Christal Cool had every reason to believe her son would be safe. She’s been a nurse for 21 years, so she was in a position to trust the system that he was entering when he checked himself into Vernon Jubilee Hospital one day in early February after he decided he needed help with his mental health.
Ezra Cool was experiencing psychosis. And yet almost a week after entering the hospital, the 22-year-old never made it out of the emergency department to one of the hospital’s two psychiatric wards.
Instead, he wound up dead on the side of the road.
Family has said that despite the fact that Ezra was admitted as an involuntary patient under the Mental Health Act and as such required 24/7 supervision, he managed to escape the hospital.
Ezra was the victim of a Feb. 12 hit-and-run by a semi-truck on Highway 6, just over a kilometre away from the hospital. His body was found only a couple hours after he walked out of the hospital in just his socks and pyjamas, said the family. The driver of the semi has not been found as of March 25, according to police.
“I trusted my son would be safe. He was not. My son should still be alive,” Christal told The Morning Star.
Her words are echoed by a trio of nurses who spoke to The Morning Star about Ezra’s case, and about the broader circumstances at Vernon Jubilee Hospital which may have contributed to his death.
The Morning Star is not publishing the names of the three nurses, who spoke on the condition of anonymity out of concern for their job security, but felt that nothing would change at the hospital if their perspectives from inside its walls aren’t heard.
“His death could have easily been prevented,” said the first nurse The Morning Star spoke to.
“It was just a matter of time before something tragic happened,” the second nurse said.
The third nurse described the position of himself and his colleagues as “the frog in the boiling pot, where things keep worsening, and we sort of become numb to it.”
Christal said Ezra was the best big brother and son anyone could hope for. A former Royal Canadian Sea Cadet, he had moved out but lived five minutes away from his family and visited every weekend to play Dungeons and Dragons with his sister and her friends, took both his sisters up to Silver Star Mountain, enjoyed hiking and playing video games and laughing with his siblings.
“It is so devastating that he’s gone,” Christal said.
She added she’ll spend the rest of her life advocating for Ezra, and for remedies to the cracks in the system through which he fell.
The nurses all expressed the same wish as Christal: for change to take place so that another avoidable tragedy doesn’t come to pass.
Inside VJH
Everyone who works in Vernon Jubilee Hospital’s emergency department is to some degree an adrenaline junkie, said Nurse Three.
“It’s a chaotic, fast-moving, unpredictable, sometimes very dynamic situation, to say the least,” they said.
It’s a highly capable team that comes to the aid of whoever walks through the emergency room doors, they added. The problem is that the team is severely understaffed.
There are varying beliefs as to why this is.
“We are constantly understaffed, and we’re being told that there are no nurses,” Nurse One said. “Well, there are nurses. Unfortunately it’s just a toxic environment, where anytime you speak up too loud you’re hauled into the office and you’re disciplined, you’re being told you need to be a team player.”
Nurse Two likewise suggested there is a culture of one-way accountability at Interior Health that’s hurting morale among those actually caring for patients.
They offered an example of what nurses are told when a patient becomes violent toward them or other patients.
“Whenever there’s a violent incident, the first question is ‘how could you have handled it differently,’ or ‘what could you have done differently to not end up being the victim of violence.’ It just feels like there’s always this kind of almost gaslighting from the management level.”
Together, the nurses described a vicious cycle in which an increasingly dysfunctional workplace culture leads to staff attrition, which leads to more demands put upon the remaining staff, which leads to even more dysfunction. To cracks in the system.
Nurse Two said a review of Vernon Jubilee Hospital was done around the time the province was announcing established nurse-to-patient ratios in hospital settings. They said the reviewers who toured their units determined that somewhere around 19 nurses needed to be on shift at a time. They said their baseline is barely over half that complement of nurses.
“It just feels like we’re getting no break from this really high risk environment, and of course there’s always the risk that the health authority attempts to blame us for things to avoid taking accountability for themselves.”
No break relief at VJH
As it happens, Nurse Two’s comment of “getting no break” was meant almost literally.
The three nurses confirmed that there is no break relief at Vernon Jubilee Hospital. Nurse One said they’ve never seen or heard of that at a hospital before.
Having no break relief means no one is there to cover nurses’ patients while the nurses take a break for food or rest in the middle of a 12-hour shift.
Having no break relief is a significant safety concern, the nurses said.
Nurse One stated emphatically that if break relief had been in place, it would have been the safeguard that would have prevented Ezra’s death.
“They refuse to do it because it always comes down to budget, budget, budget,” they said. “There’s been emails sent out asking for break relief, asking for changes, and it’s either not answered we’re or told, ‘we’ll look into it.’ And then it never happens. Had they actually taken safety seriously, Ezra would be alive.”
