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Coroner's report on Kamloops care home death calls for changes

Jack Shippobotham, 79, died three weeks after a violent assault at the Overlander Extended Care Unit in Kamloops.
Image Credit: John Shippobotham obituary/
November 02, 2016 - 11:10 AM

KAMLOOPS - The B.C. Coroners Service has made two recommendations following the death of a Kamloops senior at the hand of another care home resident three years ago.

In her report on 79-year-old dementia patient Jack Shippobotham’s death, coroner Margaret Janzen recommends the Ministry of Health establish a committee or task force to review a report by the Senior’s Advocate on resident-to-resident aggression and determine next steps to implement those recommendations.

She has also recommended the Interior Health Authority report all assaults which result in injuries to the police without delay, something that didn’t happen in Shippobotham’s case.

Shippobotham was a resident at the Overlander Extended Care facility in Kamloops, where he was known to wander into other residents’ rooms, Janzen says in her report. There was another resident who was “known to be very territorial about his room” and “had been violent with people who entered his room uninvited.” Shippobotham entered that man’s room on June 12, 2013 and was assaulted by him.

“A health care aide was passing the room when he heard cries for help,” Janzen says.

Shippobotham suffered a broken nose as well as a hip socket and pelvic fracture. He was treated in hospital and released back to the care home. He required at least four more hospital visits for complications before developing pneumonia and succumbing to his condition on July 2.

Janzen ruled the death a homicide — a neutral term that does not imply fault or blame. The cause of death was identified as pneumonia due to immobilization following the assault. Dementia was contributory, Janzen said.

Further investigation by the coroner revealed staff had concerns with the volatility of the other resident’s behaviour. A lock had been placed on the resident’s door until the facility was told to remove it by the fire marshal.

After the incident, the care home installed a sensor on his door which alerted staff when the door was opened, Janzen says.

“The facility did not report the incident to the RCMP; a family member reported the assault to the RCMP who investigated and determined that Mr. Shippobotham had been assaulted by the other resident,” Janzen says.

Following Shippobotham’s death, criminal charges were forwarded to Crown counsel, which declined to prosecute the case.

Shippobotham’s family waited more than three years for the report, and were continuing to call for results as recently as this past summer. His daughter, Moneca Jantzen, says in a written statement to she is pleased the report is finally concluded, although it was painful to read the description of her father's attack. 

"It is quite clear that much was wrong with the living situation in the Blueberry Ward at Overlander Extended Care. The attacker was known for certain behaviors that made it unsafe for other residents to be housed along with him. Removing the locks from this man's room turned out to be a deadly decision by the fire marshal for my father," Jantzen says. "My father was in relatively good health when we took him to live in this facility in February of 2013 and yet he was dead only four months later. In retrospect, it was an entirely traumatizing experience from start to finish and that he should meet his end the way that he did is tragic."

She hopes the case will bring about improvements for the care of seniors in B.C., and personally would like to see single rooms for mobile dementia patients, locks on doors, increased levels of care with properly trained nurses and aids, improved floor plans and an end to the use of anti-psychotic drugs. 

She applauds the work of the B.C. Senior's Advocate, and is happy to see the coroner recommend Interior Health report all assaults that result in injuries to the RCMP. The Senior's Advocate herself pointed to a lack of standardized reporting upon the release of her study on resident-to-resident aggression. 

"Facilities mustn't be given an opportunity to sweep these incidents under the proverbial carpet," Jantzen says. "Changes can't happen without proper reporting of what is actually going on in the care homes. While such patients are unlikely to be convicted of a crime due to a cognitive impairment, reporting an assault to the police changes the way the incident is treated by the authorities and the degree of accountability goes up considerably."

— This story was updated at 3:40 p.m. Nov. 2, 2016 to add comments from Moneca Jantzen.  

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