Report released into Ontario man’s death at mental health facility

WATCH: A coroner has made 46 recommendations after the death of Kulmiye Aganeh who was in custody in a mental health facility. Marianne Dimain reports.

TORONTO – The family of an Ontario man who died while in custody at a mental health facility in Penetenguishine says a coroner inquest has given them a sense of closure.

“I wait five years,” said Aganeh’s mother Ikram Said. “Now everything’s finished. Today I’m happy everything’s finished.”

Kulmiye Aganeh died in March 2009 while in custody at the Centre for Mental Healthcare now called Waypoint. The 22-year-old suffered sudden cardiac arrest after he was put in a chin hold and then administered Olanzapine used to treat his schizophrenia. He was then put in confinement while he lay unconscious where he later died. The coroner cites his death as the result of Olanzapine toxicity.

“He was left there for between seven to 10 minutes without any form of treatment or assessment,” said family lawyer Julian Roy. “Those were his last minutes and that is a terrible tragedy.”

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The jury in the coroner’s inquest came back with 46 recommendations for the maximum security institution to consider.

Among them, a recommendation for inexperienced physicians to consult with more experienced colleagues before administering anti-psychotic medication. The report also says staff should be given proper training.

One key recommendation is for the facility to prohibit the use of force as a restraint near the throat, neck, or chin.

“Waypoint should encourage other forensic psychiatric units to discontinue the use of the three person restraint involving the ‘chin lift’,” the report says.

“This verdict is a devastating indictment of the hospital and its staff and physicians,” said Roy.

Lawyer Suzan Frazer represents 15 male patients who have been detained in mental health institutions and have been calling for an end to chin restraints for years.

“We need to deliver humane care,” said Frazer, a lawyer for Oakridge Client Group. “We need to deliver culturally competent care and we need to ensure that the least amount of restraint is used.”

Aganeh was a patient at the facility from Dec. 2007 to March 2009. His mother said she has been taking medication to help with the stress and grief she’s suffered since his death.

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“I suffer alot,” said Said. “I don’t want any mother to suffer.”

The jury also recommends vital signs should be taken twice a day when a patient is in confinement. Under the coroners act an inquest is held any time a person dies while in custody.

Aganeh’s family hopes the Waypoint Facility will implement the recommendations to protect mental health patients from the same fate. She and her family seek comfort in knowing Aganeh is no longer suffering.

“No more give him injection, no more give him medicine, no one abuse him, now he’s nice place, he’s sleeping well,” said Said.

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