Death By Chemical Straitjacket

In 2002 I spent six months researching and then writing a detailed account of the life and death of a troubled young man, Joshua Durnford.

Josh, who was 18 but had the mind of a 10 year-old, died because the people who were supposed to protect him from himself instead decided to drug him into a state of stupor. They did this because it was easier and cheaper than actually having to deal with him. Even though that was their job. And so Josh ended up dead.

He died at the hands of 'professional parents': group home workers, social workers and even those working in youth offender institutions: people who are supposed to make life better for these kids when they intervene. Not worse.

Now, please don't think that those involved in Josh's care were bad people. They absolutely were not. They were just symptoms of a diseased system that has evolved in the last ten years: a system that 'believes' any 'abnormal', abberant, challenging, 'non-normal' behavior displayed by children should be medicated into submission. A pill for every ill.

Only it doesn't work that way. Sometimes, medicine is not the answer. Sometimes what is needed is love, patience and vigilance. But there's no time for that in today's underfunded, undereducated, risk adverse social care system.

Psychotropic medication has become the Holy Grail of group home management - group homes which, never forget, are usually private companies operating for profit.

I tried to get a newspaper or magazine to publish the story, but after a year I got nowhere. In a gruesome reflection of life, it seemed Josh did not fit into anyone's agenda, not even those that considered themselves among the intellectual, liberal media elite.

So, here it is then, at last: Josh's life story.

If this kid deserved anything, just one last grace from life, then it's that the world knows who he was and what happened to him and why.

This story takes place in Canada, but it is a story that has been and is being repeated throughtout the USA, UK and many other countires in Europe. Trust me. I have boxes full of evidence.

It's a long story - 5,000 words - so grab a beer or a coffee (cigarettes too, if you are brave enough to defy the Health Taliban) and make time for us.

This is for you, Josh.

Simon

CHEMICAL RESTRAINTS

IT took Joshua Durnford six days to die.

During those six days he was alone and afraid, his body gradually shutting down, its processes and functions slowing until his brain began to be starved of oxygen. It was, a doctor would later testify, a terrifying death. Rigid, unable to speak or move, Joshua’s last hours on earth would, the doctor said, have been filled with ‘anxiety, fear and an impending sense of doom.’

An inquest would later conclude that the cause of this terrifying death was a rare toxic reaction, Neuroleptic Malignant Syndrome (NMS), which occurred ‘accidentally’ as a result of powerful psychotropic drugs prescribed to Joshua by a psychiatrist.

Joshua was 18, a big, powerful lad who weighed over 200lbs. He was also developmentally delayed, his hulking body home to a mind that operated on the level of someone aged somewhere between seven and 10 years old.

Since the age of 10, Joshua had been under the care of Hastings Children’s Aid Society in Ontario, Canada, his parents – themselves burdened with physical illness and developmental disability – unable to cope with Joshua’s increasing needs; with his sometimes uncontrollable anger; with his desires. In 1994, Joshua became a permanent Crown Ward

In the six years between the CAS’s assumption of Joshua’s parenthood and his lingering death, the boy crashed through the care system, his problems getting dramatically worse and his carers apparently unable to help him in any way. In that time, Joshua was the subject of 16 ‘placements’ – social worker jargon for the homes or institutions chosen for their charges. During the course of those placements, Joshua’s care plan evolved from one that emphasized behavioral management through intensive and skilled intervention and counseling, to one that relied increasingly on drugs to subdue him.

By the time of his death, Joshua was taking eight different drugs, six of which had been newly introduced in the previous two months – Prozac; Ritalin; Nozinan; Modecate; clomipramine; Cogentin; Alprazolam; Tegretol. His prescription read like a pharmaceutical compendium, his body was saturated with anti-depressants, anti-psychotics and anti-hyperactivity medication (Ritalin), used to treat children diagnosed as having Attention Deficit Disorder (ADD).

