‘I’ve already written his obituary,’ said mother who couldn’t save her son from homelessness, mental illness and drug addiction

Ross Biancale sits in front of his birthday cake and smiles for the camera.

He wears a pair of oversized glasses with orange-tinted lenses, a fur hat with long flaps over his ears.

The unconventional attire is just another sign to his family he's unwell.

But it's a happy moment, especially in light of his struggles with schizophrenia and addiction.

We sang to him and blew out his candles," mom Elizabeth Biancale recalls.

In the fog of illness, Ross hadn't been to his family's Brant County home for a birthday in years.

It was so nice to have him here, sitting there with his brothers," Elizabeth says.

That Nov. 20 was to be Ross's last birthday.

Less than two weeks later, he died of a suspected drug overdose in a small apartment in Hamilton. He was 32.

It haunts me - that picture," Elizabeth says about the birthday photograph that forms part of a memorial in her home.

If I would have known, I would have hugged him harder that day."

Ross died at the vortex of overlapping crises - homelessness, mental illness, a toxic drug supply - fuelled by a lack of resources and failed policy, say experts from various fields that care for society's most fragile.

Sadly, that is too common a story across the care of people with serious mental illness in our community," said Dr. Sandy Simpson, chief of forensic psychiatry at the Centre for Addiction and Mental Health (CAMH).

It's a lack of seriousness by government to understand the nature and complexity of needs of people, and support them adequately in terms of community mental-health teams, financial support and housing and continuity of care."

And a dire local landscape - people living in tents, packed shelters, rampant overdoses - has spurred Hamilton city council to declare emergencies relating to homelessness, mental health and opioids with the hope of galvanizing provincial action.

Though devastating, Ross's tragic demise wasn't entirely unexpected to Elizabeth.

In late 2017, she all but predicted her son's grinding cycle of wandering the streets, slipping in and out of treatment, and doing time behind bars would kill him one day.

I've already written his obituary," she told The Spectator at the time.

If I couldn't save my son ...

Elizabeth offered that agonizing admission in a downtown fast-food restaurant after picking up Ross from a shelter.

His black, curly hair was long and his beard unkempt. His hand was badly infected and swollen.

Ross explained that foreign actors were tapping into his vision to monitor his movements. But he didn't believe he was mentally ill.

They're seeing through my eyes."

Despite that outlook, coupled with a suspicion of health care, Ross held out hope to get back on his feet again.

In fact, he never got rid of the pair of steel-toed boots he'd worn as a welder - a promising career upon which he'd embarked before he became ill.

It just takes time. I gotta put myself out there."

A clean-cut graduate of Ancaster High and Fleming College, he earned $40 an hour in Cambridge. He had an active social life and girlfriend.

But starting in his early 20s, paranoia and erratic behaviour started to derail his life. He lost his apartment, his relationship, his job.

Meanwhile, homelessness and run-ins with the law erased any semblance of normalcy.

Minor thefts escalated to bizarre incidents, such as climbing a 250-foot crane at a downtown Hamilton construction site.

Now, reeling from her son's death, Elizabeth says she lost him in spite of her dogged efforts to advocate for his well-being, whether in the courtroom or the psychiatric ward.

But all that energy - while caring for four younger boys and running a dog-breeding business - was expended on a revolving door of incarceration, hospitalization and homelessness.

Ultimately, Elizabeth couldn't sidestep the pitfalls: the subpar housing; the courts that sent him to jail instead of care; her limited ability to make her son adhere to treatment.

I just know that if I couldn't save my son, there's nobody that can save their son."

From scratch'

In the depths of his illness, Ross wouldn't stay with his mom.

For a time, as well, with younger siblings at home, child protective services wouldn't allow it, Elizabeth says.

But she tried to keep him off the streets, which was no easy feat with landlords reluctant to rent to mentally ill people on social assistance.

When Ross had a roof over his head, it didn't last that long and ended in catastrophe.

In late 2019, for instance, he was one of 19 people displaced from a troubled lodging home the city had ordered to close.

Backed into a corner, Elizabeth paid for Ross and other vulnerable ex-residents to stay in a motel before finding him another place to live.

And once, after a stint in jail, he returned alone to an apartment he'd shared with another mentally ill person only to find himself on the street in his underwear as flames shot out the window because of a fire.

Later in hospital, Ross claimed someone else had been in the unit and started the blaze, which wasn't the case, Elizabeth recalls.

