She was found naked in the men’s bathroom. Her family says CAMH failed to protect their ‘eternal child’

When the 26-year-old woman was admitted to the early psychosis unit at the Centre for Addiction and Mental Health, doctors observed she was often seen clutching a beloved teddy bear and appeared younger than her stated age.

Her older sister by three years describes her as an eternal child" - gullible, innocent and trusting - due to an intellectual disability. At the time her favourite movie was Disney's Frozen" and she would soothe herself by listening to Taylor Swift. She had to be reminded not to talk to or go with strangers.

The woman was admitted to the psychiatric hospital in downtown Toronto on Sept. 6, 2017, when the symptoms of her schizophrenia, which had manifested in her late teens, became worse and she started hallucinating, hearing voices and becoming paranoid. For the first time, she had started referring to herself in the third person when she spoke, as if what was happening to her was happening to someone else.

Her hospitalization was a relief for her worried family including her mother, who makes medical and financial decisions for her.

We had never seen her like that," her sister said in an interview. She had to be admitted to get the support and help and treatment that she needed."

According to the woman's medical records, a male patient on the co-ed unit was seen two days later making sexual advances towards her and gesturing that they have intercourse."

A nurse intervened and the man angrily walked away. She remains very vulnerable," her doctor wrote, and ordered that she be placed on continuous observation - the highest level of monitoring with a nurse watching over her 24 hours a day.

Just over two weeks later, doctors reduced this to a nurse checking on her every 15 minutes, though they said the woman was still vulnerable to targeting."

On the third day of every-15-minute monitoring, the woman reported she'd been sexually assaulted by two men in the men's washroom. A rape kit analyzed by the Centre for Forensic Sciences found semen on her underwear and external genitals. The DNA from the semen matched the DNA of a male recovered from saliva on her neck and chest.

The mother and sister of the woman, who the Star is not naming because she is the victim of a sexual assault and cannot give informed consent to disclose her identity, launched a $1.7-million lawsuit against CAMH in 2019. The case is ongoing. The woman's family claims CAMH failed to protect her from being sexually harassed and sexually assaulted, alleging that she was not properly monitored, that key people including her family were not kept informed of crucial information and that the hospital failed to respond appropriately in the aftermath.

We were so concerned for her safety, we were constantly visiting her, my mom was there every day," the woman's sister said in an interview. I personally feel disappointed and scared for (my sister) and other people like her ... no one has been held accountable."

She said she decided to speak about what happened to push for change.

What happens in the future when she needs treatment? Is this something that is going to keep happening, is nothing going to change?" she said. We have to help her deal with this trauma for the rest of her life."

No charges were laid following a police investigation in which officers took two statements from the woman and spoke to at least two CAMH nurses and a CAMH psychiatrist.

A Crown prosecutor who reviewed the file found there was no reasonable prospect of conviction, even if a DNA match was found with a male patient. The police file notes that the woman's accounts were confusing and that she said at one point that she wasn't sure if what had happened was a dream or reality.

In a statement of defence, CAMH denied any breach of duty, want of care or negligence" and asked that the lawsuit be dismissed.

The Hospital pleads that at all material times it supervised the plaintiff in a reasonable and appropriate manner and in accordance with acceptable standards and took the requisite level of care to ensure the plaintiff was reasonably safe while a patient at the hospital," the statement said.

CAMH did not respond to the Star's specific questions about the case and general questions about their policies, citing ongoing litigation.

One of the most disturbing allegations in the lawsuit involves an incident from the night before the sexual assault.

According to a psychiatrist's note, a clothed male patient was found in the woman's bed and told the nurse he had been cuddling" with her.

There is no mention of the incident in observation records from that night. The psychiatrist said he learned about it for the first time the next day at 1 p.m. from two other nurses, after he was told about the sexual assault.

Had he known about it earlier, the doctor wrote, they might have put the woman back on constant monitoring.

The woman's medical records do not say if this incident was ever verified with the nurse who directly observed it.

Her sister said the family only learned about previous incidents involving other male patients later, when they received the woman's CAMH medical records.

The woman did not have the capacity to consent to sexual touching of any kind, including cuddling," the family's statement of claim alleges.

In a statement, their lawyer Elizabeth Grace said the family believes women with mental health challenges have been profoundly misunderstood, if not entirely overlooked, in the context of institutional responses to sexual abuse of women and children. My clients would like to see systemic changes made by mental health facilities and police forces to prevent and, where it happens, respond more appropriately to sexual assault of this highly vulnerable group."

Experts familiar with the psychiatric system say sexual assault is not uncommon on psychiatric wards - although statistics are not publicly available. Such cases show the need to increase access to women-only wards and for reports of sexual abuse and harassment to be taken seriously, they say.

Women with a cognitive disability or mental-health-related disability are twice as likely to be sexually assaulted than other women and are less likely to report sexual assaults to the police, according to research by Statistics Canada. They are also more likely to be repeatedly violently victimized.

Knowing that many of the women coming into psychiatric wards are likely survivors of sexual abuse makes it more important to provide care and an environment that is appropriate, said Jennifer Chambers, chair of the patient advocacy body known as the Empowerment Council at CAMH.

