This story is part of 20 Years in Isolation, the Star’s ongoing investigation into the use of psychiatric seclusion at Waypoint Centre for Mental Health Care. The Star’s initial four-part series on the hospital’s practices has been met with calls for an independent review of Ontario’s mental health system.
The Ontario government has been aware for at least eight years of serious concerns about a psychiatric hospital’s practice of keeping patients in isolation for prolonged periods of time, the Star has learned — a practice that was recently found to be akin to torture.
Documents filed in a proposed class action lawsuit also reveal that when the Ministry of Health looked into Waypoint Centre for Mental Health Care’s use of long-term seclusion, officials did not visit the facility and spoke to only one hospital executive over the phone before deciding no further action was necessary.
One of those ministry officials, Dianna Cochrane, manager of the forensics and justice unit, is the same individual who appeared to be co-ordinating a secret review earlier this year of Ontario’s forensic mental health system amid an ongoing Toronto Star investigation into the use of long-term seclusion at Waypoint.
Leading experts have described the hospital’s practice as “egregious,” “abusive” and unlike anything seen in other North American facilities.
The ministry’s actions, or lack thereof, almost a decade ago are being described by critics — including the former Waypoint psychiatrist who brought his concerns to the government — as a “missed opportunity” to help seriously mentally ill patients who have been kept in isolation at Waypoint for sometimes years and in at least one case, decades.
The ministry “had the opportunity to intervene and force Waypoint to correct course back then,” said lawyer Anita Szigeti, an expert on mental health law who has several clients in long-term seclusion at Waypoint, the province’s only maximum-security psychiatric hospital, located on Georgian Bay in Penetanguishene.
Szigeti’s clients include Camelott Hamblett, in isolation at Waypoint for more than 20 years, and Andrew Azevedo, for more than five. “It’s a missed opportunity that has cost a lot of people their freedom,” she said.
The hospital has consistently refused to divulge how many patients are being kept in long-term seclusion, but it was revealed during an Ontario Review Board hearing earlier this month that there are at least 11 secluded patients just in the 20-bed unit where Azevedo is kept.
An independent assessment filed during the hearing concluded that seclusion would fall under the United Nations’ definition of solitary confinement, and that secluded patients at Waypoint are being kept in conditions that the UN has “deemed to constitute torture” in similar settings. Waypoint’s CEO, Dr. Nadiya Sunderji, has said the hospital “categorically” disagrees with those findings.
The records outlining the concerns that were brought to the government’s attention in 2018, and the ministry’s subsequent probe in 2019, were filed as part of a proposed class action against the hospital by Toronto firm Rochon Genova on behalf of several plaintiffs who have been kept in long-term seclusion.
The courts declined to certify the matter as a class action, concluding that the decision to seclude a patient is an individualized process and plaintiffs alleging wrongdoing would have to bring individual claims.
The office of Health Minister Sylvia Jones did not respond to the Star’s request for comment for this story; Jones’ ministry has not responded to any requests from the Star regarding its coverage of seclusion at Waypoint.
The concerns were raised in December 2018 — a few months after Doug Ford’s Progressive Conservative government came to power — by forensic psychiatrist Dr. John Bradford, one of the world’s leading experts in forensic psychiatry who briefly worked at Waypoint.
“I was concerned about the serious and irreversible harm that patients would suffer in confinement,” Bradford said in an affidavit filed in court.
He said that patients were being confined for long periods of time in “horrific conditions, the likes of which I have never seen in any other psychiatric hospital in Ontario.”
In an interview with the Star this month, Bradford said he felt his concerns were taken seriously by the ministry. However, he didn’t have the full picture about what the ministry did with those concerns until this summer, when he viewed the other records filed in the proposed class action.
“I’m floored,” he said.
Bringing concerns to government
Bradford worked for decades as the clinical director of the forensic psychiatry program at what was then the Royal Ottawa Hospital, and is a past chair of the examination board for forensic psychiatry of the Royal College of Physicians and Surgeons of Canada.
He worked at Waypoint between 2016 and 2017. He resigned after his concerns about the prolonged use of seclusion went unaddressed after raising them with the hospital’s senior executives, including then-CEO Carol Lambie.
People being in seclusion for long periods of time, even years, “was very, very foreign to me in any of my previous psychiatric experience,” Bradford told the Star. “I’d seen similar situations in correctional facilities, but never in a health care facility.”
He decided to raise his concerns externally. He first went to the Ontario Human Rights Commission, where he felt they took the issues seriously, but Bradford was worried about their lack of power to compel Waypoint to do anything.
He and another Waypoint psychiatrist decided to go instead to the provincial government. They had a meeting in December 2018 with then-assistant deputy health minister, Tim Hadwen. Bradford recalled there was also a lawyer from the attorney general’s office and a representative from the local health integration network at the meeting. He said the main focus was the “abusive” prolonged seclusion.
Bradford understood that there were limits to what the ministry could do. Waypoint, at the time operating under a different name, was divested from the Ontario government in 2008 along with other psychiatric facilities, meaning the government was no longer responsible for the day-to-day operation of the hospital.
