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A judge has not given any recommendations as part of a fatality inquiry report that probed the death of Carol Pifko.
The 61-year-old died at the Royal Alexandra Hospital in 2009, after receiving a double dose of a psychiatric drug. During the inquiry, representatives for the Pifko family made recommendations on changes in how treatment is carried out, however the judge dismissed them.
Health Minister Fred Horne says the file will be reviewed.
"In this case, because there aren't any we'll have to go back and look at the original circumstances," Horne told reporters. "I haven't read the brief but I've been told that the family themselves had some ideas of what could be done differently. We'll look at that and we'll look at the other processes in the health system that might need to be refined or amended."
"This is about preventing this from happening to some one else."
A public fatality inquiry is held to establish the cause, manner, time, place and circumstances of death. Once the inquiry is complete, the judge provides a written report and may make recommendations for prevention of similar incidents.
Fatality inquiries do not include any findings of legal responsibility. (sj/scb)