Yet Joshua had no diagnosis for depression, psychosis or schizophrenia, the conditions these drugs (except Ritalin) are meant to be for. His diagnosis for ADD was questionable. Indeed, he had recently been seen by a child psychiatrist who had recommended that Joshua not be medicated at all. At Joshua’s inquest, Dr Patricia Rosebush, the psychiatrist tasked with reviewing Joshua’s tangled medication history, stated, “I could find no clear rationale clinically or pharmacologically’ why Joshua was taking so many drugs.”

At the time of his death, February 15th, 2000, Joshua was detained at Maplehurst Detention Centre in Ontario after an incident at the group home where he had been living. In the preceding two months – the same two months during which his body was pumped full of drugs - Joshua had been told by that group home’s management that they no longer wanted him there, and were forcing him to leave. Then on January 12th, his father died suddenly at the age of 60.

On February 7th Joshua had a temper tantrum in his bedroom and threw a coffee cup against a door. When three social workers charged into his room, he began to throw the pieces at them. One of the fragments hit a social worker on the head, causing an injury that needed stitches; another received a scratch on her hand. Staff at the home called the police and Joshua was arrested, charged with two counts of assault with a weapon and held overnight in a police cell. The next day he appeared in court and was remanded to Maplehurst until February 15th. Because of his mental vulnerability and a previous conviction, Joshua was placed in the centre’s protective unit.

On February 9th medical staff at Maplehurst noticed a mild tremor in Joshua’s limbs. His blood pressure was high and he was sweating and clammy.

On the 10th, Maplehurst’s consulting psychiatrist Dr Mark Ben-Aaron reviewed Joshua’s medical file and found the pharmacological regimen ‘worrisome’, describing it as a ‘cocktail’. He found was no evidence of psychosis, depression, mania, schizophrenia or seizure disorders and added: “That in medicine as a rule, the first thing you do is not hurt a patient, therefore I felt the need to get as much information as possible.” He immediately reduced Joshua’s medications, cutting out all but two drugs. He also sent a fax to the psychiatrist who had prescribed the drugs, a Dr Zdzislaw Mech, asking for more information on Joshua’s medication and medical background.

By the 12th, Joshua was shaking, was having difficulty in speaking and had a headache. 24 hours later, the shaking was uncontrollable.

January 14th rolled around. In addition to the uncontrollable shaking, Joshua was losing the use of his limbs. His muscles were clenched and he didn’t seem to be able to relax them. His speech was slurred; he was drooling and could not swallow. He could not dress himself or stand, and it took three officers to get him to his feet. Inside Joshua’s body, his muscle fibers were breaking down and literally being swept away in his blood stream. His brain was swelling and starting to cook inside his skull as his temperature soared.

On February 15th, Joshua was able to cry out for help. “I’m sick, I’m sick.” He had become incontinent, but was unable to move, unable to get off his mattress now soaked with urine. He was dreadfully thirsty, but could not hold a cup. His pulse was rocketing towards 190 beats per minute (the normal, healthy rate is between 80-90bpm). Sweat was pouring from his dehydrated body, his temperature was around 105 degrees, and after an hour or two he ceased to cry out and just made low moaning sounds.

At 9am, Maplehurst’s doctor clocked on for the day and found Joshua face down and ‘rigid’ on the bed. When a guard helped to turn Joshua over he noticed his gloves were slicked with Joshua’s sweat. At last, a decision was made to take Joshua to hospital. An ambulance arrived at 10.35am and Joshua was rushed to Milton General Hospital.

At 12.01pm he was pronounced dead.

At 2.51pm the fax machine at Maplehurst whirred into life and began to print out a slow stream of paper. It was Joshua’s medical notes and a list of his medications, sent by Dr Mech.

In late Spring 2001, an inquest was held into Joshua’s death. It answered many questions about the standards of care at Maplehurst and exposed obscene failures in the prison’s systems and reporting structures that allowed Joshua to slide into a death expert medical evidence showed could have been prevented if prison staff had acted four days sooner.

