PSYCHIATRIC FACILITY IN THE HOT SEAT
An inquest into a mentally ill man’s death leads to a damning list of recommendations,
When Kulmiye Aganeh was declared not criminally responsible for a 2005 carjacking, his family believed that the Toronto-area teenager, who struggled with schizophrenia, would finally begin receiving the mental health treatment he so badly needed.
Instead, Aganeh died four years later of cardiac arrhythmia, alone on the floor of a cell with his hands bound to his waist after an altercation with staff in the Oak Ridge division of the Mental Health Centre Penetanguishene — Ontario’s only maximum security psychiatric facility. Aganeh was 22 years old.
“My brother was very happy,” Timiro Aganeh says. “He loved music. He loved poetry. But when he turned 17, he started to become withdrawn. It was gradual — it wasn’t something that happened overnight. But you could see him going down.”
Convinced that Aganeh’s death was suspicious, his family pushed for a coroner’s inquest. After five painful years, on Dec. 19 a coroner’s jury finally delivered a verdict from a conference room in a Barrie hotel.
Aganeh’s death, the jury stated, was the result of sudden cardiac death caused by toxic levels of Olanzapine — a drug he had been prescribed in high doses for his schizophrenia. Along with that verdict, the jury also released a damning list of recommendations so such a death could be avoided in the future.
“The verdict and recommendations represent an indictment of how Kulmiye Aganeh was treated while at Oak Ridge,” Julian Roy, the family’s lawyer told the Star after the verdict was delivered. Roy also represented Ashley Smith’s family in a coroner’s inquest after the teenager strangled herself to death in 2007 while under suicide watch at a federal prison.
“It is clear from their recommendations that this jury believes that Kulmiye Aganeh did not have to die on March 14, 2009, and that his death could have been prevented,” Roy said.
After being moved between institutions, Aganeh eventually found himself in the maximum security division of the Mental Health Centre Penetanguishene, now called the Waypoint Centre for Mental Health Care. In a division of the centre designed to treat those who have been declared not criminally responsible for dangerous offences, the inquest heard that Aganeh endured long periods of seclusion where his mental health deteriorated.
In its list of 46 recommendations, the jury stated that Waypoint should prohibit restraining patients by applying pressure to their throats. It also stated that orders for prolonged seclusions must be accompanied by written justifications and that patients in seclusion must be assessed at least once per day. The jury said that physicians lacking experience with prescribing high doses of potentially toxic anti-psychotic drugs must consult more experienced colleagues before issuing prescriptions. While the jury’s recommendations are not legally binding, Carole Jenkins, the lawyer representing Waypoint at the inquest, said the facility will not ignore them.
“We will give very serious consideration to all the recommendations that they’ve made,” Jenkins said after the jury delivered its verdict. “A number of them that they adopted were joint recommendations, and so my client, I believe, is already working on how to put some of those recommendations into place.”
Waypoint personnel declined to comment for this story.
Aganeh’s family said that they were pleased with the jury’s work.
“He’s in a better place now,” Aganeh’s mother, Ikram Said, said on Friday.