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Patient jumped from St. Clare's Mercy Hospital window in 1998
Almost 23 years is an awfully long time to wonder about an open window.
But Tom Careen and his family have agonized over it and likely will never know why the window of Johnny Careen’s room was wide open, allowing him to jump to his death from a seventh-storey window at St. Clare’s Mercy Hospital on July 28, 1998, despite being on suicide watch.
Johnny was 43 years old.
It wasn’t explained in a Crown attorney’s legal opinion to the Royal Newfoundland Constabulary in 2000 suggesting there was no point filing criminal charges.
“Prior to his going out the window, there was no indication that Careen was upset or in a state of distress so as to warn of an imminent suicide,” the document states.
Johnny Careen, however, was under constant care due to a previous suicide attempt at the Waterford Hospital. The day he died, Johnny had been transferred to St. Clare's after a suicide attempt hours earlier at the Waterford Hospital. He tried to hang himself there in a closet, but was found unconscious and was revived by staff.
“While the performance of duty to protect Careen was tragically not able to ultimately prevent Careen’s suicide, that does not necessarily mean that anyone committed the criminal act of failing to provide the necessaries of life,” said the Crown opinion.
"... the open window was the problem. It’s always been the problem to me." — Tom Careen
But all these years later, Tom Careen remains the family spokesman still pushing for answers about why their youngest sibling died that day. The family is convinced there’s a real story that has not been told, no matter who says the case is closed.
Why were Johnny’s rights under the Mental Health Act not factored into that legal opinion, which did not explain the open window, asks Tom Careen, who lives in Placentia.
“I can’t get around it, the open window was the problem. It’s always been the problem to me,” said Tom.
“He had his Charter rights ignored. … I think it’s criminal, to tell you the truth.”
Johnny Careen’s struggles
Johnny Careen suffered from schizophrenia, and would stop taking his medication because he felt it slowed his thinking down, and it caused trembling in his hands. But he also feared the voices in his head and never wanted to hurt anyone, his brother says.
“He said to me one time, ‘I just want to be normal,’” said Tom.
“Jesus I near burst into tears. I should have shouted back at him, ‘Nobody’s normal.”
Johnny wanted what everyone else had — a job and a family, Tom says.
He had a good one — a steward and then a deckhand — on the CN gulf ferry boats and would have been retired at 48 with a good pension, Tom speculated.
But he left that and went out West, where Tom was working as a labourer.
He didn’t do much, other than play his guitar in the apartment, and went back home after about a year.
"Johnny was a ward of the state — he was supposed to be taken care of and he wasn’t, so what happened?” — Nick Careen
Both Tom and his older brother, Nick, remember Johnny most as kind, that all the nephews and nieces loved him, and that he was witty.
Early on the morning Johnny died, Nick and his wife and his sister and her husband were getting ready to go in and visit him at St. Clare’s. They were near Whitbourne when they got word of what had happened.
They turned around and waited until 8 a.m., when they could go see their father at his nursing home.
He looked up from his breakfast and asked why they were there.
“And then he said, ‘Johnny,’ and he started crying. … When he seen us, he knew something was up,” recalled Nick.
He said the family keeps pushing because they never want the health care and justice systems to forget how Johnny was failed.
"Johnny was a ward of the state — he was supposed to be taken care of and he wasn’t, so what happened?” asked Nick.
After the tragedy, he went in and sized up the hospital room window.
“It was big enough for me to get out of, and I am not small,” Nick said, adding it remains a mystery why, if Johnny was suicidal, he was admitted to the highest floor of the hospital.
“Some time or other someone might reveal what really happened,” Nick said.
Nothing could be done: former CEO
Sister Elizabeth Davis, the CEO of the then Health Care Corp. of St. John’s, was on vacation when the vice-president of medical services contacted her regarding Johnny’s death.
“I will remember it until I die,” she said in a phone interview decades after her ties to the health authority ended.
Tom has written to Davis over the years, and she said she eventually stopped answering him because she felt she couldn’t provide closure.
