In the months before an elderly North Vancouver woman died of hypothermia in Lynn Canyon Park, the Alzheimer’s patient wandered from her care facility twice and her wrist monitor was not regularly checked, despite concerns raised by her family.
The family of Joan Warren, 76, knew she was at risk for wandering — a condition common among Alzheimer’s patients — and had relayed those concerns to staff at the Lynn Valley Sunrise care home when Warren moved to the facility four months before her death.
Despite that, Warren’s care plan did not address those issues. Between September and October, the elderly resident was found outside the building twice and nobody checked to see if she was wearing a wrist monitor to track her movements.
Even if she had been, the pagers that were supposed to be triggered by the wristbands if residents left the building weren’t working. They had been “malfunctioning for some time with no action taken to address the issue,” according to a coroner’s report into Warren’s death.
On Dec. 6, 2013, the last day Warren was seen alive, a staff member saw her heading to the front doors of the care home, putting on her jacket. But the staff member, who had not been properly trained, didn’t recognize that behaviour as concerning and didn’t intervene.
Those are some of the disturbing findings from coroner Lisa Graham’s investigation into Warren’s death. The coroner has ruled Warren’s death as accidental.
A hiker in Lynn Canyon Park found Warren’s body two days later, off a trail south of Twin Falls. She died of hypothermia, likely after falling and breaking her arm, according to the coroner. At the time Warren disappeared, temperatures dipped well below freezing and searchers had previously combed the park and surrounding area without finding her.
After her death, both Warren’s family and health authorities questioned how she was able to get out of the care home, given the concerns that had been raised about her wandering.
The coroner’s report makes it clear that many of the procedures supposed to be in place weren’t being followed at the time.
Following Warren’s death, both the manager of the care home and regional manager of Sunrise facilities were removed from their positions. The care home also changed its procedures to check wristbands more often, install security cameras, and retrain staff to recognize residents at risk for wandering.
The coroner’s report concluded changes made at the facility had subsequently addressed the problems that contributed to Warren’s death.
Paul Markey, regional manager of community care facility licensing for Vancouver Coastal Health, said once problems were identified, the facility quickly made changes needed.
Some of the problems — such as the propensity for residents to cut off their wrist monitors — weren’t ones staff would necessarily have been able to predict or ones that would have been picked up in more routine inspections, he said.
“There’s always a balance with residential care facilities,” he said. “These are people’s homes. They’re not in a secure prison.”
