Escalating escapes
There has been a spike in forensic patients walking away from Hamilton’s mental health hospital. While an increase in overall patients is a factor, there are few explanations for the surge, and no obvious solution. As The Spectator’s Joanna Frketich explains, the escapes leave both the public and patient in jeopardy.
ESCAPES
have risen dramatically over the last seven years from the forensic unit at Hamilton’s mental health hospital that detains and treats those found not criminally responsible.
There were 10 abscondments in the first seven months of 2018 from the West 5th campus of St. Joseph’s Healthcare, reveal data obtained by The Spectator through access to information legislation.
It compares to six escapes in all of 2017 or a 65 per cent increase so far this year.
In 2012, there was one abscondment that lasted less than four hours.
So far in 2018, patients have gone missing for a total of 321.5 hours.
“As you can imagine, that is a massive concern for us,” Dr. Gary Chaimowitz told The Spectator’s editorial board Aug. 17.
“Once we know they are out there we don’t sleep,” said Chaimowitz, head of the forensic service. “Public safety is paramount ... We’re charged with that responsibility.”
The increase in escapes has come as the forensic mental health unit has nearly tripled in size to 114 beds in 2018 from 42 in 2012. In addition, St. Joseph’s oversees about 86 forensic mental health patients living in the community.
However, not all of the year-to-year jumps in abscondments have corresponded with an escalation in patients. In fact, the number of escapes went down in 2017 when the unit expanded by 12 beds.
QUESTIONS HAVE BEEN
raised about whether “contagion” could be a factor where one escape prompts another.
But for the most part there are few explanations as to what is driving the surge or the best way to stop it.
“There has been very little research on what to do about it,” said Dr. Sandy Simpson, chief of forensic psychiatry at the Centre for Addiction and Mental Health (CAMH) and the University of Toronto. “Services have been late to examine their performance in this area and researchers to understand the patterns.”
The significant gap in knowledge about who escapes, why they bolt and how to prevent it is considered at least partly to blame.
“Incidents of absconsion in forensic psychiatric units can have potentially serious consequences, yet surprisingly little is known,” states a study from the United Kingdom and Australia published in PLOS One in 2015. “No attempt has been made to develop an empirically-derived risk assessment scale ... The absence of rigorous research findings limits the ability of clinicians to make informed decisions about leave and how to manage the level of risk.”
The scope of the problem came to the public’s attention in June after two high-profile escapes from West 5th within nine days of each other. Violent offender Syna Lorn walked away from the hospital during an unsupervised grounds pass while Jason Murray bolted from two staff and jumped a fence to get away.
The potential danger to the public led Coun. Terry Whitehead to demand St. Joseph’s be more transparent and fix the abscondment issue at West 5th.
Lorn called the hospital asking to return after 32 hours and Murray turned himself into police in Sarnia after seven days.
Neither caused any harm while they were missing. In fact none of the escapees in Hamilton over the last seven years have committed crimes while they were at large.
But it doesn’t mean abscondments should be met with complacency.
“This business is one where there are catastrophic events,” said Chaimowitz. “There is going to be a mistake because you can’t completely manage risk.”
Research led by Simpson warns abscondments from forensic mental health units are “hazardous” no matter how low the rate of public harm so far.
“Some of these patients had committed an index offence involving serious violence and were also judged to be at elevated risk for future violence,” states the study published in BMC (BioMed Central) Psychiatry in 2015.
While escapes put the public in jeopardy, those most in danger are actually the patients.
“The impact of absconding may be most acutely felt by patients themselves as these incidents may slow recovery by prolonging hospitalization and interrupting treatment efforts,” states another paper by Simpson published by BMC Psychiatry in 2014.
“The literature suggests an association between self-harm behaviours and absconding. A recent review found that 25 per cent of all suicides among in-patient psychiatric clients over a 10-year period in England and Wales took place after patients had absconded.”
Escapes are also significant because they erode public confidence in forensic psychiatry which is already often misunderstood. The 114 medium and minimum security beds at St. Joseph’s are very different from the roughly 185 other mental health beds at West 5th.
THE ENTRY POINT
to the forensic unit is a court and patients fall under the Criminal Code of Canada instead of the Ontario Mental Health Act.
Their care is overseen by the Ontario Review Board which, along with medical staff, determine how long patients are detained and the scope of privileges available to them.
“People are longer in the forensic system than if they went to jail for the same charge,” said Chaimowitz. “Patients don’t want to be found NCR (not criminally responsible) because there is no exit. You could be here for the rest of your life.”
Forensic unit staff assess those who have come into contact with the law for fitness to stand trial and criminal responsibility.
If a court finds an accused NCR, than the unit will detain and treat them. As they recover, the goal is to have patients gradually re-enter the community starting with supervised privileges, moving to unaccompanied passes and eventually living on their own with check-ins before being discharged altogether.
Chaimowitz calls it the “platinum credit card” of mental health care boasting a recidivism rate of 9 per compared to 30 per cent to 50 per cent among those who have been in jail.
