Stephanie Coulter died at 31 of a fentanyl overdose. But her life shows how Ontario’s mental health system failed

On a frigid December morning, Flo Coulter drove an hour north from her Richmond Hill home to Royal Victoria Hospital in Barrie.

She had just received a call that her daughter, Stephanie, had spent the night at the psychiatry unit after being dropped off by police. Coulter was worried. Stephanie had long struggled with her mental health, and had recently suffered a string of life-altering hardships. Her relationship of five years had ended; her Ontario disability payments had been cut due to a paperwork error; and she was on the verge of being evicted from her rented home.

The night before, Stephanie had left her home and sought to walk in the cold for an hour and a half towards Alcona, south of Barrie, stopping 20 minutes at a Tim Hortons to take off her shoes after getting blisters. The employees called 9-1-1 to get her help, and police arrived to take Stephanie to the nearest hospital.

When Coulter arrived at the hospital the next morning, she found her 31-year-old daughter standing at the front doors by herself in the cold. Stephanie slowly entered the car and curled up in the back seat. She seemed disoriented, and Coulter grew more concerned.

She said, I don't feel anything. Am I even here? Am I alive?' " Coulter recalled. It was clear to her that Stephanie was still in distress.

She drove to Stephanie's old home to grab her belongings. She brought her back to their Richmond Hill home, determined to set her up with stable housing and long-term mental health care in Guelph, where her daughter wanted a fresh start. At the time, Coulter's husband and Stephanie's father, Steve, was in hospital battling leukemia. That night, Coulter slept with her arms wrapped around Stephanie. Their two dogs, Ruth and Ernie, lay by their side.

I felt like I had a plan," Coulter told the Star.

But Coulter never saw her daughter get better. On the Monday following Stephanie's move to Guelph, Coulter and her husband received a call from Guelph General Hospital. Their daughter had overdosed on fentanyl the day before and was on life support. They quickly drove to visit her, and kneeled down by her bedside while they played her favourite Christian song, Way Maker" by Leeland, on an iPhone.

In their shock and grief, they sang along to the lyrics, miracle worker, promise keeper, light in the darkness," to comfort her before she was taken off life support.

Stephanie is one of more than 7,300 Canadians who have died from an opioid overdose during the first year of the pandemic - a period that saw the drug crisis worsening dramatically, with deaths almost doubling across the country. That number is likely much higher now, as it is estimated that 20 people die from overdosing every day in Canada.

But Stephanie's family says her story is also one of systemic failure by Canada's mental health-care system, as she struggled for most of her life but was never able to access meaningful, long-term help. Stephanie spent weeks in psychiatric wards at several hospitals, only to be discharged without follow-up care, they said.

With disability benefits as her main income, she couldn't afford therapy sessions with a psychologist, relying mainly on her family doctor for mental health care despite her complex needs. When in distress, Stephanie leaned on police for help, yet she was never connected to support beyond a short stay at the hospital.

The circumstances that led to Stephanie's death are as tangled and complicated as the system she tried to access for support - gaps that were exacerbated by the fog of COVID. Her death occurred despite her loved ones' best attempts to secure adequate care, at a time when the nation is grappling with an increasingly toxic street-drug supply.

Experts and advocates say the faults in the system, laid bare by Stephanie's story, have been observed for decades, yet a lack of co-ordination and resources, coupled with more people looking to access services, has made things difficult to improve. For years, data has shown that many vulnerable Canadians are struggling to find adequate mental health care.

Only a third of patients discharged from psychiatric care in Ontario see a family doctor or a psychiatrist within a month after leaving hospital.

On average, Ontarians waited 22 weeks to see a psychiatrist and access treatment after getting a referral from their family doctor, and that length of time is estimated to have grown during the pandemic.

And while around five per cent of calls to police are for people in mental health distress, the response of each police force varies based on protocols and resourcing, and often results in the distressed person being dropped off at a hospital's emergency department instead of being connected to support in the community.

Our daughter didn't have to die," Coulter said. She could've been helped."

A label, but no follow-up

Friends and family of Stephanie describe her as extremely outgoing. She was lively. Fearless. She had a deep love for animals, especially her parents' dogs Ernie and Ruth, and loved caring for her plants - a hobby she inherited from her father, Steve. The youngest of three sisters, Stephanie was deeply loved and cared for by the adults in her life, including her godparents and people from her parents' church community.