But what the inquest did not fully manage to answer was why was a boy, for whom the only clear and consistent diagnosis was developmental and behavioral retardation, on a drug regime most chronic mental patients would not be subjected to? A drug regime that ultimately led to his death.

And more troublingly, if Joshua’s ‘behavioral management’ not been reduced to what amounted to a chemical straightjacket, would he have ever been reduced to a state that resulted in him being sent to prison?

There is no dispute that Joshua was developmentally delayed and, in the words of his social workers, ‘profoundly under socialized’. He was the kind of boy that people generally didn’t want to get to know – he was fat, ugly, sweaty, pimply, slow but willful, at times aggressive, crude and destructive. On paper, he looked like a monster.

In the ten years Joshua lived in ‘the system’, his troublesome behavior seems to have grown in proportion to his physical bulk – he was reported to display ‘extreme personal and interpersonal disturbances’, to be verbally and sometimes physically aggressive and, most troubling of all, he began to exhibit unusual sexual activity. He would sometimes masturbate obsessively, touch his genitals in public and try to engage others in touching and sex games. He reportedly had sex with other boys at some of the homes he lived in.

As early as 1993, the decision was made that Joshua needed psychotropic medication. Evidence later presented at his inquest made it abundantly clear it was Joshua’s social workers who wanted him to be on drugs that would, to quote one report, ‘control Joshua’s behavior.’ This use of language is key to understanding how the system was closing in around Joshua, and how its aims changed from wanting to rehabilitate him, to wanting to ‘control’ him.

Thoridizine was prescribed, with a social worker’s, a drug classed as an anti-psychotic (these class of drugs are now mostly referred to as neuroleptics). But, as with all the other drugs that were to be pumped in Joshua’s body over the next six or so years, they did nothing to change his behavior for the better, a fact noted by his key social worker Sarah Power, who also ‘noted’ that after he was put on thoridizine Joshua became incontinent and more ‘intense’. He was reduced to making animal noises and grunts, banging his head, rocking back and forth and to gnawing at his hands.

The drugging, however, continued, although records of what drugs and dosages Joshua was taking are incomplete in places. Certainly Prozac and Ritalin were prescribed, as well as clonadine, a drug used in the treatment of ADD, and described as the pharmaceutical equivalent of a ‘sledgehammer’ by one ADD expert.

In July 1995, Joshua was moved to Grand River View Homes near Ottawa where he lived for the next two years. It was noted here that he ‘continued to oppose authority’ and was discovered engaged in ‘inappropriate sexual behavior.’ Between April and June 1997, Joshua was assessed at the Royal Ottawa Hospital, where it was concluded that his sexual acting out was the result of poor impulse control and an increased sex drive. It was sensibly concluded that Joshua’s anger and hostility was related to insecurity caused by his tumultuous childhood.

Then on August 10th, 1997, Joshua committed the crime that was to seal his fate. While wandering around an Ottawa department store, Joshua came across a nine-year old boy, took him into a public washroom and sexually assaulted him. Joshua then ran off and was discovered by police at a bus stop. He was masturbating.

Joshua was charged with sexual assault and released back into the care of Grand River View Homes. After Joshua absconded from that home in September, the CAS successfully applied for an order that Joshua be sent for 180 days to the Robert Smart Center, a secure youth facility in Ottawa. On September 19th Joshua entered the facility, but by February 2nd, 1999 Robert Smart staff told the CAS they had to find an alternate placement for Joshua as he ‘was not benefiting from their treatment program.’

On May 14th 1998, Joshua was sentenced for the sexual assault and received 14 months open custody to be followed by 10 months of probation.

In October 1998 Joshua was taken to see a psychologist about his continued ‘bizarre’ sexual behavior. The psychologist concluded that Joshua ‘was not a candidate for any form of counseling or therapy’. A year later, Joshua was taken to the Clarke Institute in Toronto where a psychiatrist there, a Dr R Dickey, also concluded that Joshua was ‘not a candidate for counseling or therapy.’

