Montreal's Douglas Hospital closes group home after death of mentally ill man
CBC Montreal Investigates uncovers troubling allegations about how patient's health issues were handled
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Ten days after a mentally ill Montreal man died last March, the Douglas Hospital shut down the group home where he had lived for the past six years, blaming workers there for incompetence and a lack of judgment.
Steven Bunce, 60, died from a pulmonary embolism and extensive blood clotting, a month after being rushed to hospital.
Bunce's sister, Nancy Nadon, is relieved his former residence is closed but says that doesn't let officials at the Douglas Hospital off the hook.
"They are in charge of these group homes," said Nadon. "To me, it looks like they are trying to pass the buck."
Nadon says her brother might still be alive if the people responsible for his care hadn't failed him.
"My poor brother lost his life over this."
Schizophrenia diagnosis in his 20s
"He was a natural," said Nadon.
But those dreams dried up after Bunce was diagnosed with schizophrenia in his early 20s.
As he got older, he needed help to manage his money and make sure he took his medication, ate well and showered.
Eventually, Bunce moved into a group home on Marcil Avenue in NDG under contract with the Douglas Hospital.
Warning signs of declining health
In 2015, Bunce's health began to slide, and he was hospitalized several times.
In mid-December, too weak to walk, Bunce was taken by ambulance to Verdun Hospital with internal bleeding and a blood clot in his lung.
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While he was still in hospital, the owner of his group home, Elaine Husband, went to Jamaica for her annual vacation.
She told CBC she asked the hospital not to release Bunce until she returned, as he needed a lot of care and had to be driven to frequent medical appointments. Husband had hired a back-up caregiver, but she said that person didn't have a car.
In January, about a month after Bunce's admission, Nadon said the hospital told her that her brother was getting better and it was poised to release him.
But Husband's absence meant he couldn't be sent back.
Nadon called his social worker to find out what was going on.
"She said don't worry, I'll take care of it," recalls Nadon. "She called me a day or two later, and she said it's all taken care of, Steve is going to be able to go home."
The last time Nadon saw her brother at the hospital on Jan. 23, he was sporting a large bandage on his neck. Bunce told her it was an "infection," but otherwise he was in good spirits.
"I was at the elevator, and he stood up at the door, and he came running toward me," said Nadon, who gets choked up recalling the memory. "He said, 'I just want one more hug.'"
Bunce was released that night.
Brief return to group home
His sister said he returned to the hospital for at least two follow-up blood tests. CBC Montreal Investigates was able to confirm one of them through a daily log book the group home kept on Bunce, tracking how well he was eating, his appointments and any problems that came up.
After Bunce's hospitalization, the log book shows he also went to appointments at two local CLSCs.
Nadon, who lives outside Montreal, was checking in on Bunce by phone. The first sign she had that something was wrong was on Feb. 10.
Bunce told her he had a sore leg.
"I said, 'What happened to going to the hospital?'" said Nadon. "He said, 'Oh, she left after she did the dishes and decided not to call.'"
Nadon says he told her he'd get his leg checked at the CLSC on Feb. 15. However, a day before that appointment, Bunce couldn't walk or get out of bed.
The log book is empty on Feb. 13, but the next day, Husband's son, Earl Harris, went to check on him. He said he found Bunce's feet were swollen.
"When I did take his socks off, this is when I saw the blueness on his toes, proceeding up to his ankles," said Harris.
By the time the ambulance arrived, Harris says one of Bunce's hands had also begun to change colour.
Deadly infection
The following day, Nadon found out her brother was in the Verdun Hospital's ICU on life support.
She was stunned. Her surprise turned to horror when she saw him.
He was waving his arm around in front of him, waving it, he'd go, 'No hand, no more hand, no more guitar.'- Nancy Nadon, describing her brother Steven Bunce's behaviour after his triple amputation
"I wasn't expecting to see what I did," said Nadon, breaking down. "I could clearly see his hand was very enlarged, and it was like, black."
"He had blankets over his feet, and I couldn't really bear to look. But when he was lying on the bed, I could see his toes – and they were black."
Doctors told her he had been admitted with internal bleeding, once again, as well a blood infection, which had led to septic shock.
To save his life, both his legs and his left hand were amputated.
"He fought very hard for his life and wanted to live," said Nadon. "I told him, 'You are the world's bravest man. No one is braver than you.'"
Bunce's condition seemed to improve, but after a few days, Nadon noticed he was bloated.