Currently, hospital staff take breaks in the fleeting moments when it feels possible to do so, and it’s the nurses who already have too many patients under their own watch who have to cover for one another.
“When things feel safe we try to allow each other to take breaks, and at that time we then double the number of patients we’re supervising. And when things aren’t safe we just don’t take breaks, and that’s happening more and more,” said Nurse Two. “I mean, there’s many days going where nurses are getting one of three meal breaks on a 12-hour shift because it’s just not feasible to take any more breaks because things are too busy and it wouldn’t be safe to leave.”
Interior Health told The Morning Star in an an email that break relief is provided to all employees within the health authority, as required under various collective bargaining agreements.
“Each unit will set their specific meal break periods for all shifts to meet the needs of patients and the teams providing direct care, including regular rest breaks and equitable workloads for staff. Staff communicate with colleagues, charge nurses, and patient care coordinators if any changes to break coverage is required,” Interior Health said.
However, Norse One clarified that this is not true break relief of the sort seen in other hospitals. True break relief, they said, entails having designated workers come in during day or night shifts specifically to provide break relief. At Vernon Jubilee Hospital, break relief is being provided to nurses by other nurses who also have their own patients to look after.
“(Other hospitals) do break relief to make sure all these patients are getting the care they need and they’re being watched appropriately, so no one leaves, like (Ezra) did, because it’s too busy,” the nurse said. “They need appropriate break relief, meaning that someone’s there covering my assignment, covering triage, covering trauma, covering the mental health area that does not have patients of their own to watch.”
Nurses can typically be on a four to six patient assignment at the hospital, the nurse said. When another nurse goes on break, that nurse has to take on an additional four to six patients.
“It’s unsafe,” Nurse One said. “No one can watch that many patients.”
What Interior Health is calling break relief is not in fact break relief, the nurse asserted, adding real break relief was always in place in other hospitals they’ve worked at.
Real break relief is the safety valve that prevents people like Ezra from escaping the hospital, the nurse said.
Nurse One is concerned that not enough is being done in the wake of Ezra’s death to prevent a repeat incident. On March 19, a month after Ezra died, they said the emergency department was down numerous staff and there was no one doing break relief besides those on assignments, meaning nurses were having to watch up to 12 patients at a time, and only one nurse was at triage and having to watch a full waiting room while registering and triaging patients.
The nurses wonder why more money isn’t being invested things like break relief, or more generally, in on-the-ground patient care. They insist there are nurses to go around, and the B.C. government itself recently touted that 83 healthcare professionals had been recruited to the health authority from the U.S. since last year.
Nurse One has an answer. It’s that nurses are expensive, and the health authority has budgetary priorities.
“The directors chose to be ‘budget over safety,’” the nurse said. “That wasn’t an option for the charge nurse.”
They were referring to the charge nurse who was working when Ezra escaped, who they believe is now on leave. That charge nurse was put in a dangerous situation and now has to live with the idea that they were the one on duty when Ezra died — an unfair burden, according to Nurse One.
“They’re probably going to try to blame her,” they said.
‘Bureaucratic bloat’
While Nurse One believes that a prioritization of ‘budget over safety’ is a major pitfall for Interior Health, Nurse Three believes there is in fact enough money in the system to fix the problems at Vernon Jubilee. The problem is that money is being poorly allocated.
“Our healthcare system is straining under the weight of its own bureaucratic bloat,” they said. “There is just an infinite, stratified, multi-layered management system of managers and assistant directors and directors and associate directors and clinical directors, and endless non-clinical positions where we spend so much money on these people that are not actually delivering patient care in a system that is largely static.”
According to Interior Health financial disclosures, the health authority had a corporate budget of of $295.4 million for the year ending in March 2025. That’s up from $252.2 million the previous year, a 17 per cent increase. Prior to the pandemic, the year ending in March 2020, the corporate budget was $172.5 million.
Interior Health’s expenses have accelerated across the board since the pandemic. The year ending in March 2020 saw a budget for acute care of $1.3 billion. That budget has ballooned to $2.2 billion in 2025.
But the nurses believe money is being spent on upper management when it could be better spent elsewhere.
In February 2024, Dr. Robert Halpenny was appointed chair of Interior Health’s board of directors, replacing Dr. Doug Cochrane after his passing earlier that month. At that time, the health authority also announced the addition of two new directors, William Gerrand and Bonnie Pearson, increasing the size of Interior Health’s board of directors.
Nurse One claims that a 2025 investigation by the Ministry of Health found that Interior Health has too many directors, but the concern was ignored. In an email to The Morning Star, the ministry confirmed that the province launched a review of the Provincial Health Services Authority (PHSA) and regional health authorities in spring 2025, but said a specific review of the number of Interior Health directors was not part of that review.