Later, Dr Dickey supervised two sets of what is known as phallometric testing – a process where men’s sexual preferences are calculated on how their penis reacts to pictures of nude male and female children, adolescents and adults.

The tests were, to use the Dr Dickey’s own word – ‘uninterpretable’ - because it seemed that Joshua was sexually stimulated by absolutely everything he saw. But despite the uniterpretability of the results, it was stated that within Joshua’s s reactions, a ’strong response to young boys’ could be identified and the CAS were given a diagnosis. Joshua was, according to Dr Dickey, a ‘Homosexual Pedophile’ and required drug therapy to reduce his sex drive. This label was branded into all Joshua’s subsequent files and records.

The apparent untreatability of Joshua; his apparent homosexuality; his apparent pedophilic tendencies; his continued inappropriate sexual behavior. All the doctors, psychologists, therapists and social workers who could seemingly do nothing for him. What was wrong?

Now that Joshua is dead, that answer can never be conclusively answered. But there is ample evidence, obtained during research for this article, that the reason all these people failed is because they had missed, or never looked for, the most obvious answer of all. That Joshua himself had been the victim of sexual abuse as a very young child.

In preparation for his inquest, Ontario’s office of Child and Family Service Advocacy – which stood at the inquest in Joshua’s shoes – had Joshua’s records reviewed by Neill Carson, an expert in the behavior of developmentally delayed people.

Mr Carson, who works for Toronto’s Center for Addiction and Mental Health, made two crucial findings. Firstly that no-one had properly appreciated the depths of Joshua’s developmental handicaps; and that there was a strong possibility that Joshua was himself a ‘survivor of sexual abuse’.

The failure to grasp the extent of Joshua’s handicaps is a crucial oversight. Throughout his life in the system, Joshua’s care reports are infested with criticism and condemnation of his own ‘failures’ – failure to participate in treatment and therapy, failure to follow instructions, failure to do as he was told. The reports are redolent with the sense that here was a boy who was manipulative and hopelessly recidivist.

However, Mr Carson’s report highlights a phenomenon of the developmentally delayed known as the ‘cloak of competency’. “This cloak of competence”, wrote Mr Carson, “is a defense that prevents the young person from engaging with others in an honest and genuine manner.” In other words, says the report. “Mr Durnford may have appeared higher functioning that he actually was. This might have given care providers the sense that they were being manipulated when he failed to follow through instructions. It might have also predisposed him to conflict with others.

“It would have certainly meant that in many interactions with care providers there was a higher level of stress for Mr Durnford that was evident to those around him.” The report also states, ”The failure to address the cloak predicts a poor outcome for therapy.”

And then, the report turns to an issue that had Joshua’s care providers ever comprehensively addressed, might have saved not only his life, but also prevented the sexual assault he committed. “Though not specifically stated in the material I read, there is a strong implication that Mr Durnford was a survivor of sexual abuse. The repetitive and somewhat compulsive nature of his acting out and the presence of bizarre forms of self stimulation raise this issue in my mind.”

Indeed, based on only what is in the files there is a strong implication, one which should have been picked up earlier. What cannot be explained however, is why no-one did pick this up. Because regardless of whether his carers could read between the lines of his behavior and deduce possible sexual abuse, sitting in the CAS files in black and white was specific information that Joshua was the possible victim of sexual abuse. The source of that information? Joshua’s own mother, who had complained to the CAS as far back as 1986 that Joshua had been sexually assaulted by older boys at a care home he was living at.

Apparently, those allegations could not be proven, as is often the case in an ‘it’s his word against mine’ situation. But given that in the aftermath of the allegations Joshua’s behavior dramatically deteriorated and became aberrantly sexual, there is nothing in his files that shows anyone ever made the connection, or if they did, did anything about it.

So Joshua continued his freefall through the system, a freefall that in July 1999 - three months before his second visit to the Clarke Institute – saw Joshua moved into his 15th placement in 10 years, a group home called for Digs for Kids (DFK) in Brampton, Ontario.

