Sexual assault victims were turned away from New Brunswick emergency departments more frequently in the months leading up to the case of a Fredericton woman last summer than in the previous eight years, documents obtained by CBC News reveal.
Roxanne Paquette, provincial co-ordinator of the sexual assault nurse examine program for both New Brunswick health networks, made the comment in an email to interim Horizon CEO Margaret Melanson the day after the case became public.
CBC News had reported that a 26-year-old sexual assault victim in Fredericton had gone to the Dr. Everett Chalmers Regional Hospital's emergency department to get a rape kit performed during the New Brunswick Day long weekend. She was told no one trained to do the exam was available until the next day.
This response to assault victims wasn't new, according to the email from Paquette, who'd been in the job since 2014.
Treatment triggered outrage
She told Melanson that when examiners with the program, known as SANE, weren't available, patients were sent between the Horizon and Vitalité health networks or asked to schedule an appointment.
"We have been transferring patient[s] between VHN and HHN or booking SANE appointment when SANE are available more often in the last 6 months [than] we have done since I am a provincial coordinator," Paquette wrote.
SANE has been challenged by the same staff shortages as other health services, and "COVID certainly didn't help."
Paquette sent the email on Sept. 13 in response to an email from Melanson about the "very unfortunate circumstance with the patient" in Fredericton.
Victim told to go home, not use bathroom
The Fredericton victim, whom CBC is not naming, was instructed to go home overnight, not shower or change, and to use the washroom as little as possible to help preserve any evidence.
She did get an examination a couple of hours later, after a police officer intervened, and a SANE nurse was called in after working the night shift.
The story triggered national outrage, however, and an internal review of the SANE program.
Horizon later announced sweeping changes to the program, which sees sexual assault nurse examiners provide forensic exams, including the collection of physical evidence admissible in court.
They also provide medical exams, medications to prevent pregnancy and sexually transmitted diseases, compassionate support and resources for followup.
The changes, worth about $1.16 million, included plans to add full-time examiners, who would be dedicated to the SANE program instead of being on-call on top of their regular duties.
Horizon has filled "nearly all" of the new positions, the equivalent of about seven examiners, Greg Doiron, vice-president of clinical operations, said last week.
Vitalité is hiring "a number" of permanent sexual assault nurse examiners, as well as a regional co-ordinator, said Sharon Smyth Okana, senior vice-president of client programs and nursing.
The roughly 100 pages of documents obtained from Horizon through a right to information request offer a look at what went on behind the scenes after the Chalmers case emerged.
CEO was informed of 'SANE incident'
They show Melanson was informed of the situation by at least Aug. 3.
On Aug. 2, Pamela Lewis, a risk management analyst for Horizon, flagged the "SANE incident" in an email to the director of risk management as "something that Margaret Melanson would be interested in knowing." Most of that email has been redacted.
Risk management director Sandra Rooney directed Lewis to follow up with the SANE co-ordinator for the Fredericton area, as well as the Chalmers ER night manager and the ER's administrative director.
On Aug. 3, Rooney forwarded the email chain to Melanson, saying, "FYI … more information related to the staffing issue for SANE."
By Aug. 12, the ER's administrative director suggested the executive director for the Fredericton area would "likely have to alert [the executive leadership team] as this is a potential media concern."
A few days later, the SANE provincial co-ordinator emailed several Horizon and Vitalité officials regarding an interview request from CBC about how the Fredericton victim was treated, "so a decision can be taken all together."
Paquette said she was "made aware of the situation" by the SANE regional co-ordinator.
"Let me know how you want me to handle (or not) that situation with media," she wrote.
On the day the CBC story ran, Melanson emailed Doiron, asking him to have someone prepare a "one pager on the staffing/availability of the SANE nurse examiners."
CEO unsure of provincial co-ordinator's role
The emails suggest Melanson didn't know what Paquette's job involved.
"Can you please clarify for me what your understanding is of your role and leadership regarding the SANE program within Horizon?
"I have an immediate need for new policy and practices to be instituted."
Paquette replied her role is to "ensure program development, provincial orientation, that we are following best practices and education guidelines, community engagement and [to] act as a consultant for the regional SANE co-ordinators."
It's also to work with various government departments, police and community groups to ensure awareness of the program, Paquette said.
Managerial oversight was the responsibility of each health authority, she wrote.
The next morning, Melanson advised Paquette that Doiron was leading "an entire process review" of the program.
"I'm sure you will agree that a strong provincial program will strengthen all," Melanson said.
What is supposed to happen
Horizon's police manual for the care of victims of sexual assault and intimate partner violence is included among the documents. It details what's supposed to happen when a rape victim shows up at an emergency department.
A triage nurse assesses the victim, takes them into a designated examination room, informs the ER doctor if the victim needs medical assistance, and asks the receptionist to contact the sexual assault nurse examiner on call.
According to the policy, the nurse must arrive at the emergency department within one hour of being called.
If the nurse doesn't respond to the call within 10 minutes, the receptionist is supposed to call them again on their cell or at home.