Part of the challenge in responding to sexual assaults by other patients is that the patient accused of doing the harm may also have a serious mental illness, may not intend harm or may not understand what they are doing and that they might face long-term consequences, Chambers noted.

Both people need protection," she said.

Chambers said the women's unit at CAMH is known as one of the best units to be on, which is a good indication there should be more such spaces available in psychiatric hospitals.

The need for women-only units has been long-established, including by a 1999 inquest into the death in childbirth of 39-year-old Cinderella Allalouf, said Anita Szigeti, a lawyer who has long specialized in mental health law. Allalouf was the only woman in a forensic psychiatric unit at CAMH with 19 male patients and somehow became pregnant.

CAMH in particular should be very alive to the fact that for some of their most vulnerable women clients, they absolutely must make space on units that are not co-ed," said Szigeti, who is not involved in the family's lawsuit.

This is compounded by the fact that these patients may be experiencing delusions or hallucinations in an acute mental health crisis, and may not be able to clearly communicate, she said.

It's about identifying people who are extraordinarily vulnerable and making sure that their environment is protective but not overly restrictive or invasive," Szigeti said.

It's also critical for hospitals to have clear and transparent policies on how they respond to sexual harassment and sexual assaults so that patients and their families can understand them, she said.

Patients in the co-ed early psychosis unit on the 10th floor of CAMH's College Street facility can walk around freely, and the doors to each room don't lock. In the three weeks the woman was there, she twice reported being bullied or harassed by other patients, according to the statement of claim which alleges nothing was done in response.

Some of her stuffed animals and clothes were also stolen from her room, which left her extremely distressed.

Her family members visited often - her mother daily - and became concerned about male patients interacting with the young woman and peering into her room.

It was apparent (she) was in a confused state of mind and had trouble understanding others," the statement of claim alleges, describing how the family feared a fellow patient could easily victimize or take advantage of (her) vulnerabilities."

Out of concern, her sister specifically asked a nurse if her sister was watched by staff even when she was asleep and was assured that she was.

When the woman's monitoring level was reduced to every 15 minutes, she was also moved to a different room, closer to the nurses' station and opposite the men's washroom.

On the morning of Sept. 28, 2017, the woman's family met with her medical team to discuss treatment options and future plans.

After the meeting, the woman's mother and sister left her sleeping in her room - she seemed drowsy from new medication - and then went to work.

A nurse told police that she last saw the woman at 12:15 p.m. When the nurse came back from a break at 12:27 p.m. she prepped the woman's medication and went to her room, but she wasn't there. The nurse found the woman naked in the men's washroom at 12:35 p.m.

According to the nurse's note in the woman's medical records, the nurse asked if anyone else was there and the woman said no, but another staff member found a male patient in the shower. The woman at first said nothing happened and that she was there to take a shower, the nurse wrote.

According to her medical records, the woman soon after told her medical team there had been sexual contact and inappropriate touching" in the bathroom involving two men, though she also said nothing happened because she was in her dream world" and delusional."

The woman has given accounts of what happened in the washroom to doctors, to her sister, to a sexual assault nurse and to police. Though she often speaks in a confusing and disjointed way, key parts of her account are consistent. She gave a physical description of a man who she said brought her into the washroom and told her to undress. She said he told her to touch his penis and that she refused. She also covered her mouth and repeatedly told him no to oral sex.

He told me come on touch my penis ... come on it's relaxing,' " she said, according to her second and clearest audio-recorded police statement in December 2017, done shortly before she was well enough to be discharged. And then he wanted to touch me and then I said, No, I don't want to do that ... I was not comfortable touching your private parts, leave me alone, I need space.' "

The whole time I said no and he was forcing me," she said.

In the police interview, the woman appears to mime the action of masturbation to the officer, but it is later apparent that she didn't understand the meaning of the words masturbation" and ejaculation" when used by the officer - when asked, the woman defined masturbation as it means to have kids, not married have kids, you love someone and want to have babies."

She also said the man tried to penetrate her with his penis, again appearing to physically mime the action to the officer.

Then she saw another man, who she gave a physical description of, peering over a bathroom stall at them. He then did the same thing to her, she said.

He wanted me to touch his penis and I said, I don't want to touch your penis, I said leave me alone,' " she said.

She told a sexual assault nurse that a man put his mouth on her lips and neck, and swabs were taken as part of the rape kit. Saliva with male DNA was found on her neck and breast, according to a forensics report.

According to her medical records, her psychiatrist became aware of what happened around 1 p.m. and her medical team met with the woman and explained to her she could file a police report if she wanted.

On this, her sister wonders why they discussed the option of a police report with the woman directly, without her mother and substitute decision-maker present.

She recalls how her sister became convinced that she was the one in trouble and that she was going to go to jail.

That was heartbreaking to hear," the sister said. She didn't understand the police are here to investigate who did this to her."

The sister also wonders why the family was only called two hours later, around 3 p.m. The medical records say her mother had to be contacted in order to decide if her daughter should be tested for sexually transmitted infections, and for consent to contact the sexual assault team at Women's College Hospital.

