On Sept. 2, 2017, a nurse was nearly strangled to death by a patient in the Montreal General Hospital’s psychiatric emergency ward. The incident prompted a national outcry.
Last week, the Montreal Gazette published a series of articles on “Hospital (In)Security,” in which they attempted to uncover the reason for the attack.
The newspaper blamed the incident squarely on budget cuts, suggesting they had resulted in a lack of security guards on the ward.
Isolation as incarceration
But this was not why the attack occurred, or why it took so long before someone came to the nurse’s aid.
Countless studies have shown that rates of violence are the same in the general population as they are in mental health patients.
Security guards aren’t always posted in the Montreal General’s psychiatric ER, because security just isn’t an issue there, the way it is in other parts of the hospital. The psychiatric ER functions like a prison.
When the Montreal General Hospital renovated its psychiatric ER in 2015, five new isolation rooms were built. The hospital foundation boasts about the construction of these locked, heavily secured rooms, equipped with security cameras, on its online fundraising page.
Mental health patients are admitted through the hospital’s main ER, and then escorted past the thick, locked metal doors into one of the rooms in the psychiatric ER.
Martine Alfonso, an administrator at the Montreal General Hospital, stated in an op-ed published in the Montreal Gazette last week that the hospital doesn’t use risk assessment tools during patient intake.
In other words, they treat all mental health patients the same.
It is therefore safe to assume that run-of-the mill psychiatric patients, 90 per cent of whom, according to statistics, will never commit an act of violence, even at their sickest, were locked in secure rooms on the night the nurse was attacked.
The man who attacked the nurse was brought to the hospital by police because he threatened to bomb an airport, according to the Montreal Gazette investigation.
He was likely left lingering on a stretcher in the hallway, which can happen on busy night in any hospital ward.
The practice of placing all psychiatric patients in isolation rooms upon admission is illegal, according to section 118.1 of the Quebec Health and Social Services Act, which states that these rooms can only be used in exceptional cases. But it is still standard procedure in many Quebec institutions.
In fact, isolation rooms shouldn’t even exist anymore in Quebec hospitals, according to directives issued by the Quebec Health Ministry in 2002.
It’s been over 15 years since the Quebec government called on hospitals to reduce, with the goal of completely eliminating, the use of isolation rooms, forced chemical injections and restraints — commonly called control measures.
But numerous investigations conducted by the Quebec ombudsman over the past few years have shown that mental health patients are still routinely subjected to the illegal and abusive use of control measures.
Caroline Larue, vice-dean of the Faculty of Science at the University of Montreal and a researcher at the Centre de recherche de l'Institut universitaire en santé mentale de Montréal, is Quebec’s foremost expert on the topic.
She says she’s seen the suffering these measures cause. “It makes mental illness worse. When patients are put in isolation for a long time, depersonalization happens.”
And not only are control measures harmful to a patient’s psychological health, an expose published by the Hartford Courant in the 1990s linked them to more than 142 deaths.
Larue started off as a nurse. She’s spent her entire career researching and speaking about the issue and trying her hardest to change things.
"No one cares," she says as she crunches into an apple during her lunch break at her office at the University of Montreal. “You know, in the ’60s we used to beat our children here.”
Larue says that in Quebec psychiatric wards, patients can be put in isolation rooms, injected with chemicals or strapped into restraints for raising their voice or gesticulating. This can also happen when there are linguistic or cultural barriers and staff can’t understand their reaction.
“But anger and aggression are normal feelings,” says Larue, who points out that staff mistakenly view these emotions as indicators of violence, even though risk assessment tools, which she says are rarely used, can adequately determine if a patient will commit an act of violence.
In 2007, a report issued by the Quebec ombudsman gave an example of one investigation the office had conducted, to illustrate that psychiatric patients were still being subjected to the illegal use of control measures, despite the 2002 health ministry directives.
The case involved a patient who was placed in protective custody in a Quebec hospital because she presented a danger to herself due to her illness.
The patient was put in an isolation room on admission. She asked to go to the bathroom and then refused to return to her locked room. A code white was called. Staff undressed the woman in the hallway and placed her in a straitjacket and incontinence briefs.
A few days later, the same patient took a soft drink from a visitor. Nursing staff called another code white, and the woman was forced back into an isolation room.
The report noted that the file made no mention of aggressive behaviour on the part of the patient during the code white, and that restraints stayed in place for hours, even though observation notes stated the patient was calm.
But nothing changed.
In 2011 a class-action lawsuit forced a Valleyfield hospital to hand over $600,000 to 240 psychiatric patients who had been subjected to the abusive use of control measures.
In 2014, the Quebec ombudsman addressed the National Assembly and accused hospitals of continuing to show “a flagrant disregard for the law.”
The ombudsman said that year after year the office continues to receive a large volume of complaints and that in the majority of their files there are gaps in the notes taken by hospital staff, who are supposed to record every time a control measure is used as well as the reason for its use.
The ombudsman said the investigation revealed the problem had nothing to do with budget constraints, but was instead “related to an organizational culture.”
In 2015, MNA Amir Khadir took up the cause after a petition demanding that the 2002 health ministry directives be upheld was circulated by Action Autonomie, a patients’ rights group, and deposited in the National Assembly.
Quebec Health Minister Gaetan Barette and Khadir exchanged several letters on the topic.
In 2016, Barette wrote to Khadir finally that “efforts had been made to sensitize Quebec hospitals to the issue, and an intervention could be made at some point, if it seems necessary.”
“We have a lot of work to do, but there is no political will,” says Larue.
“In England, if you put someone in an isolation room they treat it like a heart attack. They call the patient’s family, a whole team makes the decision. It’s really an exceptional thing.
Larue says that in other parts of Europe, restraints are locked in a cabinet, so nurses have to make an effort to get them, whereas in Quebec, they are attached to patient’s beds. “They are right there, so it becomes an easy way to solve a problem.”
Larue says research has also now demonstrated that there is a direct correlation between a reduction of violence in hospitals and a reduction of the use of control measures. She says studies have shown that most workplace accidents occur when a patient is being forced into an isolation room.
If the environments of psychiatric wards were improved and patients were not kept in cramped quarters, deprived of their privacy, and not allowed to go outdoors, control measures would be used far less frequently, says Larue.
Perhaps though, the tragedy of the near death of the nurse at the Montreal General Hospital has a silver lining. It highlights a dire need to end discrimination in health care.
The man who attacked the nurse would surely have been flagged for special attention, and maybe even monitored by a security guard the way gang-related gunshot victims and their visitors are, if the Montreal General Hospital used risk assessment tools on all patients and stopped singling mental health patients out for special treatment, by locking them away on isolated wards and treating them like dangerous criminals.
“It’s 2018, not 1920. Patients deserve dignified care,” says Larue.