An August 24th media release from the North Shore Schizophrenia Society:
Vancouver Coastal, in a review of the death by suicide of Marek Kwapiszewski, has ducked the leading question they needed to answer: Why is “dangerousness” still considered a requirement for involuntary admission rather than “to prevent the person’s... substantial mental or physical deterioration,” as spelled out in the Mental Health Act?
What was promised by CEO David Ostrow [pictured] to have been an “independent” review, moreover, turned out to be not so independent after all, with senior managers under question in the review taking part in drawing up its recommendations.
Kwapiszewski, 54, of Vancouver, who suffered from schizophrenia, jumped off the Granville Street Bridge to his death June 29, 2008. His sister, Halina Haboosheh, together with her lawyer, had made 16 different attempts to get him the treatment he needed – treatment which required involuntary admission since Kwapiszewski, like many suffering from schizophrenia, did not have insight into his own condition.
Instead of dealing with the factors leading to Kwapiszewski’s death, the review came up with three brief items in a so-called action plan, which involved no changes or improvements in practice, nor was any fault determined although it was an obvious case of clinical failure.
“The ‘action plan’ should have been called an ‘inaction plan,’” NSSS president Herschel Hardin commented. “It was as if a review had not taken place.”
The so-called action plan was presented to Haboosheh and the North Shore Schizophrenia Society, which made the original submission in the case, at a meeting July 26, in Vancouver Coastal’s boardroom.
The first item, to facilitate a discussion to consider development of an operating definition of “deterioration,” makes no commitment to ultimately do anything, and is highly questionable to begin with in any case. Nor does it apply to the Kwapiszewski case, where the deterioration was quite clear and substantial.
The second and third of the three items were bureaucratic filler, not representing anything new and showing no grasp of what the problem was.
The review also completely missed two other crucial factors in the case: the failure of Vancouver Coastal staff to involve the sister, Halina Haboosheh, as an integral member of the treatment team, following best practices, and the concomitant failure to share clinical information with her. If that had been done, Marek Kwapiszewski might well be alive today.
It was also learned that the items were not the independent work of the external lawyer and psychiatric consultant hired to undertake the review, but were a consensus arrived at with senior community mental health managers and, possibly, Vancouver Coastal’s risk management officer. In effect, they had a veto over what would be presented.
As well as forfeiting the review’s independence, this meant that a major shake-up of senior mental health management, called for in NSSS’s 2009 submission, could not even be addressed. Instead, the primary subjects of the review, as NSSS considered them, were parties to the review’s outcome.
In response to Vancouver Coastal’s items, NSSS has presented four recommendations of its own to Vancouver Coastal and has asked Ostrow and his Board for leave to speak directly to the recommendations at a Board meeting.
Attached [please click here and here] are the NSSS recommendations and the Vancouver Coastal items. The NSSS submission on the case, June 26, 2009, is available on our website at www.northshoreschizophrenia.org/marek.pdf. A brief background analysis of the Vancouver Coastal items, such as they are, is also available on the NSSS website.
North Shore Schizophrenia Society President