WARNING: This story contains references to suicide.
A Chatham, Ont., woman is fighting to hold hospital officials accountable, saying they should have done more to save her adult son who had been struggling with mental illness before he died in the family home.
Leonie VanPuymbroeck says Robert Martin, 26, died by suicide April 8 after years of struggling with mental illness.
"This is the worst thing I have ever seen in my life," she said. "Parents should never have to bury their children."
VanPuymbroeck believes that, although her son had received treatment from health-care professionals since 2018 when he first started showing signs of mental distress, not enough was done to help him in his final months.
She said he was released early from a two-week involuntary hospital stay at the end of January after he was found wandering the streets in the cold, unsure of where he lived, and going in and out of strangers' vehicles.
"He was already in the hospital safe," VanPuymbroeck said "They could have kept him there until he was no longer manic. They could have found a therapist for him, listened to him, changed his psychiatrist when he asked for it. Maybe there could have been a different outcome. I don't know that. But he could have at least been given a chance."
VanPuymbroeck has filed complaints against Martin's psychiatrist, to both the Chatham-Kent Health Alliance (CKHA) where the doctor works, and to the College of Physicians and Surgeons of Ontario (CPSO).
While the CPSO said it was prohibited from confirming or discussing complaints, CKHA confirmed it would be conducting an internal review.
"The hospital takes all patient and family concerns seriously and is committed to providing patients with quality care," an emailed statement reads.
VanPuymbroeck said her son first showed troubling symptoms in 2018. He was diagnosed with attention deficit hyperactivity disorder (ADHD), bipolar disorder and, later, substance abuse (for use of caffeine drinks and marijuana) that may have contributed to psychotic episodes.
He told his mom he heard voices in his head. He was also at various times taking anti-psychotic medication and injections, but he thought they inhibited his creativity.
There had been visits from the mobile crisis team and support from a Canadian Mental Health Association case worker, and Martin had a psychiatrist he saw regularly through CKHA. Martin's daytimer showed he had been scheduled for an appointment with the doctor the day he died.
Since Martin was not a minor, his family was not privy to all his treatments and relied on him to share information.
During one 2018 visit to CKHA to speak with a crisis nurse, VanPuymbroeck said, the hospital determined he was not a threat to himself or his family and sent him home. She had also at one time requested further therapy and a new psychiatrist, which she says was denied.
"It made me feel helpless because how am I supposed to help him when health-care professionals won't?" she asked.
Sonja Grbevski, chief executive officer for the CMHA's Windsor-Essex County Branch, said the legal bar to keep someone in hospital involuntarily is high. Caring for a sick adult is also challenging, as professionals in mental health care must protect privacy.
WATCH | Sonja Grbevski of CMHA's Windsor-Essex County branch on what it takes to keep a person in hospital involuntarily:
"That is probably one of the most difficult areas that we're often faced with," Grbevski said. "The fact that when you have an adult child who's not doing well, we can't make them do anything different because people have to want to be helped, short of holding someone against their will and then, they have rights, even when you do hold the person against their will."
VanPuymbroeck said she didn't seek power of attorney over her son because she didn't want to take his rights away.
CBC is not naming Martin's psychiatrist because no patient issues have been noted in the physician's public register profile through the CPSO.
It's not clear yet if the CPSO will find grounds to act on VanPuymbroeck's complaint.
Hoping for change
As VanPuymbroeck grieves, she holds on to the memory of her son.
"He was empathetic. He was kind. He always worried about other people. He never really cared too much about himself. He always went to the quietest, loneliest looking person in the room and talked to them. He just was an overall great, amazing kid. He really was."
She said that since her son's death, other families have reached out to her with similar stories.
"My heart hurts and I have a knot in my stomach, and that's all it is. And now, I want to fight for others so that this doesn't happen to them, because that's what Robert would do.
"The system is broken and it's failed a lot of people," she said. "And I don't know what I can do to fix it, but it has to be fixed."
If you or someone you know is struggling, here's where to get help:
This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.