Stephanie, or Blinken" as her family lovingly called her - a nickname born out of the wide-eyed staring contests she had with her sisters as a baby, where she rarely blinked - was also known for her great sense of humour and candour.

She would make people laugh until their stomach hurt," her mother recalled.

But Stephanie also lived in agony. She struggled with severe eczema since birth, and was bullied relentlessly as a young child. She had trouble connecting with people her age. Her parents and sister, Jordan, recalled a time in Grade 8 when girls in her class got together and made a website titled We Hate Stephanie" to torment her. This episode led to her attending a different high school than her older sisters in a bid to start fresh, though she continued struggling to make close friends.

She only needed one good friend," said Flo Coulter, Stephanie's mother. But she's been rejected many times."

Stephanie's struggles followed her to post-secondary and her work life, as she wasn't able to finish college or maintain employment. Her challenges were in part due to her eczema, a painful disease that left her skin dry, flaky and blistered in a cycle of scratching and bleeding. She was tortured by it," Steve, her father, said.

In a blog post for the Eczema Society of Canada, Stephanie wrote that her skin condition worsened over the years and made daily life often impossible. I couldn't just wash the dishes, I couldn't go out in the sun for too long, I couldn't go anywhere overnight without my suitcase of creams and inhalers," she wrote, adding that she worried about the prospects of having a meaningful career because of her illness.

Her parents said she exhausted all available medication over the years. At the time of her death, she was awaiting a decision on whether an expensive treatment, Dupixent, would be offered to her at a subsidized cost.

Stephanie's physical pain was coupled with mental anguish. When she was six years old, her mother - now 66 and retired - said she was diagnosed with Oppositional Defiant Disorder after being referred to a child psychiatrist. It was just a label put on her," Coulter recalled, adding her daughter received the diagnosis during a one-time visit 25 years ago, at a time when mental health care was less acknowledged and understood. Stephanie met a few counsellors, but did not receive consistent treatment or follow-up, her mother said.

Later in her teenage years, Stephanie's family said she began drinking and using drugs, mainly marijuana and cocaine. Her parents believed it was a crutch, used to mask her physical pain from the eczema and her mental health struggles. She moved out in her early 20s, and her parents were no longer able to access her medical records. But they said Stephanie later informed them she had been diagnosed with bipolar disorder.

Interactions with the hospital system

Throughout her adult life, Stephanie was in and out of hospitals for mental health treatment. In between, she tried to become a 9-1-1 dispatcher, but she didn't finish the training program. She also worked numerous retail jobs, including at PetSmart, where she was named employee of the month, her mother recalled.

In 2016, Stephanie spent six weeks receiving treatment for behavioural issues and substance use at Bellwood Health Services, a private facility, financed by her parents. The facility was recommended by a counsellor she briefly saw at Addiction Services for York Region, her mother recalled. The cost was prohibitive, however, and most of the care she received after that was through the public health-care system.

Afterward, she stayed at Southlake Hospital in Newmarket, where she was admitted to the psychiatry unit for five weeks under a court order after getting an impaired-driving charge, and was discharged early due to signs of improvement. She'd also had a brief stay at Ontario Shores before she discharged herself, her mother said.

After her overnight stay at Royal Victoria Hospital in Barrie in December, Stephanie's mental health continued to deteriorate. She was mostly quiet, but displayed signs of severe depression. Unsure of what to do, she and her family phoned a police mobile crisis team the next morning, who dropped her off at Cortellucci Vaughan Hospital. There, she received care for seven days, her mother said. Stephanie then checked herself out of the hospital and left at 11:30 p.m. on a Sunday in the middle of a blizzard, said her sister, Jordan, adding she had no reliable mode of transportation.

The hospital told the Star patients can check themselves out if they are there voluntarily.

Stephanie's family said she wasn't seen by a mental health professional after her last discharge from hospital and they were concerned with how easy it was for their daughter to leave hospital without any follow-up.

They allowed her to just wander out alone into the cold winter night in her unstable mental condition," Stephanie's sister, Jordan, said. Even though she was clearly in need of further care."

Unless ordered otherwise under Canada's Mental Health Act, adult psychiatric patients have the right to discharge themselves from hospital. But 2016 data from Health Quality Ontario, part of Ontario Health, shows that only 36 per cent of patients older than 16 got to see a psychiatrist or a family doctor within seven days of their discharge from being hospitalized with a mental illness or substance-use issue. And only one in three received follow-up care within 30 days.