“We’re charged with protecting the public but also rehabilitating the individual,” said Chaimowitz. “That’s a fine balance.”
Patients may only go missing for a matter of hours but the impact can be long lasting in terms of how the community views the hospital and the forensic mental health system.
“It’s a marker of things not going right,” said Simpson. “We need to be respectful of public concern and be able to answer questions about that. We’re only too acutely aware that the ability for us to do this work well and safely requires public support and confidence.”
The Australian and U.K. researchers fear escapes fuel stereotypes that link mental illness and violence.
“These cases may further increase stigma toward people with mental illness in the general population by enhancing the link between mental illness and risk of harm,” states the 2015 study.
The details provided by St. Joseph’s under the access to information legislation shed some light on local escapes.
St. Joseph’s waived the usual fee it could have charged for the information because it was considered to be in the public’s interest.
The patterns found in the abscondments at West 5th for the last seven years are similar to those seen in the study by CAMH in Toronto:
• All of the escapes were while the patient was on a pass to leave the secure unit to visit either the hospital grounds or the community. Patients start losing privileges once they are five minutes past when they were supposed to return. They are considered to have absconded once they are 30 minutes late;
• The vast majority of escapes occur when patients are unsupervised. Only four of the 35 abscondments involved patients bolting from staff;
• Over half of escapes are short with patients returning in under 12 hours. Fewer than one-quarter of escapees were missing for more than 24 hours;
• There were 22 patients who escaped a total of 35 times. One escaped five times in the last three years, two patients absconded three times and five absconded twice;
• Nearly 60 per cent of patients return to the hospital on their own with the rest being brought back by police.
The information provided by St. Joseph’s gives no insight into why the patients escaped. But the research done by Simpson into 102 abcondments over two years at CAMH provides some clues.
“Most commonly it’s a sign of boredom and frustration,” he said.
At CAMH, these fed-up patients accounted for about half of abscondments. Similar trends were found by researchers in the United Kingdom and Australia as well as by a study at Ontario Shores Centre for Mental Health published in the Journal of Forensic Psychiatry and Psychology in 2018.
“They are despairing about the amount of time they’ve been in the system,” Dr. Stephanie Penney said during a presentation about the Toronto study available online from the CAMH Education Network.
“There was evidence in the month prior of clients voicing things like, ‘I just need a break, I just need to get out of here for a little bit.’”
ANOTHER COMMON REASON
to bolt from treatment was a compelling need to get something done.
“It was, ‘I need to go to the library, I need to go get a haircut or I need to take my brother to go somewhere,’” Penney described in the presentation. “It was mundane day-to-day things that people need to do and at the time they didn’t have the privileges to let them do that.”
This group can include patients seeking drugs or alcohol, as those with substance abuse disorder are more than twice as likely to abscond.
Just over one-quarter of escapes are actually due to the patient’s mental health issues such as auditory hallucinations or delusional beliefs.
Only three of the 102 escapes were determined to be genuine accidents where the patient lost track of time or could not get back because of a situation beyond their control.
One of the most striking findings in the CAMH 2014 study was a series of warning signs in the month before patients escaped:
• 80 per cent had their privileges increased or decreased;
• More than half had been non-compliant with privileges such as coming back late or failing to sign in or out;
• 39 per cent had stressors or adverse events documented particularly around their annual review board hearing;
• One third told staff they were thinking of absconding;
• One-third of abscondments happened after changes to medication or mental health symptoms.
The Toronto studies have started to fill in the blanks by producing a map to better decision-making that forensic units across Ontario and in parts of Canada are looking to replicate.
St. Joseph’s has created its own improvement plan that is scheduled to be complete by Sept. 30. It looks at everything from how privileges are granted to better determining risk to working with police.
But overall there are few concrete answers in Hamilton on what can be done to reduce a growing number of escapes.
It illustrates why Simpson’s 2015 research at CAMH concludes there is an urgent need for empirically-guided intervention strategies.
“Absconding from secure setting remains a significant clinical, institutional and public safety issue, yet there continues to be relatively little data.”
“There has been very little research on what to do about it. Services have been late to examine their performance in this area and researchers to understand the patterns.” DR. SANDY SIMPSON Chief of forensic psychiatry, CAMH and University of Toronto
“It was, ‘I need to go to the library, I need to go get a haircut or I need to take my brother to go somewhere.’ It was mundane day-to-day things that people need to do and at the time they didn’t have the privileges to let them do that.” DR. STEPHANIE PENNEY From the presentation of the CAMH study
The significant gap in knowledge about who escapes, why they bolt and how to prevent it is considered a big part of the problem.
A recent review found that 25 per cent of all suicides among in-patient psychiatric clients over a 10-year period in England and Wales took place after patients had absconded.
Escaping patients may only be missing for hours but the impact can be long lasting in terms of how the community views the hospital and the forensic mental health system.