DFK, a for-profit company, states on its website that it is ‘known and well regarded in our work with young people with developmental disabilities, autism or pervasive developmental disorder’ and promises ‘unique individualized care’ as a ‘central feature of our service capabilities.’ A letter from Hastings CAS gushed its gratitude to DFK, saying it was ‘fortunate that Digs For Kids was willing to accept him [Joshua].’

However, at the time Joshua moved into DFK’s ‘Lizzie House’ program, DFK was having severe problems of its own. In September 1997, Waterloo Family and Children Service had pulled its entire compliment of five children out of DFK after evidence emerged that children were being excessively restrained and had suffered injuries as a result. One mother described how her mentally handicapped daughter was so badly bruised she could hardly walk. Nine months later, a 13 year-old autistic girl, Stephanie Jobin, died after being restrained by two DFK workers. Stephanie had been pinned face down on the floor, while a worker placed a bean bag chair on her back and sat on it.

Before Joshua could move to DFK its directors demanded, and got, an agreement that the CAS would fund one-to-one supervision for Joshua. DFK would have been receiving among the very highest fees the CAS pays to homes that look after its children – somewhere in the region of $400 per day.

However, no one from the CAS bothered to check if DFK was capable of providing the right environment for Joshua. A cursory inspection would have revealed it was not. None of the front line workers tasked by DFK to care for Joshua had diplomas or degrees in social work or child and youth work. Even DFK’s program director did not have a degree in social work. DFK’s staff were low paid and did not have specific training in dealing with sex offending youth. DFK’s ‘Lizzie House’ was a semi-independent living program designed to help youth aged 16 and over prepare for life outside the system, whereas Joshua needed a specialized treatment environment.

Judy Finlay, Ontario’s chief Child Advocate, tried to help Joshua during his latter years in the care system, a task that left Advocacy staff frustrated and concerned. “Plan of care meetings for Joshua often consisted of seeking any residence willing to take Joshua, not in finding the best placement, treatment and services to suit his needs. As a result, staff at these homes resorted to medication to bridge the gap between their shortcomings and Joshua’s real needs,” she said.

The consequences of those shortcomings were disastrous. DFK’s front line workers, no matter how well intentioned, were hopelessly out of their depth. Inadequately and inappropriately supervised, Joshua’s carers fell well behind his need for help and began to seek additional medication for Joshua other than the Ritalin and Prozac he was already on. A number of psychiatrists were asked to take Joshua as a patient. Many refused; one psychiatrist who did agree to see Joshua even reduced his medication, to the dismay of DFK’s staff. Joshua’s family doctor Andrew Johnson stated that a DFK residential worker had later telephoned him to say staff there were ‘upset’ that Joshua’s Prozac dose had been decreased.

On November 25th, 1999 DFK had Joshua admitted to Peel Memorial Hospital under an emergency psychiatric admission, known as a Form 1. A senior DFK worker, told doctors Joshua had been making threats – threats to kill himself, threats to commit sexual offences. But at the inquest Tammy Dance, Joshua’s primary carer at DFK, told the jury that she could not recall Joshua making any threats to kill himself in the lead up to his admission to hospital, despite the fact she was the worker who had most contact with Joshua.

Joshua was kept at Peel for 72 hours. During that time he admitted to doctors he sometimes felt suicidal, but denied wanting to commit suicide and denied being angry. Staff at the hospital remembered him as being ‘bright and active’. A nurse who supervised him one evening said: “He played games with some of the other patients – he was just hanging out with the guys, and seemed to be enjoying it since his life at the group home seemed so isolated.”

Joshua was released, and to the horror of DFK’s staff, was released without medication other than the Ritalin and Prozac. The inquest would be told that the absence of additional medication caused DFK to be ‘very alarmed’ and that was the ‘urgent basis’ on which they began hunting for another psychiatrist.

