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in looking at nicole’s charts, ywca regina ceo melissa coomber-bendtsen said she saw someone failed by a system, someone who wanted to get sober, had goals and was making steps to achieve them.
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also, they suggested checking windows and room buzzers as part of introducing residents to their rooms. the inquest found that the window crank in nicole’s room was broken at the time of her death, allowing for it to be pushed open further than normal.
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