Camille Quenneville, the CEO of the Ontario branch of the Canadian Mental Health Association, said these numbers are evidence that hospitals have struggled to ensure people are getting the care they need upon discharge.

Upon hearing Stephanie's story, Quenneville added it was apparent she was never meaningfully connected to any kind of community-based mental health service, whose role is to have a long-term relationship with the people it serves.

The notion of requesting police support on route to hospital really skips over where I think she could have been far better served had she been connected to community-based providers," Quenneville said. Such providers would try to help people find supportive housing, manage their mental health medication and ensure they are not cut off from financial supports like ODSP.

When looking through Stephanie's papers after her death, Coulter, her mother, said she found a few photocopied brochures for community mental health services that her daughter was likely given, but no evidence to suggest she was connected to any.

While hospitals play a pivotal role in stabilizing people in distress, Quenneville said they are also the last place we want people who are struggling to be," because it means all other supports have failed a person who has now become very ill.

Dr. Aristotle Voineskos, a psychiatrist and vice-president of research at the Centre for Addiction and Mental Health in Toronto, says health-care providers try to do what they can to transition a patient from a hospital care to community care, but it's often the case that not all of those things get done."

Continuity of care - meaning the process of ensuring a patient continues to be looked out for as they move through the health system, from hospital to community providers and vice-versa - has long been seen as best practice for long-term health. Policies for continuity of care are outlined by the College of Physicians and Surgeons of Ontario, generally focused on things that are in the physicians' control, but there is acknowledgement that systemic factors can get in the way of a patient receiving timely care.

When hospitals do try to connect a patient to a service in the community, Voineskos said they often find there is no one available to take on new clients, or that the client has to be placed on a months-long wait list before they can finally access support and treatment.

The family doctor

For years, Stephanie's main provider for mental health care was her family doctor. This is the case for up to 80 per cent of Canadians who rely mainly on their primary care provider for their mental health needs, according to a 2018 report by the Canadian Mental Health Association.

Stephanie's sister, Jordan, said the doctor prescribed her Venlafaxine in recent months, an antidepressant primarily used to treat major depression and anxiety, as well as panic disorders.

The medication is a familiar one for Jordan, as she struggles with anxiety and depression, and had been prescribed it years prior. But Jordan quickly learned that side effects of Venlafaxine could be severe. The medication is known to increase risk of suicide and mania in some people, and its withdrawal symptoms can be difficult to manage.

It would completely change my personality," Jordan said. I became a totally different person on it."

The medication is also known to be particularly harmful for people with bipolar disorder, as it can increase bouts of mania and distress, evoking emotions ranging from despair to irritability. It's also not recommended to drink alcohol while taking this drug. For this reason, Jordan was concerned that her sister was told to take a high dose of it, and she remains perplexed as to why her sister was prescribed this medication if she was indeed bipolar and struggled with substance use.

Dr. Leslie Buckley, chief of the addictions division at the Centre for Mental Health and Addiction in Toronto, said Stephanie's experience is an example of how getting high-quality care is difficult for people who struggle with both substance use and behavioural disorders, despite that combination being the norm. Research shows that more than half of those seeking help for an addiction also have a mental illness.

It can take months to make an accurate diagnosis," Buckley said, as people's substance use affects their behavioural disorder and vice-versa. Sometimes the mental health issue gets missed and sometimes it is the other way around and people seeking help for mood or anxiety are not asked enough about their substance use."

While Jordan doesn't know the full details of her sister's interactions with her family doctor, Jordan reflected on her own struggles as she tried to receive treatment for her mental illness. She said she believes family doctors often fall short in providing people with effective care for mental health or substance use.

They are not qualified diagnosticians for the intricacies and nuances of mental health, and here is where I believe our mental health system breaks down," Jordan said. She added that she had been prescribed multiple types of medication, many of which didn't work, and referred to a handful of specialists, only to be met with a lengthy wait time or be connected with someone who couldn't offer the treatment she needed.

Another issue, Quenneville said, is that family physicians often don't feel confident treating somebody with a serious mental illness" or substance use problem. This is because of limited training in medical school on caring for acute mental health patients.

A warm hand-off to a community-based provider often doesn't happen," Quenneville added.

This issue is reflected in 2019 data released by the Canadian Institute for Health Information, which found that only 23 per cent of family doctors feel prepared enough to care for a patient with more severe mental health issues.

Calling 9-1-1 for help

At the height of her distress, Stephanie called police departments for help a handful of times, often in a bid to be seen by a mental health professional at a hospital. She was desperate," said Jordan, her sister, adding she would call when she felt there was nowhere else to turn.