Doctors assured her it was due to the treatment for a severe staph infection. But tests later showed the swelling was due to extensive blood clots.
Bunce became increasingly agitated.
"He was waving his arm around in front of him, waving it, he'd go, 'No hand, no more hand, no more guitar,'" said Nadon.
Playing the guitar had been one of her brother's few pleasures.
He begged Nadon to take him home and repeatedly tried to get out of bed.
He died on March 12 – almost a month after being admitted.
Douglas takes action
CBC Montreal Investigates has learned that ten days after Bunce died, supervisors from the Douglas Hospital and the local CLSC converged on his group home and shut it down.
In a letter to Husband dated the same day, the hospital lists its concerns with the residence, dating back to 2014: cleanliness, serious safety issues and the competency of the people in charge during Husband's absence.
The letter then zeroes in on Feb. 14, the day Bunce was taken to the hospital.
"He had not been able to move by himself since the previous day due to swollen and blueish feet," the letter states.
"Your son, Earl Harris, who at the moment was not a qualified back-up caregiver, noticed but decided to wait to consult a doctor. Unfortunately, it was established that the client's medical condition declined due to the decision to wait to consult."
The letter concludes "this death was due to issues in competencies and lack of judgment of the workers at the resource, which is something we have been working on with you for the last years."
"The negligence to address these preoccupations unfortunately resulted in a death that could possibly have been prevented."
It chides Husband for failing to pass on relevant clinical information regarding the residents to her back-up caregivers prior to leaving on vacation.
The letter goes on to say, "The neglect to ensure quality services and safety of the clients placed under your care constitute a serious motive that results in the termination of our agreement."
Elaine Husband denies the allegations. Over the years, she says, she made whatever corrections the Douglas asked of her.
Just five months before the Douglas closed her group home, Husband said, the hospital's residential resources department had extended her contract until the end of March 2017.
In a follow-up letter, department staff thanked her for 30 years of dedication and hard work. There is no mention of any problems.
Husband, a senior citizen, planned on retiring next year, and in that letter, the Douglas outlined a transition plan to gradually place her clients elsewhere
"Why would they give me people if it was so filthy dirty, and my service was no good?" asked Husband. "We looked after him, he was not neglected."
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Husband says she wants an apology from the hospital and is fighting to have her cancelled contract paid out in full.
She knew that Bunce was hospitalized in December, but she said she didn't know it was for internal bleeding and a blood clot.
Not all medical information is shared with group home staff due to privacy laws.
But Husband said if she'd known how serious his medical problems were, she wouldn't have accepted him back.
Unanswered questions
Three months after her brother's death, Nadon is still plagued with questions about the care he received.
Was he released from Verdun Hospital in January too early?
With his deteriorating health, was a return to the group home really the best option? Could he have been saved if the caregivers at the group home had called the ambulance as soon as Bunce began to complain about leg pain?
Nadon tried to get information from Urgences Santé, the Verdun and Douglas hospitals, as well as the CLSC, but under the law, a patient's information is confidential.
"I've just gotten the door slammed in my face over and over again," said Nadon.
Nadon also reached out to the Douglas Hospital's ombudsman shortly after Bunce's death.
Although Bunce was a patient at the Douglas for years, his sister says no one ever called her to offer their condolences or explain what happened with his group home.
The regional health agency that oversees the Douglas refused to comment on Bunce's case, citing patient confidentiality.
"That being said, please rest assured that all users receive the best possible care and services adapted to their situation," said a media relations officer for the agency, the CIUSSS de l'Ouest-de-l'Île-de-Montréal.
Patients' rights lawyer Jean-Pierre Ménard said it can often be difficult for people to get access to their loved ones' files. However, he says, if Nadon is considering legal action, she has a right to them as his next-of-kin.
The Douglas Hospital also has a duty to disclose information to her.
"If her brother hasn't been treated properly, if something unusual happened to her brother, the hospital has an obligation to disclose that to the sister," said Ménard.
She's happy Husband's residence is closed, but wants to see stricter oversight for group homes.
Nadon says the Douglas Hospital's letter to Husband shows a mistake was made, which it also has to answer for.
"It is shocking what happened to Steve in a three-week period of time," said Nadon.
She feels she owes it to her brother to find out what went wrong.
"That's all I want to see is better care," said Nadon.
"It's too late for Steve, but if I could change that in the future for other mentally ill people, I will feel that I have done something."
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