Her son, in a spiral after not taking his medication while in jail, had set the fire and sat there in a daze as smoke filled the apartment.

The neighbours had to bang on his door for him to come out. He would have died in that apartment."

Meanwhile, Ross, his belongings torched, had burned through another landlord.

So we had to start all over from scratch," Elizabeth says.

There's not enough affordable housing with connected health and social services to help keep people with complex challenges stable and off the street, experts point out.

Housing is huge," says Sue Phipps, chief executive officer of the local Canadian Mental Health Association branch.

If you're focused solely on surviving, you're not thinking about your health. If you're looking for a place to stay every night, you're not able to focus on improving your health or well-being."

As it stands, 689 households are in the queue for supportive units through Hamilton's centralized waiting list for affordable housing, with more applicants to be consolidated to the hub this summer, the city says.

In particular, a gaping hole is housing with the highest tier of supports - daily, 24-hour, wraparound" services - for those with the most acute needs. About 200 in Hamilton could use that kind of housing, the city says.

That shortfall has been in spotlight at city hall, where in addition to council's emergency declarations, staff have drafted a multimillion-dollar blueprint to end chronic homelessness by 2025 but flagged scant municipal funds to carry it out.

We are missing a number of pieces of the puzzle, but permanent housing with an enhanced level of supports definitely is missing," says Graham Cubitt of Indwell, a local non-profit that operates deeply affordable and supportive housing.

But Indwell's 15-unit Railway City Lofts in St. Thomas, Ont., which has housed people directly from encampments after long periods of homelessness, is an example of what can be done.

And all are achieving tremendous stability because the supports are tailored to people; the whole housing model is tailored to those tenants."

The lofts were a co-operative effort" between Indwell, the city and the hospital system that allowed for the crucial merging of housing and health funding, envelopes typically separated in bureaucratic silos.

Are solutions possible? Absolutely. We just need to link the resources, new housing and new support models together to create what we need as a community."

Underfunded' but dynamite'

During his illness, Ross faced a gauntlet of systemic obstacles. And so did his mom.

Just convincing those in positions of authority that her adult son was desperately ill and didn't belong in jail was challenging, Elizabeth says.

She notes her frustration at not being able to exercise more influence over her son's treatment under Ontario law.

I just wanted help, but I went years before anybody would listen to me because he was over 18."

Despite the setbacks, an underfunded" but dynamite" multidisciplinary group of caring professionals rallied around Ross, she says.

Among its tasks, the assertive community treatment (ACT) team made sure he received regular injections of medication under the auspices of a community treatment order (CTO).

A CTO is a doctor-issued order designed to help those who are frequently sent to psychiatric facilities adhere to care and treatment in the community.

A patient or substitute decision-maker agrees to the CTO, which serves as an alternative to hospital detention.

St. Joseph's Healthcare Hamilton has four ACT teams in the area. Each supports roughly 80 to 90 people. Two teams are dedicated to Hamilton proper.

They generally have eight or nine full-time staff, including a psychiatrist, social worker, registered nurses, occupational therapists and community support counsellors, a hospital spokesperson noted.

They collaborate with housing services, pharmacies, primary care providers, correctional services and a variety of city programs.

ACT teams are very good at staying connected to patients," said Dr. Gary Chaimowitz, head of the forensic psychiatry program at St. Joseph's West 5th campus. They provide very, very strong wraparound care."

But there are not enough of them, Chaimowitz said.

In fact, the wait for an eligibility assessment alone for ACT services in Hamilton, Haldimand, Niagara and Brant is 45 days.

For actual care, it's 374 days, according to Connex Ontario, a provincially funded agency that tracks wait times and provides information about mental-health services.

CTOs have proven to be an effective approach, notes Phipps, of the Canadian Mental Health Association. But their success relies on adequate human resources in a sector that's stretched.

The mental-health system is just so fractured," says Erin Boudreau, director of operations for the Institute for Advancements in Mental Health.

There aren't enough psychiatrists and other health-care professionals to offer treatment, such as cognitive behavioural therapy for psychosis, to keep people from spiralling into crisis, Boudreau says.

There are not enough early-intervention supports available to, in theory, prevent people from this severe state in the first place."

Meanwhile, caregivers make sacrifices to fill in the gaps, Boudreau said.

There's an impact to well-being, to the economy, to their mental health, to their loved one's mental health."

