Montreal woman alleges negligence at group home put her autistic sister in danger

A Montreal woman said she feels betrayed by health authorities for leaving the recently hired manager of her autistic sister's group home in place despite what she alleges are serious incidents of negligence.

The specialized group home, located in Montreal's Saint-Laurent borough, is for people with mental disabilities, autism and complex behavioural issues.

Electra Dalamagas's sister has been living there for more than a decade. Last December, a new manager took over the group home and brought in new staff.

To help her sister adjust to the change, Dalamagas visited regularly and took her on outings. During those visits, she noticed a growing number of problems. 

Dalamagas alleges staff made errors in the administration of medication — both with the timing, frequency and combinations of drugs — as well as with the charting of her sister's other health data, such as bowel movements, nutrition and sleep.

When she pointed out the errors to the new staff, she said nothing changed.

Her concerns peaked after returning to the home from an outing in late December.

Dalamagas said she was helping her sister in the bathroom when she found oven cleaner in an unlocked cabinet.

"You should not have these things lying around because a client could spill it on themselves or decide to drink it," said Dalamagas.

She questioned the only employee on site, who had been left alone to run the home at that time, but she said the woman appeared to have a cognitive impairment and didn't seem to understand Dalamagas's concern.

"If there's a fire, if somebody bolts — because some of our guys are runners — that woman won't be able to stop them," said Dalamagas, an advocate at Autisme Montreal who is also a trained social worker.

"My faith, confidence and trust was completely shattered that night."

'Breach of trust'

The home is part of a network of group homes run by a non-profit agency, Miriam Home and Services.

Believing that the health and safety of all the clients at the group home were in jeopardy and u​​​nable to reach a manager at Miriam Home over the Christmas break, Dalamagas went to the CIUSSS West-Central Montreal, the health and social services authority which oversees Miriam.

She demanded the contract of the newly hired group home manager be cancelled.

"I'm like, what are you waiting for, a coroner's inquest?" Dalamagas said she asked the health authority. "This is folly. Nobody's overseeing anything."

A few days after she lodged her complaint, Dalamagas learned that another group home worker had recorded a cellphone video of her sister, naked on the toilet, and had shown it to other people.

With that, Dalamagas had had enough, and she temporarily removed her sister from the home to ensure her safety.

"Why would you film somebody naked — somebody so vulnerable?" asks a mortified Dalamagas.

She said she believes that worker took the video out of spite, because she'd made the complaint.

"It's a breach of trust."

Language barriers, lack of oversight

Dalamagas said her sister's group home had been well-run for a decade.

The former manager and most of her staff had years of experience working at schools for people with special needs, she said.

They all spoke English, which helped them build relationships with the clients, offer structure and diffuse behavioural problems.

But last spring that manager gave her notice, leaving Miriam Home and Services seven months to find a replacement for her and her staff.

Dalamagas said she helped persuade one of the day staff to stay on for a few months to help ease the transition to a new team.

The new manager, James Marcellin, is francophone and speaks English poorly, said Dalamagas.

The French-speaking staff he hired to work evenings, nights and weekends also have limited English, she said, making it difficult for them to communicate with the mostly non-verbal clients, who are anglophones.

The families were promised the manager would be on site daily, but Dalamagas said he rarely showed up.

Occasionally, staff would ask her to pick up items for the home — something that should be the manager's job, she said.

Dalamagas said she was worried about the effect all the changes were having on her sister, who is non-verbal but was crying more often and having more frequent staring spells and problems sleeping — and had other ways of signalling her unhappiness.

"My sister was locking her coat and boots in the locker at her day activities and refusing to leave," said Dalamagas. "She did not want to go back to the home."

Dalamagas said she'd expected there would be challenges with the transition to a new group of caregivers, but what she could not tolerate was her sister being left in what she saw as an unsafe environment.

After the incident with the oven cleaner, Dalamagas met with the health authority and Miriam staff on Jan. 7. She outlined everything she had witnessed. She blamed Miriam for hiring the manager in the first place and not properly monitoring the transition.

Dalamagas suggested to officials the names of two other workers who could take over the group home, who were used to working with a special needs clientele.

"They told me, no, they wanted to continue working with the current manager," she said.

"I will never forgive that," she said. "Clients shouldn't be hostages to contracts."

Following her meeting, Dalamagas said she was told Miriam staff did an unannounced spot check. But that happened during the day, on a day that the only worker left from the previous administration was present.

Confidentiality promised

Dalamagas said she had been promised her complaint would be kept confidential.

But the next time Dalamagas visited her sister's group home, she said the staff member on duty greeted her rudely and spoke to her in an angry, scolding way. She suspected that person knew it was her who had complained.

The following day, the same staff member wouldn't let her in the home until she phoned the group home manager.

Once she learned about the video that was taken of her sister on Jan. 10, Dalamagas said there was no going back.

She alerted the health authority and asked again that the manager's contract be cancelled immediately. She also alerted the provincial Ministry of Health and Social Services.

Dalamagas said she was later told by administrators that the employee who took the video had been fired. She said they told her while the incident was "proof of poor judgment," no malice had been intended — that the employee had only wanted to take a picture of the broken toilet.

With her sister temporarily under her care, Dalamagas said she didn't hear back from the health authority for a full week.

On Jan. 17, she was told there would be a month-long administrative investigation that would either lead to recommendations for improvements at the home or the cancellation of the manager's contract.

In the meantime, the manager remains in place.

"The trust is completely broken," she said.

Investigations underway

In a statement, the CIUSSS West-Central Montreal said it followed the rules and regulations when it hired the manager.

In an email, CIUSSS spokesperson Barry Morgan said the transition had been quick because the agency wanted a new manager to step in as soon as possible. He said the new manager had only been away for four days during the holiday period and had been covered by a staff member used to working at the group home.

Morgan said the reported allegations were taken very seriously and resulted in immediate action. He said there are two separate investigations now underway. He did not provide specific details about what issues are being examined.

He said those investigations are expected to be completed by the beginning of February.

"The quality of the services that are provided by CIUSSS West-Central Montreal and the safety and well-being of our users are the focus of our concerns," Morgan said.

"Thus, appropriate measures are always implemented to ensure that vulnerable individuals in our facilities receive services of superior quality in a safe and secure environment."

Morgan said no further comments would be made due to confidentiality and to ensure the integrity of the investigations.

When CBC called the group home manager, Marcellin, he declined to comment, citing the investigation which is underway.

The Quebec Health and Social Services Ministry told CBC in an email it is aware of the situation and is following the investigations closely.

"No situation of mistreatment is tolerated," said Marie-Claude Lacasse, a ministry spokesperson.

'Unconscionable,' critic says

Liberal critic Jennifer Maccarone said Dalamagas's experience shows that instead of protecting the most vulnerable, the government is protecting the people it hires to oversee, staff and run these group homes.

Maccarone is the mother of two autistic children, one who just recently celebrated her 18th birthday.

She said she is worried about the challenges new adults on the autism spectrum face once they transition from the youth system, into the adult sector, which she says offers a "desert" of services.

Last fall, she unsuccessfully tried to convince the Legault government to hold a parliamentary commission on services for people with autism, particularly when they reach the age of majority.

"I am scared because I would not send my children to a place like this where I wouldn't even send my dog," said Maccarone.

"It is ridiculous and unconscionable for me to think that we don't have the time to talk about what's happening on the ground and hear from the people who are living these situations like Ms. Dalamagas and her sister."

Dalamagas's sister remains in her care.

"I feel betrayed," Dalamagas said.

"Instead of protecting clients, the agency is protecting the caregiver."