She said he has made it clear he doesn’t think she did all that could be done.
“But I anguished over this. I Looked at it from every possible angle I could have looked at it,” she said.
“If I had felt, as the leader at the time, if there was something that was covered up, something that was missing, something that wasn’t covered in those two independent … separate external investigations, I certainly would have pursued it.”
“I will remember it until I die." — Sister Elizabeth Davis
Davis noted there was internal work to find out what happened, as well as the chief medical officer’s investigation and a review by an independent team from outside the province. Four months after Johnny died, before new security devices were installed on the windows, another man jumped to his death from a patient lounge on the same floor. The independent consultants looked into 10 suicides of city hospital patients between 1991-99. (Four patients drowned themselves, three in the pond next to the Health Sciences Centre.)
But Davis said the investigation work doesn't take away from the Careen family’s continuing pain.
“My heart breaks for them, actually,” she said.
“But from an organizational point of view, from our staff point of view and from my point of view as leader of the organization at the time, there was nothing further I could do to give them the closure they needed.”
Davis said she had no conversations or input into a decision by then justice minister Kelvin Parsons, who declined to appoint a judicial inquiry into Johnny’s death as requested by the family.
“An investigation was conducted into Mr. Careen’s death by the chief medical examiner, in accordance with the Fatalities Investigation Act, and recommendations were made to the hospital,” a 2000 news release by Parsons stated.
“In addition, an independent team of professionally trained medical experts was retained to review all suicides that occurred within the last 10 years, at all institutions which come under the auspices of the St. John’s Health Care Corp. This report was made public in September 1999.”
Numerous justice ministers have come and gone.
Several reviews of the circumstances surrounding Johnny Careen’s 1998 death at St. Clare’s Mercy Hospital have taken place, a justice spokeswoman said.
“The chief medical examiner, the RNC, Public Prosecutions Office, citizens’ representative and a private consultant have reviewed this matter. As well, several internal reviews of the file have taken place by the department,” the spokeswoman said stated.
“This death was an unfortunate tragedy. However, in the absence of new evidence the department considers this file closed.”
Eastern Health said since 1998, hardware has been put in place on windows at St. Clare’s Mercy Hospital to prevent them from fully opening. Windows of the inpatient psychiatry/mental-health unit at the Health Sciences Centre do not open and those in the Waterford Hospital only open partially. Psychiatry/mental-health units at the Health Sciences Centre and Waterford Hospital are locked units and policies have been created and enforced since that time as it relates to levels of observation required.
For privacy reasons due to the low number of individuals involved, Eastern Health would not provide the number of suicides within its facilities since 2008 and said it hasn’t got data prior to that date.
If you need help
- Mental Health Crisis Line, 709-737-4668 or toll-free at 1-888-737-4668. Call if you feel like you are unable to cope, are thinking about suicide or if you are unsure where to turn for help. The Mental Health Crisis Line is a free, confidential service for individuals, family and friends. The crisis line is province-wide, 24 hours a day.
- Mobile Crisis Response Team (St. John’s), 709-737-4668 or toll-free at 1-888-737-4668. If you have a mental-health-related crisis in your home or community and you are in St. John’s and area, call the Mobile Crisis Response Team.
- Sexual Assault Crisis Line, 709-726-1411 or toll-free at 1-800-726-2743. If you have been affected by sexual violence, call the Sexual Assault Crisis Line, 24 hours, seven days a week. Available provincewide.
- Crisis Text Line, text "Talk" to 686868. The Crisis Text Line is powered by Kids Help Phone. Children, youth and adults in Newfoundland and Labrador can text "Talk" to 686868 to connect with a trained, volunteer crisis responder who will help with any issues, big or small. The service is free, confidential and available 24 hours a day, seven days a week.
- In case of emergency, go to the nearest emergency department or call 911 for an ambulance. Emergency departments are staffed 24 hours a day. Nurses and physicians are there to support you during urgent situations.
- A full listing of Eastern Health’s mental-health services and programs can be found at mha.easternhealth.ca/.
— Source Eastern Health