REPORT ON THE INQUEST INTO THE DEATH OF Edmond Wai-Hong Yu Jury Recommendations: 1. The Ministry of Health should provide continued funding for research into the cause and treatment of schizophrenia including research into non-medical and non-drug alternatives. Rationale: Evidence was given that one percent of the population suffers from schizophrenia, therefore, research on the efficacy of these alternatives is required as some consumer survivor groups reject the medical model for treatment. 2. As part of the “Making It Happen” draft, the Ministry of Health should proceed with these initiatives and be encouraged to ensure that ethno-specific psychiatric services and community-based non-medical outreach programs are funded. We would encourage these communities to present their needs to the Ministry of Health. Rationale: Evidence was presented that Mr. Yu did well at the Hong Fook Clinic and Rainbow Boarding House where ethnicity was respected. Supportive initiatives at this level would enhance Assertive Community Treatment team’s ability to ensure that basic street level needs are fulfilled. 3. The Ministry of Health should provide a long-term funding commitment, and appoint a long-term position, to the Mental Health Law Education Project. Its mandate should be extended to provide education to members of the public, in addition to mental health care professionals. The project should include a public relations campaign to inform consumers and their families of mental health services regarding the operations of the Mental Health Act and other mental health legislation. Particular attention should be paid to consent and capacity legislation and leave of absence provisions. Rationale: It is unfortunate, but on many occasions, receivers and providers of psychiatric services and families failed to comprehend and apply the mental health legislation as it is currently written. One of the provisions in the Mental Health Act, specifically the Leave of Absence provision, might have been a mechanism the Yu family could have used to help Mr. Yu when he needed it the most. 4. The Ministry of Health should include a member of the mental health community in the drafting of amendments to mental health legislation in order to facilitate its comprehension by members of that community. Rationale: The current legislation is difficult to understand, interpret and apply in a consistent manner. Legislation should be written in “plain English” that can be comprehended by all members of the community to whom the Act is being applied. This would also allow for easier translation into other languages. 5. Ensure that all psychiatrists and psychiatric residents receive training and/or further education on the Mental Health Law of Ontario. Rationale: See rationale for recommendations 3, 4. 6. That all psychiatrists and psychiatric residents be educated that there are ethno-specific issues in psychiatry. Rationale: Evidence was presented that there are varied effects of anti-psychotic medications on different ethnic groups, such as Asians who tend to be more sensitive to neuroleptic medications. 7. The Ministry of Health and Ministry of Community and Social Services should continue initiatives for existing and new consumer-based employment organizations. The Ministries should consider proposals for consumer-based employment organizations as determined by consumer survivor groups. Rationale: Existing consumer-based employment initiatives have large waiting lists for employment. Consumer survivors require flexible hours and part-time work where needs are understood. Often work available is limited and not seen as meaningful. Employment would assist consumer survivors to contribute to and decrease the burden on society, therefore assisting to stop the vicious circle of illness. 8. The Ministries of Health and Community and Social Services should continue funding for the purchase and construction of new housing for consumer survivors in Toronto. Such housing should include short-term “safehouse” facilities such as the Gerstein Centre. Rationale: Housing is not always affordable and is difficult to obtain and retain because consumer survivors are not always seen as desirable tenants. Housing is a mental health issue and the absence of decent housing is a major determinant of health. 9. The Ministry of Health should create a long-term case management system whereby caseworkers will follow consumers of mental health services on a long-term or permanent basis. Rationale: In the matter of this inquest it would have been helpful if one or more persons knew all the information regarding Mr. Yu’s mental health, forming a continuum of care. These persons may have worked with the Yu family to monitor his situation so that awareness of his decline in health and decompensation may have been recognized earlier. 10. We recommend that the Ministry of Health consider reducing the number of A.C.T. teams and redirecting this share of the funds for non-medical “safe-houses” such as the Gerstein Centre. Rationale: The Ministry of Health should be responsive to the deficiencies in the system as identified by consumer survivors, specifically lack of safe housing where their special needs are understood and accommodated. The diverted funds from the A.C.T. teams would allow for the creation of this housing. 11. The Solicitor General should amend the Police Services Act to require annual Crisis Resolution training, of at least one day, in addition to annual use of force training. Priority should be given to front line officers; however, this training should be delivered to command officers and senior managers as well. Rationale: The jury recommends that the mandating of this course by legislation will prevent it from being discontinued in the future. We feel that it should be an integral part of police training on an annual basis. 