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The Ontario government will participate in a review of CAMH patient passes and privileges after a series of patient escapes in recent weeks, the provincial Health Minister has said.

Fred Lum/The Globe and Mail

As the Centre for Addiction and Mental Health reviews its system for granting day passes after a forensic patient disappeared and fled the country, data show the number of abscondments from the Toronto hospital and other Canadian institutions has fluctuated for years.

In 2012, CAMH and other institutions reviewed and amended their security protocols after several patients with violent criminal pasts went missing across Canada. CAMH officials had already noticed an increase in such incidents, with 43 in 2009-10, 33 the next year, and 43 again in 2011-12, according to data the hospital provided to The Globe and Mail.

The hospital updated the way it assesses those forensic patients before they are allowed to go on leave and tightened security practices, particularly in low-security areas from which some patients had absconded several times. AWOL incidents dropped by 37 per cent the first year after the changes, and further in subsequent years, the data show.

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Then numbers started to climb again, returning to 43 in 2017-18. The current review was launched in late July, after patient Zhebin Cong went missing while on an unsupervised day pass on July 3. Mr. Cong, who was found not criminally responsible (NCR) for murder in 2016, then boarded a flight. The Ontario government has said it will take part in the external review. CAMH expects it to be complete by the end of the year.

People are found not criminally responsible for an offence that is committed – or made by omission – while they have a mental disorder that made them incapable of appreciating the nature and quality of the action, or knowing it was wrong. In Canada, they are detained and treated in psychiatric facilities for an indeterminate period. They earn privileges such as passes based on their progress.

NCR patients are overseen by the Ontario Review Board (ORB), an independent tribunal that determines which facilities they should be in, what level of security may be required and what privileges or conditions should be applied. Hospital staff also assess risk factors. The goal is for patients to recover to the point where they can return to the community. As patients recover, the treatment team must constantly try to find a balance between granting them some freedom while ensuring public safety.

Mr. Cong’s most recent ORB decision, released in May, said his recovery was going well, but that clinicians were facing challenges trying to move him into the community. Mr. Cong wanted to return to China to live with his mother and didn’t understand why he was only allowed to move into housing in Toronto that was approved by CAMH.

Mathieu Dufour, associate chief of psychiatry at the Royal Ottawa Mental Health Centre, said that over all, the forensic-psychiatry system works well and that patients who come through it are much less likely to re-offend than those in the criminal-justice system.

Despite the recent headlines, he said it’s not very common for patients to go missing and that processes are in place to help minimize the risk. Some of the risk factors Dr. Dufour said clinicians look for when determining whether a patient is likely to abscond include any history of going missing from the facility, impulsive behaviour and any frustration related to their stay. He said while there is no “perfect science” when it comes to managing these risks, the process is rigorous.

At CAMH, chief of forensic psychiatry Sandy Simpson says hospitals must find the right balance between granting privileges and ensuring community safety.

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“The challenge for us is making sure we’re giving people the opportunity to succeed," he said in a separate interview in 2018. "If we never get people going AWOL, we’re holding people back way too much. If people are getting liberty that they’re using with bad outcomes, then we’re giving it too much. But the idea is, there’s a sweet spot in the middle somewhere.”

Along with the review, CAMH says it is testing a new tool to determine which forensic patients should be eligible for community passes.

The tool, developed at Waypoint Centre for Mental Health in Penetanguishene, Ont., is being used on a trial basis and acts as a supplementary check to the day-pass system already in place, Dr. Simpson said. The trial started after Mr. Cong went missing.

CAMH has declined to provide details about how the Waypoint tool works. But the Waypoint Centre had to increase its security protocols in recent years after problems in its new building for forensic patients, including the stabbing of a nurse by a patient in 2016. A 2016 Ontario auditor-general’s report highlighted safety and security gaps at the facility. Waypoint officials declined an interview request. In an e-mail statement, a hospital spokeswoman wrote that the new tool was developed to supplement practices already in place and “is still being evaluated.”

In the weeks since CAMH started using the new tool, two more forensic patients have gone missing from CAMH.

Anthony Murdock, 45, ran away while on a supervised day pass near the hospital on July 30. He had long history of sexual offences against strangers and is considered a risk to the public, documents on his case show. He was located two days later in Brampton.

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Ahmed Sualim, who was also found not criminally responsible for armed robberies in 2012, was reported missing from CAMH earlier last month, but found several hours later.

The number of abscondments has been closer to the usual rate since, Dr. Simpson says – 15 patients absconded in the first six months of 2019. Some of those patients have absconded more than once, but the total number of incidents is still “down to about the normal,” he said.

“You do get cluster effects with these sorts of things,” he said. Mr. Cong’s abscondment raised a “different level of concern” for the hospital, he said. “We don’t want the public being endangered and we don’t want people leaving the country.”

Violence among AWOL patients – toward themselves or others – is rare, as is criminal activity. Dr. Simpson said the only incident in the past decade of criminal activity by a person gone AWOL while on a pass was in June, when a patient was accused of robbing a convenience store and a bakery. Before that, the most violent action against another person was when a patient threw a Coca-Cola can at a guard, he says.

Many patients leave for a specific reason, according to hospital data Dr. Simpson cited last year. From 2010 to 2014, he said, about 40 per cent of people who absconded visited home, saw someone or got their hair cut. About one-quarter fail to return because of disorganization that may be a symptom of their mental illness, an error such as getting lost or are delayed on transit.

Two-thirds returned within 24 hours. Between 20 per cent and 25 per cent return having used drugs or alcohol, Dr. Simpson said. And about one-third of abscondments involve the same patients repeatedly.

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“There’s a group of people who present chronic low risk [of not coming back at the prescribed time], for whom there’s very little that we can do,” Dr. Simpson told The Globe in 2018.

“They may run a little fast and loose with their passes, but nothing dreadful is going to happen,” Dr. Simpson said. “There are some people for whom we know their risks are there, but continuing hospitalization for them is unlikely to be helpful. And again, risks to the community are very low, so we might run a bit more of a risk of AWOLs with them, knowing that unless we push ahead, if we demand perfection, we’re never going to get there.”

In 2012, an absconded patient from the East Coast Forensic Hospital in Nova Scotia killed a prominent activist. Clinical director Aileen Brunet, who was in her first few months on the job, described the event as “very traumatic” in an interview with The Globe in 2018. After a review, changes were made within the hospital around forensic patient leaves. Abscondment numbers from the Nova Scotia hospital are comparable to those at CAMH, with 31 incidents in 2017-18 involving 19 patients. The year previous was higher, with 47 incidents involving 22 patients.

An additional issue for CAMH is its downtown location. “Most forensic hospitals are in the middle of the countryside, where it’s a lot more difficult to go AWOL. Here, you just pop out the front door and onto the TTC, right up Ossington [Avenue] and you’re gone,” Dr. Simpson said in 2018.

By comparison, the Forensic Psychiatric Hospital in British Columbia logged just one unauthorized absence and two escapes in 2017-18. That is a steep drop from 2010-11, when the hospital logged 22 unauthorized absences and one escape. The facility is surrounded by green space.

“If you look overall at the NCR process, it dramatically reduces risk of reoffending amongst this patient group relative to what you’d get with them had they gone through the criminal-justice system. So although we may focus on abscondments or people coming back late from passes and so on, if you look at the overall care pathway, the results we get over all, the risk to the public is massively reduced because of the NCR regime,” Dr. Simpson said this week.

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“That said, can we do better? And does the public … have a right to expect that of us? Absolutely.”

With a report from The Canadian Press

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