The nicest place'

After the blaze, Elizabeth and Ross didn't give up.

In crisis, he waited three weeks in St. Joseph's emergency ward before a bed opened up at its West 5th psychiatric facility.

Is it the hospital's fault? No, it's that we're overwhelmed with mentally ill people," Elizabeth says.

But once he was at West 5th, she wished - reluctantly - that Ross could be placed in the forensic unit, hoping for a stricter regimen.

He needed forced intervention," says Elizabeth, noting despite the ACT team's best efforts, it wasn't enough at times.

Under certain circumstances, Ontario law allows for periods of involuntary admittance to psychiatric facilities but makes no provisions for forced treatment at hospitals.

The forensic unit is designed for people who are unfit to stand trial, or found to be not criminally responsible, St. Joseph's Chaimowitz noted.

The rules are the same. If somebody is refusing treatment and they're capable, they can still refuse treatment."

But Chaimowitz acknowledges the frustration family members can feel.

It's really hard when that person in front of you is not looking for treatment, because you may know what is required."

Elizabeth, meanwhile, recognizes how mental-health legislation aims to balance individual freedoms and a person's well-being.

I wanted to give my son choices, too, but I think that you have to look at the person and individual and say, I don't think we can give this person choices right now.'"

After the fire and an extended stay at West 5th, Ross landed affordable, supportive housing that offered him stability like never before.

It was the nicest place he's ever been," Elizabeth says.

The Indwell apartment in Hamilton was small but clean. It had a new stove and fridge. And there he had the attention and understanding of trained staff.

At his request, they changed his locks more than once to ease his paranoia, or brought food to his apartment if he couldn't eat with others in the cafeteria.

He said there were people coming through the ceiling," Elizabeth recalls, so staff took him to the floor above to convince him otherwise.

But it wouldn't all be smooth sailing.

Ross, who didn't like the injections, convinced his ACT caregivers to switch him to tablets administered at his door. They figured he later spat them out.

Not on his medication, Ross's health took a nosedive. One day, he just left.

And I'm shaking my head, Here we go again,'" Elizabeth recalls. Because this has happened many times with him."

Around and around'

A month later, police picked up a man walking on the side of the QEW.

And they see that it's Ross," Elizabeth says.

Off his medication, he's in rough shape. He's admitted to West 5th.

At St. Joseph's, he's given an injection and discharged - too soon, Elizabeth contends.

She'd wanted her son to stay longer to allow the medication to kick in.

So he goes, he leaves. Now we've got a person who's crazy ... like literally out of his mind."

That was frustrating enough, but Elizabeth, despite being her son's substitute decision-maker, also says the hospital didn't tell her he'd been discharged in the first place.

They didn't even call me."

St. Joseph's believes family members should be actively involved in the care of their loved ones, especially if they're substitute decision-makers," Chaimowitz said.

It is one of the quality indicators that we focus on," he added, noting he couldn't speak of what might have happened in Ross's case.

That discharge set off a fateful chain of events that would ultimately lead to his longest and last stay behind bars.

Back at Indwell, Ross became embroiled in a dispute with a woman he didn't want in his apartment. He ended up pushing her.

She cracks her head on the table and he's arrested," Elizabeth recounts.

Ross's violent outburst was wrong, but he should have been placed in hospital care, she says.

Instead, he was sentenced to 10 months in Penetanguishene, where his community treatment order (CTO) no longer applied.

So in jail, he sits there and gets more sick. It's just a cycle that goes around and around in a circle."

Incarceration can sometimes do things that are good and sometimes do things that are bad," says Simpson from CAMH.

For some, it can mean cutting access to drugs and open the door to treatment, leading to better health, Simpson notes.

But jail can also dislocate people from housing, mental-health contacts and social assistance, he adds.

So when they come out again, they're starting from scratch to try and re-establish that life that was precarious beforehand."

Health advocates, meanwhile, contend mental health in Ontario jails should fall under the auspices of the Ministry of Health rather than the Ministry of the Solicitor General to ensure better care.

So you're getting the same quality of care on the inside as you are on the outside," said Boudreau of the Institute for Advancements in Mental Health.

In an email, a spokesperson for the Ministry of the Solicitor General said the province is investing more than $500 million over five years to transform correctional services through new hires and infrastructure improvements."

