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A lost opportunity with tragic consequences

Paranoid schizophrenic's family doctor, psychiatrist worked steps apart – but there's no record they consulted each other

From Wednesday's Globe and Mail

Their offices were just steps apart, yet there is no record of communication between two doctors who treated Huc Minh Chau for paranoid schizophrenia in the years that preceded him slashing his wife and two children to death.

Evidence assembled since the Feb. 9, 2006, tragedy reveals that Mr. Chau's family doctor and psychiatrist – who practise together in a well-appointed medical building in Scarborough, Ont. – did not exchange memos or consultation notes about their troubled patient.

Family doctor Edmond Lo and psychiatrist Hung Tat Lo also failed to probe deeply into Mr. Chau's increasingly frequent reports that he was suffering from profound hallucinations and fears that his family members were possessed by demons.

The killings are among a growing list of recent incidents in which mental patients have exploded into violence, including two high-profile violent attacks on Greyhound buses in recent weeks.

In interviews Tuesday, two experts in forensic psychiatry said that shortcomings in the Chau case highlight a widespread lack of expertise in the medical community about how to accurately assess and treat the danger that patients such as Mr. Chau may represent.

“I think that if we put the case under a microscope – and we really wouldn't have to intensify the magnification all that much – we would probably find a lot of problems in it,” said Hy Bloom, a psychiatrist who conducted a detailed assessment of Mr. Chau last year.

Dr. Bloom's assessment proved instrumental in a judge's decision on Monday to find Mr. Chau not criminally responsible in the slayings of his wife, Shao-Fang Liang, and his two children, three-year-old Vivian, and five-month-old Ivan.

In a key finding, Dr. Bloom said that, regardless of whether or not the two doctors chatted informally about the case in the hallways “there were, in the end, no notes from either of them reflecting a conversation with the other.”

(Neither doctor could be reached by phone Tuesday, and their office was closed for the week.) Dr. Bloom also found that “highly modest” injections of a medication that Mr. Chau was given by Dr. Edmond Lo–Piportil – may have lost their effectiveness, and likely should have been increased or administered more often.

Dr. Bloom said Tuesday that the problems fit into a larger picture of lost opportunity. “More importantly, the overarching concept is probably to have monitored him more closely,” he said.

Had Dr. Edmond Lo questioned Mr. Chau more closely, Dr. Bloom said, he might have discovered that his patient needed stronger medication. “That's a problem,” Dr. Bloom said. “He was seeing the guy every month or so to give him a needle, but the assessment ... just couldn't pick up what was there.”

Graham Glancy, past-president of the Canadian Academy of Psychiatrists and the Law, said that it is sound medical practice for doctors to contact mentally ill patients who miss appointments or may not be taking their medication. “If you were really concerned, there are mechanisms like sending community psychiatric nurse or something like that.”

Dr. Glancy pointed to a general lack of sophistication in the way that many doctors deal with potentially dangerous mental patients. “Not only are there greater expectations upon doctors, but we have better tools available to predict dangerousness,” he said.

Methods of effectively measuring dangerousness have been developed, Dr. Glancy said, “but these tools are not widely used by the people on the front line, like emergency-room doctors or family practitioners.”

Dr. Bloom noted that, in theory, Mr. Chau might have been committed involuntarily to a hospital for assessment. But the issue never arose because his doctors did not delve deeply enough into his symptoms to become alarmed. “That little exercise [could have been enough] to avert hospitalization and avert a disaster,” he said.

Dr. Glancy noted that Mr. Chau “was something of a chronic risk all the way along. You've got to look for that deterioration and perhaps things like escalation. Very often, somebody who is chronically paranoid goes out to buy a gun. You start to pay attention then. That's the time to bring them into hospital and reassess the entire situation.”

Both forensic psychiatrists observed that hospital beds are so scarce that mental patients are rarely admitted unless they have committed a serious crime. “Then, you get the equivalent of Amex Platinum Card, front-of-the-line credit card in mental-health services in Canada,” Dr. Bloom said.

“You try and get someone into hospital and you can't get them in,” Dr. Glancy said. “You phone up the hospital and they yell at you. So you're stuck with trying to manage them in the community.

“Emergency rooms have to be better equipped to deal with these people,” he said. “There have to be more crisis beds available so at least you can admit them overnight, hang onto them and think about it, rather than boot them straight out onto a Greyhound bus.”

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