Jubilee patients left at bus stop are caught up in a systems failure

Several regional media outlets reported this week on the alleged dumping of a patient at a bus stop outside Royal Jubilee Hospital. One person told CHEK News she has witnessed similar incidents at least twice a week, most recently on Jan. 21. Two years ago, a neighbour told Capital Daily he had seen multiple patients left at the stop.

What is happening at Victoria hospitals is a convergence of system overwhelm, a lack of resources and frustration. When asked about the bus stop dumping, Victoria Coun. Jeremy Coradonna said, “Basically people are incapable of functioning independently and then a hospital just kicking them out is a failure of the health-care system.”

But it’s not just the health-care system, it’s broader structural deficiencies that have failed to keep up with the factors underpinning what is happening for vulnerable people on the streets—the root causes of chronic poverty, addiction and mental health crises and homelessness.

Providing outpatient treatment or emergency room care for individuals grappling with addiction or a mental-health crisis poses unique challenges for hospitals that stem from a complex interplay of social, economic, and case-by-case health-related factors. A comorbidity—or an overlap of—addiction and mental illness amplifies the complexity of patient treatment.

For people also experiencing homelessness, a lack of stable housing can undermine the effectiveness of outpatient care. Individuals have been taken repeatedly, by paramedics or police to hospital emergency rooms that are limited in the scope of care and services they can provide.

Paramedics and police are first responders to people in crisis

Police are often the main first point of contact for people who are experiencing a mental-health or addiction crisis. The experience can be anxiety-producing, dehumanizing or downright traumatizing for people who may be afraid they will be arrested for using drugs, or due to prior negative experiences with police, as is often the case for racialized or Indigenous people.

A mental health-police services interface toolkit was developed in 2018 to better equip law enforcement officers serving people with mental-health and substance use needs, but it did not outline protocols or practices specifically for working with Indigenous Peoples. Section 28 of the provincial mental-health act authorizes police in BC to apprehend an individual “if they are satisfied that individual is behaving in a way that may endanger their own safety or the safety of others.” According to that same section, if, after someone is brought by police or paramedics to an ER and “a physician does not complete a medical certificate for the involuntary admission of the individual, the individual must be released.”

But what is called a release on paper can often in practice appear to eye witnesses such as the one who spoke with CHEK News as patients simply being unceremoniously escorted to and left at the bus stop.

‍ Being released does not mean the situation has improved

Unhoused individuals often experience a higher prevalence of co-occurring disorders requiring integrated and specialized care that is not always available. When those disorders and additional factors manifest in disruptive, dangerous or violent behaviour, hospital staff are faced with difficult choices. If that behaviour is directed at them or other patients in a threatening way, protocols are clear.

According to a statement provided from Island Health, “The health and safety of Island Health staff, medical staff and patients is our top priority and any form of violence or harassment is not tolerated. In some instances and based on patient behaviour and actions during discharge, Protection Services Officers may be involved to ensure the safety of everyone involved.”

Otherwise, “patients are generally discharged from hospital when deemed medically stable, based on the clinical assessment of the care team involved in the patient’s care.” That team may solely consist of busy emergency room staff, on any given day. The province and the CRD is investing in additional pathways to care where need and eligibility align. But is it enough?

In Dec., Capital Daily reported on a new outpatient mental-health program launched at the Jube. The day or “bridging” program was designed to improve mental-health care outcomes and to meet intersecting challenges, in the CRD, of growing client needs and access to care. One of the day program’s eligibility requirements is that participants be consistently capable of independent living and must not pose a risk to themselves or others.

Under the BC Mental Health Act, people are only placed under involuntary care intake as a last resort. “To be certified for involuntary health treatment, a person must meet four requirements: has a mental-health issue that seriously impairs their ability to live in the community; requires psychiatric care at a designated facility; requires care and supervision to prevent deterioration or to protect themselves or others; cannot safely or adequately be treated in a community-based facility.” And while the formula for qualification is a relatively neat one, it does not account for the current system’s lack of capacity to step in should individuals not meet these requirements.

Finding treatment programs, services for people with overlapping issues a challenge

According to the Canadian Mental Health Association (CMHA), the risk of violence may be higher among people who experience co-existing mental-health and substance use problems, however, mental-health struggles alone, it says, “are not a predictor of violence.”

The CMHA says “Studies have found little evidence of a relationship between the two.” However, “wherever other factors such as economic precarity, inadequate housing or the lived experience of trauma are also at play, people may be at further risk of committing acts of violence. These risks decline the CMHA says, “with proper care and treatment.”

Island Health’s policy creates a conundrum whereby if the patient exhibits violent behaviour, they will not be treated. But a lack of treatment can also lead to a risk of violent behaviour. It’s a problem clearly not being solved for people being escorted by security to bus stops outside hospitals.

And while the physical, mental, or housing status of the people Julianna Nielsen—the woman who spoke with CHEK—alleges to have witnessed has been confirmed, they do, in her words, “appear to be in medical distress,” and “begging for help and crying at that bus stop” the conundrum is being played out just outside her window.

At a news conference yesterday in Vancouver, Premier David Eby was asked to comment on videos submitted to the press which show multiple instances of people escorted to the bus stop and left there in questionable condition. “These are deeply disturbing stories that we are hearing about people who have gone to the hospital for care, and are being left at bus stops in distress,” he said.

When asked by reporters there what was going to be done about it, Eby said “Our expectation is that the health authorities will continue their work looking into these, and addressing the issue to make sure that if there is an additional role the province needs to play in terms of supports for people who are being discharged, that we’re closing that loop and meeting the needs of people as best as possible.”

‍ The real need is to prevent the crises that lead to a 911 call ‍

Coordinating care among service providers beyond the hospital, such as mental-health professionals, substance-abuse counsellors, and social workers, becomes more challenging due to the lack of a centralized system and the fragmented nature of services available to the unhoused in Victoria. The province has put some funding toward  new care resources but the need far outweighs the response to date.

Last October, the province announced funding for five additional adult substance and concurrent disorders treatment beds at Homewood Ravensview in North Saanich,15 more beds at Cedars Recovery in nearby Cobble Hill, and six beds at Victoria’s Coastal Sage Healing House. Anyone who has walked recently downtown along Pandora will know that those numbers are a drop in the city’s proverbial bucket of need.

And if the exponential leap in the number of provincially-funded substance treatment beds from 268 in 2020/21 to 436 in 2021/22, as stated in the province’s Mental-health and Substance System of Care Snapshot is any indication of a growing care crisis, one can extrapolate that those new 2023 provincially-funded bed numbers don’t square with current needs.

Ideally, people in crisis would be able to turn to the care of family, friends or a community support network. That network may include housing or shelter support. But those networks in the CRD are currently stressed. The Jubilee Hospital is clearly between a rock and a hard place but for people living precisely in “that place,” there is no good solution waiting for them at the bus stop.