All inmates have access to a variety of services and supports including mental-health nurses, physicians, psychiatrists, psychologists, social workers and addiction counsellors regardless of a diagnosis of a specific mental illness," Andrew Morrison wrote.

Correctional services staff are trained to recognize possible signs of mental illness and know how to refer these inmates to health care or other professional staff who can provide the inmate with the appropriate level of care."

The Solicitor General, which also partners with the Ministry of Health, has increased the number of acute care stabilization beds at forensic mental-health hospitals, including at St. Joseph's in Hamilton.

If those with mental health and addiction challenges wind up in jail, it should be a golden opportunity" to offer help, Dr. Lori Regenstreif says.

They're usually in chaotic settings. They may be in tents. They're committing crimes related to substances or just for survival," said Regenstreif, who has a focus on opioid treatment programs in correctional settings.

They shouldn't be in jail, but if you're going to lock them up somewhere, now's your chance to help."

But the gap" - especially with relatively short stays during which it's tricky to anchor" people in programs - is in the continuity in and the continuity out," Regenstreif points out.

This is crucial given that opioid users who abstain while in jail are particularly vulnerable to overdose during the first few weeks of their release when their tolerance is lower.

There's a heightened risk of accidental overdose at that point, and that's a well-recognized phenomenon," Simpson noted.

Bells went off'

After Penetanguishene, Ross made it back to Hamilton.

Elizabeth helped him pay for a room at the same motel she'd lined up after the lodging home closure set him adrift in 2019.

But at about $3,000 a month, the bill was running too high.

So I finally found this dump," Elizabeth recalls.

For $900 a month, the room in the small multiplex on King Street West offered a bathroom, hot plate, little fridge and sink.

He moved in Oct. 15.

Ross seemed to make friends there and asked his mom to help out an impoverished fellow tenant.

He made me go out and buy him a coat and shoes at Value Village," Elizabeth says.

But she only realized after Ross moved in that the residence was like a trap house," she says. There were tons and tons of drugs."

Before Penetanguishene, Ross had used crystal meth, which is a stimulant, but not opioids, like fentanyl, which has driven the overdose crisis.

Elizabeth speculates her son turned to that after taking methadone, an opioid used to treat addiction to powerful street drugs, while in jail.

And despite signs that Ross had regained his footing, in hindsight, his mom noticed a sluggishness in his demeanour.

I would pick him up and he'd be almost like a robot."

After the birthday gathering, the next time she saw Ross was Nov. 23, when she took him for a root canal and groceries in Stoney Creek.

We were starting to work on his teeth. He was actually allowing me. I hadn't been able to bring him to a dentist in years."

But optimism gave way to concern when Ross stopped responding to her messages to send money to pay the rent. He hadn't withdrawn anything from his account after his disability payment was deposited, either.

And that's when my bells went off," Elizabeth says.

So on Dec. 2, her husband, Archie, and Ross's ACT team social worker unlocked Ross's apartment door using a spare key.

They found him slumped forward in a turtle position." There were needles, and what's believed to be fentanyl and crystal meth in the small room.

Police suspected he'd died of an overdose three days earlier, Elizabeth says.

They're telling me that he just went down ... and that kind of gave me a little comfort."

But questions about his last moments of life continue to nag her.

Could someone - maybe another tenant - have called emergency services earlier to flag something was wrong?

Meanwhile, contact with police and the coroner's office, which is still conducting the death investigation, has been wanting, Elizabeth says.

No one called me. They just look at the place he's in. They look at his record. Look at this guy,'" she says. That's always the way he's been treated."

And to make matters worse, after Ross's death, someone kicked in the door of his unit to plunder the place.

That drew Elizabeth there sooner than she'd planned to salvage what was left behind.

On his little shelf in his room, he had his birthday cards and his candles set up like a little shrine for this birthday that we just had. That broke my heart."

At home in Brant County, she has set up memorials to Ross - a chest he had in his room, trinkets, clothes, his oversized glasses, his ashes, that haunting photograph.

His work boots, the ones he wore while welding and kept throughout his struggles, sit on a wooden bench adorned with a plaque.

He held onto those welding boots no matter what condition he was in because he felt like one day, I'm going to be back to that person.'"

Deep down, he knew something was wrong with him, and he aspired to patch his life back together, Elizabeth reflects.

But then it would not happen."

Teviah Moro is a reporter at The Spectator. tmoro@thespec.com