But Waypoint was still a public Catholic hospital, and the health minister retained some discretionary powers, such as issuing directives to the hospital’s board or appointing inspectors to review the hospital’s operations.
“If my concerns were correct, and I believed they were, then I believed that those were things the ministry could consider,” Bradford said.
Inside the ministry’s probe
Cochrane and another ministry official, Ragaven Sabaratnam, were tasked with looking into Bradford’s concerns.
In an affidavit filed in May 2023, Cochrane said they conducted interviews “with management staff at Waypoint,” as well as with the psychiatric patient advocate office, the College of Physicians and Surgeons of Ontario and the North Simcoe Muskoka local health integration network. Waypoint also shared some of its policies with them.
They brought the results of the interviews to Hadwen, who “determined that there was no need for the minister of health to exercise” any of the discretionary powers “because Waypoint had policies and procedures in place to address clinical care for its patients,” Cochrane says in her affidavit.
No further steps were taken, she said.
Hadwen communicated the outcome to Bradford in an April 2019 email, one in a series of emails filed in court.
“After reviewing the information made available to us, we are confident that Waypoint has implemented changes to address the concerns you raised,” Hadwen wrote.
He said that the ministry’s work included speaking with representatives — plural — of Waypoint.
In fact, only one Waypoint representative — then-vice-president of clinical services Rob Desroches — was interviewed, over the phone. Cochrane confirmed this when she was cross-examined on her affidavit by the plaintiffs’ lawyers in the proposed class action, when asked if her Waypoint interviews were with any of the senior executives named as defendants in the lawsuit.
“The interview was with Mr. Desroches,” she said.
The lawyer followed up: “So it was a single interview?”
Cochrane replied that it was. She said the interview would have been “definitely less than two hours.”
A summary of the January 2019 call with Desroches shows the ministry officials asked him six questions, three of which were about seclusion. The first question sought clarification on the hospital’s reporting policies and practices around seclusion.
Desroches said the hospital was in the midst of revamping some of its procedures, which would include clinical managers creating daily, weekly, and monthly reports about seclusion that would go up to vice presidents for review.
He said “several initiatives have been put in place” to reduce the use of seclusion and that an unnamed expert had been brought in from the United States to provide training on safety and the use of seclusion.
He said Waypoint had also requested additional funding to hire more people to escort patients out of seclusion more often; as the Star reported last week, the hospital is still struggling to bring all secluded patients out for seclusion relief on a daily basis due to staffing shortages.
In response to another question, Desroches said there had been no third-party review conducted specifically on the use of long-term seclusion.
‘That is not an investigation’
Back in 2019, Bradford was pleased with Hadwen’s response.
“I sincerely appreciate you taking our concerns seriously and acting on these concerns,” Bradford wrote in an email. “I appreciate you taking action in the name of quality of care and respect for the human rights of the patients detained at Waypoint.”
Hadwen then forwarded Bradford’s response to Cochrane — “Reasonably positive,” Hadwen wrote.
Cochrane, in turn, forwarded the response to other ministry staff, writing: “FYI — Hopefully we can close this file now.”
Bradford said he was dismayed when he saw the emails for the first time this summer.
In the years since Bradford’s warning, Waypoint has continued to lock patients up in long-term isolation. By 2019, Hamblett would have already been in continuous seclusion at Waypoint for almost 14 years. He’s still in seclusion to this day.
“I’m still not sure what to make of it,” Bradford said of Cochrane’s email. “It sounds as though they thought the matter was over. I took them at face value that they had sorted things out.”
Bradford said he had no idea the ministry had only spoken to one representative at Waypoint, nor that officials had not gone into the facility, “which would have been, in my mind, the most basic part of intervening,” Bradford said.
“I think there’s a big difference between hearing someone talking about policies and procedures and actually seeing how they implement them.”
Cochrane has been involved in conducting a secret review of the forensic mental health system, which the Star first reported in April.
Cochrane wrote to Szigeti, the lawyer, asking if she would participate in a “confidential discussion” about the system and requesting that she sign a nondisclosure agreement. “We believe your input will make an important contribution to informing advice to government,” Cochrane wrote.
Szigeti declined to participate as she refused to sign the NDA. The Star subsequently filed a freedom of information request for the terms of reference of the review, but was told that “no responsive records were located.”
Szigeti said in an interview this month that she shares Bradford’s concerns about the ministry’s actions in 2019.
“That is not an investigation,” she said. “That’s a phone call to ask basic questions — ‘In your opinion, are you doing everything right?’”
She said it appears that the magnitude of the problem of long-term seclusion was not revealed to the ministry during their questioning, “but it should have been.”
“If this had been properly investigated back in 2018-19 and the institution had been forced to correct course, then Camelott Hamblett may have been released from seclusion,” she said.
And Azevedo, who has been held in seclusion since 2021, may have never been placed in isolation in the first place.
Bradford said he also can’t shake the thought of Hamblett and whether his situation would have improved had things been done differently almost a decade ago.
“It’s an enormous period of somebody’s lifetime,” he said.
