Chatham Hospital, Ont., takes steps to improve mental health care after patient's death

Updated 2 years ago on October 17, 2022

WARNING: This story contains references to suicide.

Three months after Robert Martin died of suicide at his family home in April, the Chatham, Ontario hospital where he was treated is taking steps to improve mental health services.

While it doesn't take away the terrible pain of losing her son, Leonie VanPooymbrock takes comfort in the fact that some of her problems are being addressed and future mental health patients may get better results.

"I'm very happy that these changes are happening for everyone in our community," VanPooymbrock said.

"So many people told me, 'Oh, I bet nothing's going to happen.' And so I was a little hesitant, a little negative. But it didn't turn out that way at all.

[Hospital representatives] told me ... that these changes happened because I said something.Imagine if more people had said something?" - Leonie VanPuymbroeck

Martin was diagnosed with attention deficit hyperactivity disorder (ADHD), bipolar disorder and, later, substance abuse (caffeinated beverages and marijuana use), which may have contributed to psychotic episodes.

The 26-year-old was seeing a psychiatrist regularly through the Chatham-Kent Health Alliance (CKHA).

He was also admitted to the hospital in late January for involuntary treatment after erratic behavior, but, according to his mother, he was discharged early. Martin died less than three months later, on April 8.

At the time, VanPuymbrock told CBC News that she felt not enough had been done to prevent his death, and the family filed a complaint with the hospital about Martin's care.

The CKHA has since launched an internal investigation, which it says is standard protocol "whenever there is an unfortunate outcome like this," CBC News said in an emailed statement.

4 recommendations

The hospital said that all team members involved in the process came together to examine the care Martin was receiving "with the goal of improving the quality of our care."

Reflections on Robert's care resulted in four major recommendations to follow, including:

  • Ending telephone appointments for mental health patients.
  • Implementation of a reminder system for patient appointments.
  • Reviewing the referral process when a request is made for another psychiatrist.
  • Launching a clinical review of the discharge planning process in an inpatient mental health unit.

The hospital shared an implementation action plan with VanPoombrock, which was obtained by CBC News.

The first action is to stop making phone appointments for outpatient appointments with psychiatrists and therapists.

Telephone appointments were introduced in response to the COVID-19 pandemic, but now all outpatient appointments will now take place in person or by videoconference, according to the letter, "given the importance of a patient's personal mental health assessment." Prior to this, all Martin's appointments were by telephone.

The second action is to implement a system to remind patients of their appointments.

The review revealed that Martin had missed several appointments to receive antipsychotic medication by injection. Although attempts were made to contact Martin, the hospital is committed to working with the Canadian Alliance for Mental Health to improve the process by implementing reminders.

The third action was in response to Martin expressing dissatisfaction with his psychiatrist and requesting a new doctor, the letter said. VanPuymbrock said this request was denied.

According to the letter, in the future when such a request is made, "the department head will interview the patient in the absence of the attending psychiatrist to understand the reasons for the request. The request will then be forwarded to the head of the psychiatric unit to decide whether a new referral should be issued.

The fourth action is a commitment to improve discharge planning for mental health patients. This is in response to Martin being discharged from the hospital in late January with a follow-up appointment two weeks later.

VanPooymbrock explained that hospital officials say these meetings will be held earlier in the future. The hospital will also conduct a "clinical review" of the discharge planning process to standardize it and improve "collaboration with patients, families, and community organizations during discharge."

Martin's family also expressed particular dissatisfaction with the way he was treated by the psychiatrist. VanPooybroeck filed a complaint against the doctor with the College of Physicians and Surgeons of Ontario (CPSO). The CPSO had previously told CBC News that it was forbidden to confirm or discuss complaints.

CBC News is not naming Martin's psychiatrist because the doctor's public profile on the CPSO registry did not note any problems with patients.

Moving forward

VanPuymbrock hopes these policy changes will help patients feel more comfortable seeking mental health care and later save lives.

"I hope so. Even if it only saves one person," she said.

She also hopes her story will encourage others to talk more about mental health issues and suicide.

"[The hospital representatives] told me ... that these changes happened because I said something. Imagine if more people had said something?" - she said.

"The more change that happens, maybe more funding, the more things can happen if people really don't hide from all these things."

She said it all starts with the fact that families who have lost loved ones to suicide should not be afraid to say the word "suicide."

At the same time, VanPooymbrock said she was "trying to take it day by day."

When she talks about Martin, a smile appears on her face as she remembers him as a kind and sweet child, always eager to help others.

VanPooimbrock said she plans to continue pushing for more provincial funding and support for mental health in the future.

"It's not over yet."

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