On December 1st, Joshua’s social workers got what they were looking for – a psychiatrist who would take Joshua on. Dr Zdzislaw Mech graduated from the University of Toronto in 1956 and gained his diploma in psychiatry in1959. Formerly chief of Peel Memorial’s psychiatry unit, he now worked mornings at the William Osler Community Mental Health Center in Peel, and afternoons in his private practice.

Mech, who treated other children housed by DFK, was told in a three-minute conversation with two DFK workers that Joshua was a high-risk sex offender. In the previous few days, they said, Joshua had been hallucinating, grunting and yelling. They told him Joshua’s mother was a psychotic (untrue – Joshua’s mother is developmentally delayed). They provided Dr Mech with no documentation in support of any of their statements.

Dr Mech interviewed Joshua privately, during which he told the inquest he concluded that Joshua was ‘a very disturbed person’, who had never been ‘properly’ diagnosed, and in need of a series of drugs that would, in part, help to ‘control’ Joshua.

He prescribed Nozinan, a neuroleptic, described at the inquest by pharmacology expert professor Stuart MacLeod as ‘a very little used drug, as it is not particularly effective.’ Nozinan has a wide variety of side effects including Parkinsonian symptoms, tremors, dystonia (where muscles stay painfully contracted) and tardive dyskinesia, where patients suffer uncontrollable facial tics and shaking limbs. Dr Mech told Joshua the drug was ‘to help him sleep’.

Dr Mech also prescribed the anti-depressant clomipramine (described as ‘very old fashioned’ by Professor MacLeod) to help ‘control’ Joshua’s obsession and compulsions, and Cogentin (a ‘very old drug’ according to Professor MacLeod) used to counter the side effects of neuroleptics like Nozinan.

He asked DFK’s workers to bring Joshua back the next day, at which point he prescribed and administered by injection another neuroleptic, Modecate (fluphenazine). Joshua remained on the Ritalin and Prozac too.

At his next appointment, Dr Mech added yet another psychotropic medication to Joshua’s regime, Alprazolam, a benzodiazipine sedative similar to Valium. On December 23rd, the dosages of Nozinan and clomipramine were increased, and on January 14th, 2000 Tegretol, an anti-seizure medication, was added to the mix.

At the time of his first consultation with Dr Mech, Joshua was 18 and being cared for under what is known as an extended care agreement. Legally, only Joshua could consent to any treatment and to details of his personal and medical history being released to Dr Mech.

Yet all the consent forms for treatment by Dr Mech are signed by Sarah Power, Joshua’s key social worker. At the inquest Ms Power could not explain to the coroner why her signature and not Joshua’s was on the forms. She claimed Joshua had consented to the treatment. But other workers stated that Joshua had said on numerous occasions that he was afraid – even terrified - of needles and didn’t want to be injected (Modecate was injected twice weekly). Former Lizzie House care worker Luis Melo stated that Joshua had complained to him about the side effects of medications and said ‘if this is what the medication is going to do to me, then I’m not going to take it anymore.’ He told a previous doctor he didn’t ‘want to be doped up.’ Tammy Dance said Joshua ‘had no trouble saying no to things he didn’t like.’

Dr Mech told the inquest that DFK workers were present in most of the interviews, and that the prescriptions were based on behaviors they had described. The medication continued, seemingly without any positive effect. Another of Joshua’s DFK workers, Lynn Ianniello told the inquest there was no change in behavior after the injections of Modecate.

What did happen, however, was that Joshua now spent around 14 hours a day sleeping, something that DFK workers seemed to find a cause for celebration, rather than concern. Luis Melo admitted: “Everybody seemed to be happy because he was out of their hair.”

On December 30th, DFK bowed to the inevitable and informed Hastings CAS it was ‘withdrawing their residential services with respect to Joshua effective February 29th, 2000.’ The CAS began to look around for other placements, but none could be found until May 2000.

