But the Alberta government agency that operates health facilities says an internal review came to the same conclusions within weeks of the death of Lorraine Adolph, 68, who died sometime after she went outside for a smoke.
"That is actually something we've implemented," Mark Snaterse, director of addictions and mental health for Alberta Health Services, said Tuesday.
Adolph, who suffered from schizophrenia, had been given permission to step outside Alberta Hospital Edmonton for 15 minutes for a smoke. She went out at 11 a.m. on Dec. 4, 2008, in sub-zero weather and did not return.
An immediate search of the grounds — which is almost 70 hectares and include 40 buildings — was conducted by vehicle. Two other patients were missing that day and a foot search was not done until nine hours later.
A search of the hospital and inquiries at nearby businesses turned up nothing.
Adolph was found a week later during a followup search, her frozen body just 800 metres from where she was last seen. She had been admitted to the hospital just two days before she disappeared.
Snaterse said the grounds are now divided up into search areas, which are themselves marked out into grids. Search teams for each area have been assigned and are on duty around the clock.
Emergency response teams practise several times a year, rehearsing scenarios from fires to missing patients.
In 2009, staff re-created the circumstances that cost Adolph her life, Snaterse said.
"We tried to replicate that exact incident of an elderly patient who was off in an isolated area of the hospital, hidden away in an alcove," he said.
"We initiated our new grid search and we located the patient quickly. We're much more comfortable with the situation today."
The fatality inquiry also recommended the hospital have a quad or a snowmobile to speed up a search.
"We're going to have a snowmobile and a quad available," Snaterse said. "They're still determining exactly what would be best."
The hospital is still considering a recommendation to build a secure outdoor area for patients who wouldn't normally receive ground privileges.
"It's an issue that we struggle with."
Alberta legislation prohibits smoking on provincial property, but Snaterse said patients with schizophrenia who smoke find it particularly hard to do without. He said that issue is also being examined in a wider internal review of the department's policies, expected early next year.
"We do anticipate there will be some recommendations specific to that issue of smoking."
Martin Garber, the lawyer for Adolph's family members, said they didn't want to comment on the report.
During the inquiry last summer, Adolph's son said his mother had a history of wandering off and should never have been left alone. Barry Adolph said his mother had previously left another hospital and was found three days later in a hotel room.
Fatality inquiries cannot assign blame for deaths, but they make recommendations to prevent similar tragedies.