08/23/2012 07:49 EDT | Updated 10/22/2012 05:12 EDT

Just One More Shocking Example of Canada's Failing Healthcare System

Jacquie was mentally ill, this much was clear, but after age 12 her parents didn't have the ability to force her into treatment, where they knew she belonged. Sure enough, with Jacquie living on her own and untreated, she launched a horrific attack with a saw on two neighbours, a mother and a daughter, who nearly died. Jacquie was found criminally not responsible for the attacks. The two doctors who refused to deal with and treat a severely ill young lady remain in place today. They are hidden deep in a broken medical system that protects them, but also sucks them in as a new kind of unintended victim of a sick health care bureaucracy.


An article I wrote on Tuesday for this space elicited a lot of reaction. People have asked me about Jacquie Davies and the plight of her father, my dear friend, Fred Davies. Here is the story.

Fred has been friend of mine for 25 years. He was born and raised in Port Colborne, Ontario, a sleepy rural town in between Toronto and London, on the Niagara Peninsula. He has been a businessman and community leader there and in neighbouring Welland for 30 years. From a young age, Fred's daughter Jacquie was different than the other kids her age. By the time she reached high school, it was clear that she had mental health problems, although it was not at all clear what those were.

Jacquie's condition deteriorated into fits of violent behavior and started on a path of recurring hospitalization. They had seen school counselors, and psychologists, physiatrists and physicians at the local hospital. None could provide a diagnosis or help. "Whomever we saw had a different read on Jacquie and it seemed that no one within the health care system could communicate with each other to deal with it," Fred recounted to me.

"As parents we learned, and so did Jacquie, that we have no rights (she has all the rights after the age of 12), no access to information, no authority, and even though we are obliged to support and provide the necessities of life for our daughter, she had the right to shut us out of the process. And she did. Medical support staff was, for the most part, oblivious to our frustration."

The Davies family became experts in navigating the medical bureaucracy and the process of obtaining a "Form 1," which is a forced admission to hospital for up to 72 hours. For it to be duly executed, this form must be signed by a doctor, Justice of the Peace or court order on the basis that the patient is a potential danger to him or herself or others. Jacquie spent several years from the age of about 13 to 18 in and out of what is called "2 South" at the Welland Hospital Site of the Niagara Health System.

She was "formed" at least 15 separate times with stays ranging from 72 hours to eight weeks. "Surely after so many admissions the doctors would recognize that this is a very sick young lady," Fred reflected. "We felt we had ample evidence that Jacquie needed a long term plan that included treatment in a controlled facility." They had the option of applying to a Capacity Review Board, but without a doctor's support, it would cost upwards of $20,000 and with no one willing to step up, their chances of having Jacquie committed to supervised care was non-existent.

Fred finally got Jacquie admitted to St. Joseph's in Hamilton, regarded as the best mental health facility in Ontario. She was there for a few months, only after they managed to find a loophole for admission. Jacquie's mother and Fred met with one of the two resident psychiatrists that always dealt with Jacquie's admissions. They pleaded, begged and cried.

"The doctor told us that unless he saw blood, there is nothing he can do. He said there was no 'proof' that Jacquie was an ongoing danger to herself or others. He said that the health care system is expensive and was unwilling to commit Jacquie beyond a few weeks. Did he know Jacquie was sick? Of course he did. A day later, the doctor called me and told me to come and pick my daughter up. He was releasing her. It was a mission for our daughter's mental health treatment to be sure, but now it seemed that our focus was simply trying to keep her alive."

Fred and Jacquie's mother were told by the doctor that they only way he could see getting help was to get Jacquie into the criminal justice system. "He told us that if Jacquie were charged, it would be easier to get her help." Fred couldn't believe what he was hearing. "I asked him point blank and clearly: 'Let me understand you. Are you counseling me to counsel my daughter to commit a crime in order to receive treatment?' He confirmed that only the Justice system could act now because he would not take responsibility for committing Jacquie as mentally incapacitated."

The Davies were not shocked -- they had seen it all. Not only had they fallen through every crack in a dysfunctional system, they were now listening to a doctor tell them to find another crack to absolve him of responsibility. While Jacquie's doctors knew that she needed a long-term mental health plan, he was abandoning his responsibility to patient care. The only plan that was developed was "putting my 18-year-old daughter into a one bedroom apartment near my house" Fred explained. "We followed the advice, knowing it was doomed to fail, and also knowing that it was only a matter of time before the blood the doctor needed to see would soon flow."

Jacquie's new apartment was about 300 yards from Fred's house. She was now legally an adult at the age of 18. It didn't take long for what would be the final straw in Jacquie's tortured and tragic life to take place. "She was spooked by a neighbour on the balcony next door and thought she was being threatened. She grabbed a small collapsible saw that she was using to cut twigs, ran out of her apartment and down the stairs." Tragically, a 12-year-old girl and her mother were in her pathway. She slashed the mother across the face and the daughter on her head. It was a horrific attack. Both the mother and daughter who happened to have the grave misfortune of being at the wrong place at the wrong time, almost died that night.

Fred was at dinner and received a call from Jacquie: "Daddy, I think I killed someone." Jacquie was charged with aggravated assault and aggravated assault with a weapon. She was taken to the women's prison in Milton, Ontario, where she degenerated further into psychosis. This was prison, and there was no mental health program and even less compassion. This was a place for criminals and they were treated like criminals whether convicted or not. Fred reflected on his mindset at the time: "Where once we were afraid she would die if not institutionalized, we now thought she would die inside an institution."

After long court delays, the presiding judge finally ordered a psychological evaluation by St. Joseph's in Hamilton through the forensic psychiatric unit. Jacquie was sent back to St. Joe's to the forensic ward with much needed restrictions. By the time the trial was to take place, and after the continued intervention and pressure put on the two lawyers involved, and finally with a comprehensive psychological evaluation now available, Jacquie was found criminally not responsible for the attacks. She was remanded to the St. Joseph's Mountain Health Care Facility where she would receive a minimum of one year treatment at a time, after which and required by law, a yearly Capacity Review Hearing would take place to review Jacquie's ability to live in society, either supervised or on her own.

It has been three years since that decision has been made. With the lines on his face ample testament to what he and his family had lived through, and with a sigh my friend Fred Davies said: "But today, Jacquie is alive. She is not well, but she is alive."

Whenever stories like this surface -- and there are many -- the refrain is numbingly similar: Health care professionals are overworked, underpaid and certainly undervalued. There are caps on doctor's salaries and they are forced to work in terrible conditions on unreasonable shifts, and in various wards. The two doctors that refused to deal with and treat a severely ill young lady remain in place today. They are hidden deep in a broken medical system that protects them, but also sucks them in as a new kind of unintended victim of a sick health care bureaucracy.

A lawsuit was launched by the defenseless victims of Jacquie's uncontrolled violence -- a mother and her daughter. The defendant is the Niagara Health System. The Davies family offered their complete support to their daughter's victims for this action and did whatever they could to assist the claim against the NHS. They had hoped that the nightmare they suffered through would not be repeated if the fatal flaws in the system were exposed. That never happened. The NHS settled the case with the victims out of court.