If the nurse still hasn't responded within another 10 minutes, the receptionist is supposed to call the SANE program co-ordinator.
"There is always a SANE co-ordinator on call," the policy states.
Exam by ER doctor 'not a realistic expectation'
The ER doctor attends to any medical needs of the victim, and if the SANE nurse or program co-ordinator can't be contacted within two hours, may collect evidence if ER staffing allows.
But this is "not a realistic expectation," according to Ashley Stuart, the SANE co-ordinator at the Saint John Regional Hospital — "certainly not for our department in its current state."
"This policy could stand to be reviewed and have contingency efforts," Stuart wrote in a Sept. 13 email to Lori Lavric, administrative director of the emergency program for the Saint John area.
When there is no SANE nurse, Stuart said victims are always given the option of going home and returning when one is available, although this "presents the barrier of them not returning."
The Fredericton victim told CBC she was not offered the option of staying in the ER overnight while waiting for a SANE nurse.
Stuart, who'd been asked by Lavric for the local update, said she thinks victims should always be given that option.
She provided a suggestion, but the information is redacted.
Lavric noted there were only five trained sexual assault nurse examiners in the region, although two ER nurses had just agreed to training.
"As you can see from the on-call schedule, we have many gaps," she wrote.
"It is very challenging to sustain this program with the on-call piece and the current remuneration per the collective agreement."
The program's three regional co-ordinators take turns being the co-ordinator on call for a month at a time, 24 hours a day, seven days a week, said Lavric.
"We discussed [doctor] involvement in our dept meeting" Sept. 13, she said, but the rest of the sentence is redacted.
Used to rely on untrained ER doctors
Before the SANE program was created in Moncton in 2004, victims of sexual violence "relied on untrained emergency room physicians to provide sexual violence specific, trauma-informed medical care and collect forensic evidence," according to Lorraine Whalley, executive director of Sexual Violence New Brunswick.
"Due to the lengthy nature of the process, physicians would often be required to wait until the end of their shifts, resulting in lengthy delays for the victim," she told Horizon in a Sept. 15 letter in support of the SANE program.
This highly specialized, essential service for survivors needs to be protected and enhanced at all costs to ensure the safety of all New Brunswickers. - Lorraine Whalley, Sexual Violence New Brunswick
New Brunswick has been "incredibly fortunate" to have nurses who built and expanded the program throughout the province, said Whalley.
Still, she noted, there are some communities with no access.
Memo to ER staff
In the wake of the media coverage of the Fredericton victim, Horizon's executive director for the area sent a memo to all emergency department staff about this "very difficult" time for them and the hospital.
"It seems that you, and the valuable services you provide, continue to be in the media spotlight. For this, I am truly sorry," David Arbeau wrote.
"Anytime we get concerns from our patients, we should do a proper review that includes the staff of that particular service. There is always more nuance to these events, better understood by talking with you, the experts."
The SANE program review would ensure the proper resources and systems are in place, Arbeau said.
He also referred to the "longstanding, systemic challenges" faced by the emergency department, including housing patients there who are waiting for inpatient beds.
A consultant was helping with "process mapping," Arbeau said, and the hospital had hired a new nurse manager and a third physician assistant. It also had a new nurse mentor — Janet Matheson, the SANE nurse who ultimately performed the exam for the Fredericton victim after police intervened.
Matheson, 69, who retired from full-time nursing in February 2022 but went back on a casual basis, had just gotten into bed after finishing an evening shift around midnight, when she got the call.
Arbeau sent her a personal email thanking her for service "above and beyond."
Systemic challenges at issue, not staff
Like Arbeau, Melanson acknowledged how hard the previous few days had been for everyone, especially the frontline physicians, nurses and staff at the Chalmers.
"I want to be clear that the issues we face in the delivery of the SANE program — and other services — are systemic, process-driven challenges," she wrote before praising them for their work.
On Oct. 7, Doiron submitted recommendations on the SANE program to Melanson, who submitted them to the Department of Health.
The department supported the recommendations "aimed at ensuring that this important service is sustainable," according to an email from deputy minister Eric Beaulieu.
"However we do feel that it is important to reduce the current variability in the delivery of the service across the province between Horizon Health Network and Vitalité Health Network," he told Melanson on Oct. 25.
"It is our view that a single, standardized provincial operational model across the province be established."
Beaulieu expected the work could be completed by early 2023 and resource needs for the new model would be put forward as part of the 2023-24 budget to be tabled on Tuesday.
CBC asked the department to explain why it wants the new provincial model, how it will differ from the current provincial program, and what difference it will make for victims.
"The goal of a single, standardized operational model is to ensure the needs of all New Brunswickers seeking a forensic nurse examiner are met," said spokesperson Sean Hatchard.
He would not elaborate or say whether the two regional health authorities will share resources under the new model, with a Vitalité sexual assault nurse examiner responding to a Horizon victim, for example.
"Work on forming a province-wide model of care is ongoing," Hatchard said.