Suicide investigation: lots of consultations, few communications

In the years preceding her death, Suzie Aubé was hospitalized urgently on several occasions, without her family doctor being notified, reveal the work of the coroner on the suicide of the 55-year-old woman.

At the end of 2017, Ms. Aubé was rushed to hospital four times in two months for poisoning related to alcohol abuse, self-harm and suicidal tendencies. However, the family doctor who followed her was informed of only one event, because the patient told her.

Dr. Potvin gave a fairly accurate account of the many appointments with his patient on Tuesday during the coroner’s hearings. But she had to admit that she did not have all the information on her patient’s history with other health professionals, including the many psychiatrists who had assessed her.

“Sometimes we receive the information, sometimes there are hospitalizations (and) we do not receive them”, replied Dr Potvin, during his testimony before Coroner Andrée Kronström.

Remember that Suzie Aubé took her own life on January 18, 2019 after having obtained her leave from the University Institute in Mental Health of Quebec (IUSMQ). In studying her case, the coroner is looking to see if people like them could be better supported to prevent deaths.

Lack of communication between regions

The lack of communication was all the more limited in this case as Ms. Aubé moved from one region to another, from Saguenay to Quebec.

In another testimony before the coroner, the nurse in charge of the Quebec mental health access point said that she, too, did not have access to all the evaluations to which the patient had been the subject.

However, nurse Frédérique Brousseau argued that the system had improved a lot over the past two years in Quebec with the centralization of the CSLS counter to IUSMQ.

After Ms. Aubé moved, the person in charge of the counter received a request from her family doctor for her to be referred to a psychiatrist. Instead, she referred Ms. Aubé to a support service for people with borderline personality disorders, as well as to a center to treat her alcoholism problem.

When prosecutor Marie Cossette asked her why she had not followed the doctor’s instructions in referring her to a psychiatrist, she replied that the request was “unclear”. She then added that she had to do a “sorting” because sometimes, “as soon as the person is not well, they send them to the psychiatrist”, which “clogs the system a lot”.

Paradoxically, Ms. Aubé was finally seen by a psychiatrist shortly after, since she was again urgently hospitalized in Quebec and this time transferred to IUSMQ.

Ambiguous diagnosis

The discussions also made it possible to learn that Ms. Aubé had never had a clear diagnosis for what presented the signs of a borderline personality disorder. According to the count made by her sister, she has been seen by nine different psychiatrists over the years, especially during her numerous hospitalizations. However, she was never followed by one of them.

Suzie Aubé’s story is one of the five cases that the coroner has chosen to study as part of a thematic inquiry into suicides that began in December 2019.

The investigation began in December with the hearings on the deaths of Jocelyne Lamothe, Mikhaël Ryan and Marc Boudreau. After that of Suzie Aubé, the coroner will study the deaths of Jean-François Lussier and Dave Murray. All of them had serious mental health problems.



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