She also said the hospital failed to provide enough support to her sister and her family. Both she and her mother rushed to the hospital in a panic, but said there was no one waiting to meet them when they arrived. When they did speak to the medical team, the nurse who found the woman was already gone. Her mother was extremely upset, according to the records, and demanded to know why her daughter wasn't being constantly watched.

We told them that patients are taken off constant observation as they are feeling better and that if any indication of worsening occurs we put people back on constant," the note from the psychiatrist said, adding that monitoring every 15 minutes is still close supervision.

It was very unfortunate that within these 15 min something like this happened," the psychiatrist wrote, summarizing what the family was told.

Even after the assault, the hospital's plan was to move the woman to a women-only unit only when a bed became available, but until then to keep her under constant watch, still on the same unit where the two alleged assailants remained - a proposition that horrified her family, her sister said.

The woman's family said they would rather discharge her from the hospital, but were persuaded that due to her symptoms she needed to stay. She was transferred to the women's unit at 10:30 p.m. and kept under constant supervision.

When police arrived that evening after being called by the woman's sister, no CAMH staff - including the nurses, doctors and social workers - were available to speak to them, and the nurse who had found the woman in the bathroom had gone home, the statement of claim alleges.

That night, staff would not provide police the names of the two male patients who were allegedly involved, the police records state.

According to the medical records, the woman's family was told an internal investigation would be done and that the results would be shared with them when it was completed. The woman's sister said she was later told that the results of the review would not be released.

They still have no idea who the two men are, what, if anything, happened to them, and what the hospital determined took place, she said.

Those are only some of the many unanswered questions they have three years later.

Why wasn't the vulnerable young woman placed in the women's unit from the start?

Were other instances of harassment or abuse not documented in the records? To her family, the woman has repeatedly made references to interactions with a man in the computer room, laundry room and television room, including describing being caught by a nurse under a blanket with a man.

Her sister is also concerned about her repeated references to drugs, including cocaine and a white powder, which are not things she would have been familiar with before her hospital admission, she said.

She also remains disturbed by a discovery in her sister's room later in the day of the sexual assault. Scratched onto the glass window was the phrase: I wanna f--- you like an animal." Above it, in much larger letters, it says: F--- you useless c---s."

Her family doesn't recall seeing that before then, and wondered if someone had recently come into her room and done it. The woman doesn't read or write, so she wouldn't understand what it meant, her sister said.

It's just another thing to add to this horror story," she said.

The woman was alone with the female police detective when she gave her first statement on Oct. 5, 2017, though experts say it could have been helpful for her to have had a neutral support person to help her communicate effectively and offer emotional support.

A Toronto police spokesperson did not respond to specific questions about the case but said only the victim and interviewing officer are present in an interview in the vast majority of cases.

Having another person present during the interview is determined on a case-by-case basis," said spokesperson Allison Sparkes. If the victim has special needs (such as an intellectual disability) the appropriate individual or agency is contacted for assistance, as required."

The woman is described in the police file as very confused" in the 37-minute interview, often referring to herself in the third person and mixing up different incidents at different times. Though she does describe being sexually assaulted, she sometimes describes the assailants as bodyguards." At the end of the interview, she said: I don't know if I'm dreaming about it, if it's reality, maybe I'm confused. I don't know much about this stuff."

When the woman was interviewed alone a second time on Dec. 14, 2017, the officer wrote afterwards that she seemed less confused.

In notes assessing the strength of the evidence, the investigating officer wrote that although semen was found on her underwear and external genitals, it is not possible to tell if the semen came from sexual contact because the woman's underwear had been on the floor of the washroom and the sink.

The woman also didn't mention anyone's mouth coming into contact with her neck or breast in her police statements. The police report does not note that she told the sexual assault nurse this had happened. She was not asked specifically about kissing in the interviews, though she was asked about attempted penetration.

Meanwhile, CAMH's lawyer told the police they would not provide the identity of the first man without a warrant and the investigating officer didn't think there would be enough grounds to obtain a DNA warrant. There is no indication in the file that any warrant was ultimately sought.

In March 2018, a Crown reviewed the file and the investigation was closed.

After consultation with the Crown, it was determined that even if a person was identified as being the donor of the DNA which was recovered from (the complainant), there would be no prospect of conviction," the file states.

The woman recently turned 30. Some things haven't changed. Her birthday party was fairy-themed. She loves dancing to Taylor Swift with her therapy dog. She and her sister just spent time together constructing a volcano out of a science kit.

In other ways, she is different, her sister said. She is less trusting. She had been going to a co-ed day program for people with intellectual disabilities for years before her hospitalization but wouldn't go back afterwards because she didn't want to be around men. She has panic attacks and dislikes being in public. She doesn't like to be touched, even by her mother and sister.

Her sister says they are doing everything they can to make sure she doesn't have to be hospitalized again.

We are trying our best to make her feel safe," she said. She didn't deserve this. She deserved better."

Alyshah Hasham is a Toronto-based reporter covering crime and court for the Star. Follow her on Twitter: @alysanmati