Allalouf Inquest
Background:
In July 1997, the Psychiatric Patient Advocate Office
(PPAO) wrote to the coroner, Dr. Richard Isaac, to request that an inquest be held to
examine the circumstances leading to the death of Ms. Cinderella Allalouf on April 10,
1997. On the date of her death, Ms. Allalouf was a patient on the Medium Secure Forensic
Unit at the Queen Street Mental Health Centre. During her detention on the unit, she
became pregnant and subsequently died following the birth of her child.
In our letter we raised four broad concerns which we felt needed examination: 1) issues relating to the care of vulnerable female offenders; 2) patient sexuality issues; 3) medical care during pregnancy; and, 4) the duty to provide a safe and secure setting for patients.
In November 1997, when no decision about an inquest had yet been made, the PPAO wrote several groups asking for their support to lobby the coroner. Subsequently, several groups wrote on behalf of the deceased. In March 1998, the Regional Coroner announced that an inquest would be held.
Over the course of 1998 the PPAO met with several of the groups. We discussed issues raised by Ms. Allalouf's death and explored whether one or more of the groups wished to pursue an application for joint standing at the inquest with the PPAO.
In April 1999, the PPAO, along with several other parties, appeared before the Coroner to ask for standing at the inquest. Being granted standing means that a party has a right to: 1) be represented by counsel; 2) call and cross examine witnesses; 3) present arguments; and, 4) make submissions to the jury. The PPAO was granted standing by the Coroner by meeting the private law test (that we had a substantial and direct interest in participating at the inquest) and the public law test (that the public interest would be served by the PPAO's participation).
On April 12, 1999, the jury began to hear evidence into the circumstances surrounding Ms. Allalouf's death. On May 12, after hearing evidence for seventeen days, the jury came to a verdict and made recommendations meant to prevent similar deaths in future.
Coroner's Inquest Into The Death of Cinderella Allalouf
PDF - complete Coroner's Report on the Inquest (2MB)
The jury ruled that the cause of death was "a sudden unexpected maternal death following cesarean section, associated with schizophrenia.." The jury also found that the death was by undetermined means.
Jury Recommendations:
Directed to the Ministry of Health
- The Ministry of Health should create a policy, through a consultative process with psychiatric hospital administrators, clinicians and other stakeholders that recognizes a patient's right to sexuality; as well as a guideline that outlines a minimum standard for the assessment of a psychiatric in-patients's capacity to make decisions regarding consensual sexual relations. The policy and guideline respecting consent capacity should be modelled after the Riverview Psychiatric Hospital policy and manual entitled "Patient Sexuality Manual: A guide to the Riverview Hospital Policy on Patient Sexuality, April 30, 1993". Each psychiatric hospital should be required to institute the policy and guideline within a stipulated time frame.
Directed to the Government of Ontario
- The Government of Ontario should amend the Consent and Capacity Legislation to allow for an appeal by an in-patient with respect to a negative consent to sexual activity capacity assessment, in the same manner as the legislation would apply to all other consent and capacity reviews.
Rationale for #1 and 2:
There should be a uniform policy throughout the
psychiatric hospitals in Ontario with regards to sexual activity of long term in-patients.
There should also be an appeal process put in place.
Directed to the Ministry of Health and each Psychiatric Institution of the Province
- Unexplained or unexpected pregnancy should be considered a serious incident within all Ontario Psychiatric Hospitals. As a serious incident, it should be fully documented by the institution and should be subject to investigation by a person or group independent of the facility.
Directed to the Attorney General of Canada
- That Justice Canada amend in section 672.1 of the Criminal Code, the statutory definition of the word "party" for the purposes of the Ontario Review Board hearings, in order to ensure that a hospital to which the current detaining hospital wishes to transfer a patient who is subject to Board authority, will necessarily have party status at the disposition hearing that will make such order.
Directed to the Ontario Review Board and the Ministry of Health
- Whenever an institution is proposing the transfer of a patient to another institution it shall advise the other institution of such intention. It shall also canvass the other institution's attitude towards the proposed transfer and include a summary of the reasons why the institution is prepared to agree to the transfer or, if it is not, it's reasons for objecting to the transfer in the administrator's report. The detaining hospital should be required to include in the administrator's report to the Review Board information relating to the consultative process and the position of the prospective recipient hospital as to whether the disposition patient is appropriate for its' facilities and programming.
Directed to the Ministry of Health and the Ontario Review Board
- The administrator's report, prepared for presentation at Review Board hearings, about the transfer of a female accused, should include information about any special needs including treatment, safety issues and gender ratio.
Rationale for # 4, 5 and 6:
The receiving hospital should have representation at the ORB hearing concerning transfer of patient from one institution to another.
Directed to the Ministry of Health and the Ontario Review Board
- Hospital administrators, who are responsible for the administration of Review Board orders must be required to notify the Review Board within 45 days of the date of the order if he/she is unable to comply with the order wherein the hospital administrator is directed to transfer the patient from one level of secure custody to another level, either within the hospital, or with respect to a transfer to another designation hospital.
Rationale for # 7:
The Ontario Review Board should be notified if the order cannot be followed so appropriate accommodations can be made at another institution.
Directed to the Ministry of Health
- That the Ministry of Health continue its commitment to fund the renovation and operation of a 30 bed minimum secure forensic unit at the Centre for Addiction and Mental Health (Queen Street Division) with a view to designating four of those beds for women with separate sleeping accommodation within the minimum secure unit itself.
Rationale for # 8:
To provide safe sleeping accommodation for female patients.
Directed to the Centre of Addiction and Mental Health, the Ontario Ministry of the Solicitor General and Correction Services and the Correction Services of Canada
- It is recommended that the Centre for Addiction and Mental Health, the Ontario Ministry of the Solicitor General and Correctional Services and the Correction Services of Canada continue to explore the development of 14 to 16 bed medium and maximum secure unit for female patients only.
Directed to the Ministry of Health
- When considering implementation of Patient Sexuality policies, institutional staff should undergo training/sensitization pertaining to sexual assaults and the recognition that all patients, regardless of gender, appearance or conduct, may be vulnerable.
Directed to the Ministry of health, the Ontario Review Board, and all designated facilities providing forensic psychiatric services.
- The portion of the Centre for Addiction and Mental Health's policy that locked seclusion in excess of seven days amounts to a significant restriction on liberty and requires notification to the Ontario Review Board be adopted in all settings providing forensic services.
Rationale for # 11:
There should be a stricter enforcement of the policy of locked seclusion.
- The Office of the Chief Coroner, on or about the anniversary date of this inquest, May 12, 2000, will ascertain and make public the progress of the implementation of the recommendations made by this jury.
The PPAO thanks the jury for its time and attention to this matter. We also thank Ms. Allalouf's family for their support and extend our regrets at their loss.
We also wish to thank the following groups for their assistance and efforts on Ms. Allalouf's behalf:
Metropolitan Action Committee on Violence Against
Women and Children
Advocacy Centre for the Elderly
London and St. Thomas Psychiatric Hospital Patients' Council
Hamilton Psychiatric Hospital Patients' Council
Queen Street Mental Health Centre Patients' Council
Ontario Council of Alternative Businesses
Elizabeth Fry Society of Toronto
Mental Health Legal Committee
Schizophrenia Society of Ontario
Mental Health and Addictions Action Coalition
Family Association for Mental Health in Etobicoke
Psychiatric Survivor Pride Day Committee
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