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Behind the Reporting: When the mental healthcare system fails to perform a lifesaving intervention

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The emergency department of a psychiatric hospital is immersed in suffering. 

As I wait in line to see a psychiatrist, I watch a mother beg for her suicidal son to be admitted against his will. In the chair next to me, a teen is curled up motionless, for hours. In the corner of the waiting room, a desperate wife pleads with her husband to agree to hospitalization.

Every one of us here clings onto this system to perform a lifesaving miracle. But I know those miracles don’t always appear. I’ve spent the past six months adding up tragedies that have unfolded following mental healthcare system failures.

Since 2018, 159 people in Canada have been found not criminally responsible (NCR) after killing someone while in the throes of mental illness. Those types of killings are incredibly rare, making up approximately three per cent of all killings in Canada since 2018.

To examine how these fatal crises happened, my colleagues and I tracked the last contact these patients had had with a mental health professional prior to the killing. 

What we found shocked us – more than a quarter of NCR killings happened within the month of a failed mental health intervention, whether that was a hospital visit, a welfare check, or a call to a crisis line. 

Twenty-five killings happened on the same day that the person who committed the killing had contact with someone trained to respond to mental health emergencies.

I think about the case of one man who killed his partner just an hour after he left the ER despite being deemed in need of rapid psychiatric intervention. I think about the son who tried to get himself hospitalized ten times in the month leading up to the day he fatally stabbed his father. And about a man who killed his mother just days after being released from an involuntary psychiatric hospitalization. 

The crackle of the intercom interrupts my doom spiral. “Code white,” it sputters – someone in the building was deemed to have become aggressive. 

A mental image of the patient getting tackled by security guards snaps my mind back to reality: people suffering from mental illness are much more likely to be the victims of violence than the perpetrators. 

But in a society where we wrongfully assume mentally ill people to be more dangerous than the rest of the population, how did we miss the 159 people whose illnesses drove them to kill?

After all, most of those people had histories of paranoid delusions, failed mental health interventions, and some, even domestic violence. Their health and judicial files are mired in pleas from their loved ones to recognize the risk they may pose to the physical safety of themselves and others. 

Did these red flags simply get lost in the piles of intake questionnaires and triage assessments? 

Our reporting revealed several patterns which led to repeated red flags of violence being missed or ignored. 

Many patients who committed a killing suffered from paranoid delusions directed at specific people. Often, the target of their delusions were their caregivers or loved ones, who had spent years advocating to get them help. Plagued by the idea that a loved one was trying to harm them, domestic violence sometimes turned fatal. 

Experts we interviewed told us there are solutions.

First, paranoid delusions directed at specific individuals should signal a heightened risk of domestic violence.

Second, women and girls, who are often forced into caregiving roles, should be given real opportunities to voice their observations about the symptoms of their loved ones. Too often, the concerns raised by mothers, wives, and girlfriends were dismissed by the healthcare system, pushing the very people most at risk into the crosshairs. 

But perhaps the most important solution lies beyond the ER.

In a system where ongoing psychiatric care continues to be an unreachable privilege for most, how does the mental healthcare system ensure a patient continues on a path to recovery after the acute crisis is over?

The answer is not encouraging. Many patients in our database were stuck in the revolving doors of hospitals – admitted for long enough to stabilize their condition, only to be later discharged, stop taking their medication, and relapse into psychosis. 

Even multiple single-point interventions could not prevent tragedy when patients lacked medication management, stable housing, and a support system such as a therapist, social worker, or nurse. 

This is why psychologists we spoke with say continuous care plans should become the norm when treating a serious mental illness. Connecting patients with long-term resources should become part of crisis intervention.

I think about all this as I wait for my name to be called. At this moment, all I can do is hope that the system learns from its mistakes. 

Stacey Kuznetsova
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