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Inquest recommends training program, more home visits

Jun 16 2012

A training program for care providers and more home visits are among 10 recommendations made by a coroner's jury at an inquest into the death of 76-year-old Joan Andrews.

The developmentally disabled woman was in a "home-share" situation when she died after falling and hitting her head while getting out of bed on Feb. 10, 2011.

The jury said Community Living B.C., the provincial agency that provides care for people with developmental disabilities, should put a training program in place that includes such elements as basic medical terminology and provides information on dealing with various professionals and family members.

It also recommended increasing home visits from once to four times a year and that a case manager be assigned to each person in the home-share program.

On Friday, the inquest heard that an increasing number of baby boomers with developmental disabilities are growing into old age, putting the spotlight on how CLBC, which looks after their community-care needs, interacts with the provincial health system.

Increased and improved communication between the various provincial government agencies was cited as a key area of concern by health-care consultant Keith Pennock, who created the Community Response Network, which provides help for seniors at risk or in an emergency.

He was involved briefly with Andrews' care when she was living in the CLBCapproved home where she died.

"There should be a formalized policy when dealing with someone who may fall between the cracks of the various mandates," Pennock said. "It's imperative that all the major players involved in that person's care are at the table."

That didn't happen with Andrews, the coroner's jury heard.

An earlier audit of CLBC recommended that an integrated case management system be put in place, allowing information about the person's care and medical history to be shared by the groups involved.

That system is not yet in place, testified Patricia Marshall, the acting director of regional operations for CLBC North.

"One of the problems with getting it going were consent and privacy issues," she said.

Coroner Matt Brown asked what was stopping the agencies from sitting down at a table together and discussing a case.

Marshall said that is the "best practice" and a goal, but that it is often easier said than done.

"None of us get up in the morning and say, 'Let's do a crappy job.' Each of us come to this with the best of intentions. Yet the system still breaks down," she said. "I look forward to having systemic barriers removed. That is the solution to a lot of this. - The fact is, we need to work together and we do not do it very well."


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