The province appears to have identified the problem. The ministry said the province is aiming to “lessen the administrative burden on health authorities so they can focus on what matters most: providing care to patients across B.C.” It added that early findings from the review show “a real need to remove bottlenecks, reduce redundancies and create better consistency, coordination and accountability at lower costs” throughout the provinces’ healthcare system.
The review is ongoing, but the ministry said it’s working to address these findings now by consolidating administrative and corporate services into a new shared service organization, allowing health authorities and the PHSA to focus on directly caring for patients.
The ministry said an update on the shared service organization — which includes HR, procurement, supply chain, legal, and financial services — is “expected soon.”
The government is looking to make shared corporate and administrative services mandatory to “improve innovation, consistency and coordination among the regions,” meaning more money, time and effort that can be directed to caring for patients, the ministry said.
Until it is implemented, it’s difficult to say how effective this strategy will be in reducing administrative and corporate costs and directing more money towards patient care in the form of better staffed hospitals. The nurses that spoke to The Morning Star all said changes can’t come soon enough, and they’ve heard plenty of promises made with little in the way of promises kept.
Including retainers, meeting fees and expense reimbursement, Interior Health’s board was paid a total of $260,587 for the year ending in March 2025. That total was $209,264 the previous year, representing a 25 per cent increase.
Budgetary concerns have led to questionable decisions. One example that distills the issue is the recent installation of security doors in the hospital’s mental health area.
“We just had doors installed on it so it can be a closed unit,” Nurse One said. “That’s more for some people who are quite violent, but you can put stretchers in there too in case someone’s at a high risk of leaving.”
However, there’s a flaw with the security door system that speaks to the fundamental issue of ‘budget over safety’ that the nurse alleges.
“The alarming thing is that the secure area, the two doors that lock so people can’t get out, they don’t lock from the inside, they only lock from the outside. So if (a nurse) goes to get in there they have to swipe to get in, but a patient can just push the door to get out if they want to leave,” Nurse One said.
“We asked why and upper management directors declined it, saying they’re not allowed to lock the doors and make it a true secure area because they would have to staff two nurses there always,” they explained. “It’s a budget thing.”
Had that been a true secure area, Ezra could have been transferred there, the nurse said.
“It could have been locked, and he wouldn’t be dead.”
Patients stuck in limbo
Some patients at Vernon Jubilee Hospital are entering the emergency department only to get stuck in a strange void.
Nurses One and Three described what is known as hospitalist holds.
Hospitalists are doctors who are dedicated to in-patient care and work exclusively in hospitals. They’re the physicians who take care of admissions and send patients from emergency to different wards in the hospital. They’re the family doctors of the hospital, said Nurse Three, doing a lot of heavy lifting and managing admitted patients for a wide variety of ailments, from sepsis to pneumonia.
According to Nurse One, there aren’t enough hospitalists, and they were getting burnt out. Nurse Three said what followed was that the hospitalist service put a cap on the number of admissions any hospitalist will accept at any one time.
“Beyond that, patients are admitted to what we are calling hospitalist hold, which is essentially no doctor,” Nurse Three said.
“It’s total limbo. So you’re sick enough to be admitted to the hospital but you’re admitted to no doctor, so it’s falling on the nurses to manage the care of these patients without physician guidance, which is insanely dangerous from a licensing perspective.”
These patients are “languishing in emerg, filling the beds, filling the hallways, with no physician service that’s responsible for them,” Nurse Three added. “They’re deteriorating. A couple of them have died without having a physician assigned to them.”
“This is something that our upper management did nothing about, they kind of just looked the other way,” Nurse One said. “These are deaths that could have been prevented and they weren’t held accountable.”
Nurse Three said over the past few months there have been an average of 15 to 20 patients in hospitalist holds.
It’s not something they’ve seen anywhere else.
“This admitting to no doctor, as far as all of my experience in healthcare goes, is completely unprecedented. I’ve never seen that before.”
It puts charge nurses in the position of having to “play God,” as the nurse put it, deciding who gets to see a doctor and who doesn’t. Those who deteriorate enough go from having no doctor to being assigned to the intensive care doctor, “because you circled the drain long enough that you’re becoming unstable. So that’s not a good circumstance either.”
When asked about hospitalist holds, Interior Health said it’s doing what it can to bring in more staff while hearing concerns.
“Interior Health recognizes the pressure nurses and their colleagues at Vernon Jubilee Hospital face, particularly during busier times at the hospital. To address this, Vernon Jubilee Hospital is bringing in additional staff whenever possible to address immediate pressures,” a spokesperson said.