Mental-health-related calls to police are common, with Toronto police alone responding to more than 33,000 in 2020, an eight per cent increase from 2019.

In a 2012 Statistics Canada survey, it was revealed that one in five police interactions involve someone with mental health or substance-use issues, but data on how these calls are handled is scarce because there is no standardized framework or guidelines for collecting data on police interactions with people who have a mental health disorder," the report said.

Mobile crisis response teams - made up of a police officer and a mental health worker who respond to calls of persons in distress - have doubled in size since 2015 across police jurisdictions in Ontario to meet the unique needs of people experiencing a mental health crisis, but their resourcing and methods vary. Some are partnered with community mental health agencies, while others are partnered with hospitals, leading to a different experience for people in distress based on what jurisdiction they are calling from.

Some efforts are now underway to address these issues. CMHA Ontario is working on a framework for all mobile crisis response teams to reference, Quenneville said, which is expected to be rolled out in the fall. Meanwhile, Toronto has established a pilot program of non-police crisis response teams, consisting of only mental health workers, to assist callers in distress. Other jurisdictions in Ontario are working on developing similar teams.

Nobody was listening'

The lack of standards and co-ordination is part of a larger, chronic problem in Canada's mental health-care system, said Voineskos at CAMH.

This is evident in Stephanie's experience, experts who spoke with the Star said. The care she accessed, as described by her family, paints a picture of a fragmented and inconsistent system, where neither physicians nor community mental health workers had a steady presence in her life.

Ideally, people struggling with both mental health and substance use would be supported by both their family doctor and a specialist, like a psychiatrist or a psychotherapist, over a long period of time to get treatment and monitor progress, Voineskos said. Recent research has also shown the earlier a patient receives care, the better their chances of recovery.

It's possible that if (Stephanie) had gotten excellent care for her bipolar disorder or her substance use issue as an adolescent, maybe this tragedy could have been prevented," he said, though he added making an accurate diagnosis is a challenge for even health-care workers.

We're still not really taught to the extent we should be in medical schools that this is really an adolescent illness," he said. Another issue, he said, is there are very few trained mental health professionals for children and youth, despite the fact that 75 per cent of mental illnesses develop before age 25.

Quenneville of the mental health association said mental health systems in the province have long struggled with historic underfunding, which has led to a patchy care system that doesn't have enough employees or resources to meet an exponential rise in demand for mental health care.

When asked if this system is allowing people to fall through the cracks, Quenneville said, I'd like to say no to that. But I am going to be honest and say, when I consider that 4,780 opioid-related deaths (in Ontario) have happened since April of 2020, it does make me worried."

Those are really alarming numbers."

For many years, and leading up to her death, Stephanie expressed a desire to get better. The thing she craved the most, her sister Jordan said, was access to a psychotherapist, someone who talked back to her" instead of relying on only medication or hospitalization for treatment.

It was like she was screaming in a crowded room, and nobody was listening," Jordan said.

To honour Stephanie's legacy, her family never shied away from speaking openly about her mental health.

Her obituary candidly states her cause of death as a fentanyl overdose. At her celebration of life, family and loved ones reflected on both Stephanie's joyful presence, as well as the struggles she endured to be heard.

In her daughter's final days, Coulter was planning a visit to Guelph with a bag of Dead Sea salt in tow to soothe Stephanie's eczema. She also had a number for a therapist at Homewood Health in Guelph, whom she planned to call and ask about enrolling Stephanie in an outpatient treatment program. Stephanie was excited about the visit, Coulter said.

But that Sunday, Stephanie woke up feeling lonely and isolated in her new environment. To her family's knowledge, she had only used fentanyl a handful of times, and sought out drugs that day to cope with those feelings.

Stephanie went looking for help in all the wrong places, because the so-called right places were doing the wrong things," Coulter said.

The family has since suffered another tragedy. Stephanie's father, Steve, died exactly three months after his daughter from non-Hodgkins lymphoma. His obituary reads, take care of Blinken."

Coulter has since leaned on her church community, as well as her daughters, to cope with the grief. Despite the heavy weight of the last few months, Coulter remained committed to bringing Stephanie's struggles to light and to share her story.

People tend to ignore what they can't see," she said, and therefore they can't fix it."

Nadine Yousif is a Toronto-based reporter for the Star covering mental health. Follow her on Twitter: @nadineyousif_