12. The Crisis Resolution Course should have the input of mental health professionals, consumer survivor and multicultural groups, and should include, but not be limited to, the following issues : A. Every opportunity should be taken to convert an unplanned operation into a planned operation. B. Unless impractical to do so, a “cordon and containment” approach should be adopted. C. That the aim of crisis resolution should be de-escalation and the resolution of situations without physical force. D. That the “first contact” and “time talk and tactics” approach be used by police whenever possible and that “active listening” be stressed as a skill that officers must develop. E. The fear and apprehension experienced by officers as a result of previous experiences, stereotyping or lack of knowledge, whether about mental illness, race, culture or other factors. F. The fear and apprehension which persons involved with the police may feel as a result of previous experiences, stereotyping or lack of knowledge, particularly due to mental illness, racial or cultural background. G. That police officers, whenever possible, should maintain a sufficient reactionary gap to give them the time to disengage, tactically reposition themselves and or react in such a way which prevents a situation from escalating from the verbal to the violent. Rationale: All of the above items should assist in the structure of the one-day annual Crisis Resolution Course. With deinstitutionalization of persons with mental illness there is an increase in police interactions with them in the community. The police must be able to safely intervene in situations and know where to turn for assistance. 13. That the five day Crisis Resolution course be offered as a training course at C.O. Bick College until all existing officers are trained. Rationale: Crisis Resolution is taught to all recruits. All existing officers who have not previously received Crisis Resolution training will receive the current five-day course that commenced March 11, 1999 until all are trained. Thereafter, the proposed legislated annual Crisis Resolution course, taken with the Annual Use of Force course, will be the mechanism for continuing this training. 14. The Toronto City Council provide adequate funding to allow the Toronto Police Service Board and the Toronto Police Service to implement the recommendations of this Coroner’s jury. 15. That officers who work in divisions with higher concentrations of persons suffering from mental illness be given priority on the list of officers entering the Crisis Resolution course. 16. That the C.O. Brick College evaluate the Crisis Resolution training to determine its effectiveness. The evaluation should include survey research, detailed interviews and/or performance appraisals of a proportion of graduate officers. Rationale: Evidence showed that there needs to be a mechanism that can determine whether behaviours and attitudes are changed as a result of this training. The course should be adapted to reflect the defined needs of the officers. 17. Continue decentralized training, using Live-Link or other approved methods, at those divisions that are determined to have a proportionately high concentration of emotionally disturbed persons. 18. That the Toronto Police Service follow the lead of the 57 other police forces in Ontario who have joined the Video Training Alliance in order to provide better decentralized training to its [sic] officers. Rationale: Evidence showed that there was a duplication of training videos dealing with emotionally disturbed persons. 19. That the Toronto Police Service and the Ontario Police College establish a closer working relationship to facilitate the sharing of information, training expertise, and professional exchanges to avoid unnecessary duplication or delivery of conflicting training programs. 20. The Toronto Police Service Board should direct the Chief of Police to ensure that the Toronto Police Service assembles a list of available crisis teams with telephone numbers according to police division in the Toronto area. Such information should be available to front line officers through their dispatchers. Rationale: The Toronto Police service could make greater use of these teams to facilitate peaceful resolution of crises and to link persons to appropriate resources. Evidence was given that a crisis team would have attended the bus on February 20, 1997 if they had been called. 21. That representatives of consumer survivor groups, in consultation with the Community Policing Support Unit should develop a pamphlet for police to give to persons in crisis on how to access services. The pamphlet should be prepared in several different languages to serve our diverse community. Rationale: Front-line police are interacting with deinstitutionalized emotionally disturbed persons on a daily basis. A combined effort of these groups would lessen the burden on police and ensure consumer survivor input. 22. The jury endorses the Use of Force report and recommends that the Toronto Police Service implement the recommendations contained in this report. 23. That the Office of the Chief Coroner, on or about the anniversary date of this inquest, April 16, 2000, will discover and make public the progress of the implementation of the recommendations made by this jury. 24. It would be remiss of this jury not to comment on the issue of forced medication for those mentally ill persons who have a history of demonstrated dangerousness to the public. We feel strongly that the public must be protected. Failure to take corrective medication may require the law to be changed to state that the alternative would be involuntary hospitalization in a mental health facility. It is recommended that the Ministry of Health address this problem and attempt to reach a solution. Prepared by the Office of the Chief Coroner
Posted on: Sun, 28 Jul 2013 15:26:35 +0000
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