There should be a coroner's inquest into the suicides of five St. Joseph's Hospital psychiatric in-patients — including Nicole Patenaude.

A full public examination of the circumstances surrounding their deaths and a jury's recommendations on how St. Joe's — and all other Ontario hospitals — can avoid similar deaths would be taxpayer money well spent.

Hospital suicides happen more often than you might guess. An investigation by the TV show "W5" in 2014 showed in the 10 years before that at least 300 hospital patients died by suicide across Canada. Of those, 98 were in Ontario.

There have been at least six inquests in Ontario looking into the issue. One of those probed into three deaths at the same hospital. Several of those suicides were hangings. One involved a patient jumping out of a window. Another happened when a patient left the hospital, took a number of pills and froze in a parking lot. Dozens of recommendations have flowed from those inquests.

And yet …

In the past 18 months, five in-patients at the West 5th campus of St. Joe's have died by suicide. Four of those took place within the hospital itself.

Nicole, 20, was on a day pass on May 16 when she jumped from a bridge onto Hwy. 403 and died. I recently published a long story about her life, her mental illness and her suicide.

Her mom, Carol Patenaude, is left with many questions about Nicole's care and the last day of her life. At 10:30 a.m. that day, Nicole met with a member of her care team. At 11:30, Nicole wrote a suicide note and made a goodbye video. At 4 p.m. she jumped.

Carol believes an inquest may help her understand her daughter's death, help four other families understand their tragedies and bring about life-saving changes across Ontario.

But it will take the will of the Office of the Chief Coroner to make that happen. Nicole's death and the others do not meet the criteria for a mandatory inquest under the Ontario Coroner's Act.

A spokesperson for the provincial coroner's office says at this time there is no plan for an inquest into Nicole's suicide or any of the others at St. Joe's.

The act says there must be an inquest in cases where there is a death of a person in a psychiatric facility where the use of mechanical restraints were a factor in the death. But that was not the situation in the St. Joe's cases.

The act also says there must be an inquest in cases where someone dies in police custody or in the custody of a correctional facility. And yet it does not mandate an inquest for psychiatric patients who are on a Form 1 — which forces them to remain in the custody of a hospital.

In Ontario there are Death Review Committees that examine specific categories of deaths in the province and make recommendations to avoid similar deaths. It includes a Patient Safety Review Committee (PSRC). Though the latest annual report is not yet complete, The Spectator was able to obtain redacted case reports reviewed by the PSRC. They include the suicides of two patients. One was a man who was given a razor to shave and he used it to cut his throat. The other was a woman who overdosed while on a day pass.

St. Joe's is currently waiting for results of an external review it requested into the "cluster" of three suicides that took place at the West 5th Campus in 2016. The review is being conducted by a former chief coroner of Ontario and a former chief psychiatrist at a major Ontario hospital. The results were expected in February, but were not ready. Since February, Nicole died as did another patient after her.

The results of the review, which will include recommendations, are now expected to be released on Friday at noon on the St. Joe's website. [July 14 update: Link to announcement and review]

The results will be shared first with the coroner, the families and the hospital staff, says Dr. Ian Preyra, deputy chief of staff at St. Joe's, who is chief of emergency medicine and also a coroner. Then with the public and psychiatric hospitals across Ontario. The implementation of recommendations will be overseen by a senior group of St. Joe's staff.

"We're going to continue to be extremely open," he says.

Preyra says the review may make a coroner's inquest unnecessary because it could cover the same ground. He says the coroner's office will be asked to examine the results "critically" to "determine if it satisfies all the reasons why we do an inquest."

While the review is certainly a good step, it is not the same as an inquest. At an inquest, witnesses are called to testify, the families of the deceased can have standing, the scope can include all five deaths, a jury is able to ask questions and form recommendations and — most importantly — all of it is done in public.

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Of course, there is one massive flaw in the inquest process. And that is that recommendations made by the jury are non-binding.

So no matter if there is an inquest or not, any potentially life-saving changes to prevent more suicides at St. Joe's are left up to the discretion of the hospital to implement.

Let's hope it does.