Verdict at coroner's inquest - bhupinder singh kang

Ministry of Public Safety and Solicitor General VERDICT AT CORONER’S INQUEST
An Inquest was held at Chief Coroner’s Courtroom in the Province of British Columbia, on the following dates Matsqui-Sumas-Abbotsford (MSA) Hospital Abbotsford, BC

Medical Cause of Death
a) Acute combined opiate, ethanol, fluoxetine and Sertraline intoxication Giving rise to the immediate cause (a) above, stating The above verdict certified by the Jury on the Presiding Coroner's Printed Name
Presiding Coroner's Signature
Pursuant to Section 38 of the Coroner’s Act, the following recommendations are forwarded to the Chief Coroner of the
Province of British Columbia for distribution to the appropriate agency:


TO: Dave Anderson, President/CEO
WorkSafe BC
We recommend the following:

1. That WorkSafe BC obtain all relevant documents (clinical or chart notes) in the possession of the
workers GP, all treating physicians, hospitals and pharmacists on a regular basis during any period where a worker’s benefits are suspended. 2. That WorkSafe BC obtain the written opinion of the worker’s family physician and any treating specialist physician prior to making decisions involving mental illness, regardless of whether the mental illness has been accepted as compensable. 3. When video surveillance is obtained, WorkSafe BC should request a written opinion from the worker’s general practitioner or specialist regarding the relevance of that evidence prior to any decision being made based on that evidence. 4. That WorkSafe BC considers having a single employee manage each file and be responsible for any and all communication with the worker to ensure consistency in messaging as it pertains to the workers claim status and any decisions about entitlement. This will ensure a single point of contact for the worker. A different case worker can be requested by the worker. 5. That WorkSafe BC consider implementing a bi-annual training program that educates staff on the critical factors specific to dealing with patients who may have mental health issues and that it require all staff in adjudicative positions to complete it. 6. That WorkSafe BC involve the vocational rehabilitation consultant at the earliest opportunity in a 7. That College of Pharmacists of BC (PharmaNet) and WorkSafe BC work together to develop a memorandum of understanding such that the WorkSafe BC adjudicator responsible for file management has ready access to the workers PharmaNet profile with appropriate safeguards respecting personal privacy. VERDICT AT CORONER’S INQUEST
FINDINGS AND RECOMMENDATIONS AS A RESULT OF THE INQUEST 8. That WorkSafe BC ensure timely implementation of all of the recommendations outlined in the Case Review into the death of Mr. KANG that was completed by Dr. Graham, Dr. Meloche and Mr. Hopkins in April 2006. Also, that WorkSafe BC’s compliance with the recommendations be reviewed annually by an independent party and the results be published in WorkSafe BC’s annual report. 9. That WorkSafe BC consider transporting “inter-jurisdictional claimants” to British Columbia at the earliest possible opportunity for a complete “physical and mental” examination/assessment such that appropriate treatment can be initiated in a timely manner. Alternatively, a qualified team representing WorkSafe BC can be dispatched to those jurisdictions to attend the worker at the earliest opportunity. 10. Where a claim is rejected based on section 57(2)(b) of the Workers Compensation Act, WorkSafe BC consider obtaining an independent expert opinion to examine the worker’s refusal to engage in the recommended treatment in order to determine if it is willful. The expert must be acceptable to the worker prior to the examination. 11. That WorkSafe BC consider establishing a process to monitor the claims of fragile and high risk worker’s while they are in the appellate process. 12. That WorkSafe BC develops a practice directive that mandates active clinical monitoring and management of high risk mentally ill worker’s by a staff psychologist to ensure early intervention and appropriate ongoing care. 13. That WorkSafe BC letters to worker’s containing instructions about benefits be written in plain, non- confrontational, language with special consideration given to the sensitivities of worker’s with identified mental health issues. 14. That WorkSafe BC letters to worker’s containing instructions about benefits include and highlight the workers opportunity to seek the advice of advocates, social workers and worker’s advisory services regarding their claims. 15. Where mental illness is identified, consultation with a worker’s GP or specialist should take place prior to initiation of WorkSafe BC surveillance for assessment of effects on a client’s mental health. 16. Where a claim is rejected based on Section 57 (2)(b) of the Workers Compensation Act, that WorkSafe BC consider making available appellant benefits on request of the worker; and provide notice of all available appeal benefits to all worker’s whose claims are rejected or suspended. VERDICT AT CORONER’S INQUEST
FINDINGS AND RECOMMENDATIONS AS A RESULT OF THE INQUEST 17. Where suspension of a WorkSafe BC claim is pending, the worker shall be advised that he or she has 60 days before discontinuation of benefits, with the final deadline stated in the letter, and opportunities to seek independent advice explicitly stated.


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