patients, such as Perry, take their medication, under supervision, while living in the community.

Earlier in the inquest, the jury heard that Perry would not take her medication when she wasn't hospitalized. She had been admitted to the psychiatric unit three times.

Perry "might well be alive today if this was in place," Evans had told the jurors before they began deliberations.

He had suggested that if the jurors recommended community treatment orders (CTOs), as suggested by some of the witnesses, they might also recommend the provincial government consider naming the legislation "Serena's law."

It just makes me proud that a law like that would have her name because she was such a good person and she deserves it.- Tasha King, Serena Perry's sister

Perry's sister, Tasha King, was overwhelmed by the idea.

"That would be awesome because that means that she changed everything to save somebody else," she told reporters outside the courthouse.

"It just makes me proud that a law like that would have her name because she was such a good person and she deserves it, to be recognized, so much," she said through tears.

"Sorry, I'm just really emotional, really happy right now."

CTOs recommended by inquest 8 years ago

CTOs were part of the Gallant Liberals' election platform last year, but there is no word on when they will be implemented.

In an email statement to CBC News on Tuesday, Department of Health spokesman Bruce Macfarlane said legislative changes to both the Mental Health Act and Infirm Persons Act will be required.

"The government also wants to consult with consumers, groups, families, interested stakeholders, communities, partnered agencies and departments, professional associations and societies non-government agencies and others,. including the Human Rights Commission and the Office of the Public Trustee," he said.

This isn't the first time CTOs have been recommended by a coroner's jury. In 2007, a Moncton jury looking into the death of Kevin Geldart, a 34-year-old biopolar patient who died after being tasered by the RCMP, made three recommendations related to community treatment orders.

On Monday, Ward Yuzda, a Saint John-based psychiatrist, testified a community treatment order (CTO) would have been very effective in Perry's case.

It is "crucial" the system be introduced in New Brunswick, Yuzda said.

Nora Gallagher, the manager of adult mental health services for the Horizon Health Network in the Saint John area, also said it's time for New Brunswick to implement community treatment orders.

Horizon came up with 8 recommendations

Advocating for community treatment orders was one of eight recommendations the Horizon Health Network presented to the jury on Monday.

Horizon came up with its own recommendations based on testimony during the inquest, said Sue Haley, the director of addictions and mental health in the Saint John area.

"CTOs are a less restrictive option compared to involuntary hospitalization, helps the patient receive treatment in the community and reduces the risk of a worsening of the symptom severity," said Haley.

Implementing CTOs would require the support of so-called Flexible Assertive Community Treatment Teams — mental health professionals who offer support to patients in the community, she said.

The jury adopted five of the other recommendations proposed by Horizon, including:

• Explore options to enhance collaborative care for patients who will require ongoing support from the mental health system and other agencies.
• Review the ratio of registered nurses to licensed practical nurses on the unit and compare it with national benchmarks.
• Offer smoking cessation programs for the "large proportion" of mental health patients who smoke.
• Education and training for psychiatric unit staff, particularly dialectical behaviour therapy and cognitive behavioural therapy, which are designed to change unhelpful patterns of thinking and behaviour.
• Enhance the patient information system.

​Horizon's recommendation to consider moving the psychiatric unit closer to the emergency department and having the nursing station at the entrance of the unit were deemed "nice to have" by the jury.

The jury's additional recommendations included:

• Spot checks of patients when they re-enter wards to ensure they don't have anything harmful.
• Therapeutic recreational activities, both indoors and outdoors.
• Specialized training for security staff dealing with incidents involving psychiatric patients.
• Ensuring hospital administration has updated contact information for patients' primary and secondary caregivers.

Coroner's powers limited

The jury heard from about 50 witnesses during the inquest, including health officials and police officers.

It did not, however, hear from the male patient who was considered a suspect in Perry's death.

He was issued a summons, but refused to testify and the coroner could not compel him to, the courtroom heard.

The patient, whose name is protected by a publication ban, now lives outside New Brunswick,  and the coroner has no authority outside the province.

Perry left the psychiatric unit twice with the male patient on the night she died. But on the second occasion, they did not sign out and the male patient, referred to only as B.M., returned alone.

B.M. told officials that Perry, who suffered from paranoid schizophrenia, talked of suicide on the night in question and mentioned "an alien" that was following her.

He said Perry frightened him and he left the amphitheatre. As he left, Perry grabbed hold of his hospital gown and it came off.

The inquest heard there was a faulty latch on the amphitheatre door, which was supposed to be kept locked.

It had been that way for months, two security guards testified.

Horizon had recommended the electronic system that tracks requests for repairs be enhanced to notify the requestor when the work is complete.

But the jury did not include that among its recommendations.