Nurse Three said hospitalist holds is not only a detriment to the patients who aren’t admitted to a doctor; it creates chaos in the emergency department, which is already a chaotic environment at the best of times.
“The emergency department doesn’t close the doors, and so it doesn’t matter if we are full to the brim at seven in the morning, we continue to see people and continue to shoehorn people into whatever corners we can find to try and take care of them,” Nurse Two said.
Such is the environment that Ezra went into and stayed in for six days and didn’t leave until he did so on his own volition. One question his family and hospital staff alike have been mulling is why he wasn’t moved from emergency to one of two psychiatric wards in the hospital.
Nurse Three said multiple dedicated psychiatric staff have corroborated the fact that who gets transferred to these psych wards is decided by a somewhat mystifying system.
“It’s quite opaque to emerg staff as to who gets taken and why,” he said. “With Ezra, (a hospital staff member) had him as a patient on the day shift, proceeding the night shift where he eloped and subsequently died. She was advocating for him to go to the psych ward … she was told basically sorry, no, we don’t think he’d be a fit for the ward or something like that. There was some sort of bullshit reason for not taking him despite him being six days in emerg.”
Instead, according to the nurse, a woman who was not psychotic or a threat to her self, but had postpartum depression, was admitted to the psych ward.
“She had only been in emerg for 12 hours at that point and she was taken to the inpatient psych ward over Ezra.”
The nurse said he doesn’t mean to minimize the potential seriousness of postpartum depression, which can induce psychosis, but said the decision-making around who gets out of the emergency department and into the psych ward lacks clarity.
There are no windows in the emergency department, and no passes to go outside under supervision. There is noise and disruption around the clock. People screaming and crying — whatever unfolding situation that may come through the door. It’s no long-term place for a psychiatric patient with acute symptoms, said Nurse Three, who added it’s no wonder Ezra tried to get out.
Not enough changes since Ezra’s death
Nurse One says little has changed at the hospital in the six weeks since Ezra’s death.
“Came into work this morning. Zero changes made, no break relief, no care-aides to help, no extra staff for hallway volume,” they said March 1.
“Only change so far is adding a workload nurse to the mental health secure desk 9 a.m. to 9 p.m., but (Ezra) left due to no staff watching him at night so this doesn’t solve anything and it’s only temporary,” they added March 6.
Interior Health expressed in an email that it is trying to foster an environment of communication and responding to concerns among staff.
“Units have daily huddles to give staff an opportunity to raise and address concerns,” the health authority said by email.
Nurse One said this environment of ostensibly open communication isn’t in fact being fostered. Instead, those who speak up are being singled out in confidential meetings.
The nurses agree that there is a system of one-way accountability within the health authority wherein upper management avoids criticism for decisions that affect on-the-ground staff.
“No one is going to be fired, no one is going to be disciplined,” Nurse One said, referring to upper management in the wake of Ezra’s death.
The nurse exempted from criticism Vernon Jubilee’s emergency manager, who they said is “amazing” and doing the best she can under severe budgetary limitations. They instead aimed criticism at the directors who make the high-level budgetary decisions.
Accountability has been slow to manifest in the case of Ezra Cool. The Morning Star has attempted to speak to numerous individuals in high positions but has been declined interviews. A near universally cited reason for declining interviews has been that there is an ongoing police investigation into Ezra’s death. Nurse One calls this a convenient excuse.
Interior Health declined to offer an interview with its CEO, Sylvia Weir, for this reason. The same goes for the B.C. Nurses’ Union.
Vernon-Lumby MLA Harwinder Sandhu, who is also a nurse, declined an interview for the same reason, though she did provide an emailed statement.
“My heart is breaking for the family and friends of Ezra Cool in the wake of his tragic death. When we lose someone in our community, it is felt far and wide and as a mother, this is an unimaginable tragedy,” Sandhu said. “Our team has been in touch with the family as well as the Minister of Health and will continue to offer what support we can. A top priority for the RCMP, local health authority, Ministry of Health, and my office, is supporting Ezra’s family.”
Overburdened nurses are living with feelings of guilt at having lost Ezra, the three nurses said. They also feel nurses are the ones who shoulder the blame for these incidents instead of the directors.
“You rarely see upper management. They are happy to release statements on behalf of the hospital, but we don’t see them in the hallways with us when we have people lined up there,” Nurse Two said.
“I can’t begin to tell you just how devastated a number of me and my colleagues are about what happened to Ezra Cool,” the nurse added.
It’s not for a lack of trying.
“Vernon is probably one of the best emergency departments in the Interior region in terms of the quality of the doctors and the nurses that we have,” they said.
The nurse stressed that it’s an exceptional team that is exceptionally under-equipped.
The nurse and her colleagues are hoping real change takes place before the next patient slips through the cracks.