On January 2nd, Joshua was charged with assault for pushing a member of DFK’s staff. A month later, on February 7th, he had his last run in with DFK’s workers. The staff member struck by the mug fragment Joshua threw ended up with six stitches; Joshua ended up charged with two counts of assault with a weapon.

Following his arrest Sarah Power, Joshua’s CAS worker, co-signed a six-page letter sent to Peel’s Crown Attorney. The letter, describing Joshua and his life in care, concluded with an astonishing request. ‘This Agency requests that Joshua be held without bail, not to be released until an alternate secure resource can be found.’ The CAS wanted prison to be Joshua’s home until they could sort something else out. As Judy Finlay, was later to comment: “Too many children like Joshua end up being housed in the criminal justice system because there are inadequate resources in the children’s’ service sector.”

The CAS letter is also remarkable for another reason. In all of its six pages and approximately 2,700 words, there is not one positive word about Joshua, not one mention of any redeeming quality, or any description of any good deed or nice thing Joshua had ever done or said. No mention of the Joshua who loved country music and basketball, the ‘friendly’, ‘helpful’, ‘animated’, ‘jovial’ and ‘outgoing’ Joshua described by other social workers, the Joshua who told Sarah Power that he loved her. The Joshua whose last words to the outside world - a phone call from Maplehurst to his friend, former Grand River View care worker Breffni Sheridan - were to be ‘I love you bud. Bye.’

Instead Joshua was castigated for being ‘extremely demanding of staff’s time and attention’. He was ‘rude, disruptive, non-compliant and has refused to complete required tasks.’ Five paragraphs later ‘…despite the structured [care] program, Joshua was still demanding, non-compliant, exhibited sexualized behaviors, provoking and constant issues with boundaries.’ Joshua had a ‘lack of respect for authority figures.’ The letter admits that use of psychotropic drugs was to ‘control Joshua’s behaviors.’ That word ‘control’ again.

Despite being Joshua’s legal guardians, no-one from the CAS attended his bail hearing, which he faced alone represented by a legal aid lawyer. The CAS letter had its desired effect and Joshua was remanded to custody.

In the days before he died he tried to get help for himself, aware that his position was a dire one. He called his friend Breffni three times, who twice gave Joshua the 1-800 number for Hastings CAS. There is no record that Joshua ever managed to speak to anyone at the CAS. No-one from Hastings CAS came to visit Joshua during his entire eight day incarceration (in fact, the last time Joshua saw anyone from the CAS was when Sarah Power came to his father’s funeral on January 12th and had a ‘very brief’ chat with him). Joshua also told Breffni he had tried to call DFK, but they were refusing to accept his collect calls.

Breffni’s last call from Joshua was disturbing one. Joshua told him he was sitting on the floor of his cell and that someone was having to hold the phone to his ear. He kept falling silent and Breffni would have to ask ‘are you there?’ When Joshua answered his mind was wandering, his conversation erratic. At one point someone, presumably a guard, came on the line and told Breffni that Joshua was ‘not doing well’, but they would take care of him. Breffni urged Joshua to talk to a doctor. Joshua ended the call abruptly.

‘I love you bud. Bye.’ He hung up.

Two days later he was dead at the hands of the system that was supposed to save him. He was buried on February 21st and now lies in Plot C, Section 2, Lot 19, Grave 4 at Belleville Cemetery.

Joshua’s story makes for uncomfortable reading. But as Anita Szigeti, the lawyer for Ontario’s Office of Child Advocacy at Joshua’s inquest, says, “We need to bring meaning to Joshua Durnford’s life and death to ensure that no other person suffers and dies in the horrific way that Josh suffered and died.” That meaning has yet to emerge. Rather than a verdict of homicide petitioned for by Ms Szigeti, the inquest jury returned a verdict of accidental death. The jury also identified seven agencies implicated in the overall system failure that led to Joshua’s death, and made a total of 45 recommendations to improve their levels of service.

The last words in this sorry story come from an elderly female patient of a psychiatrist interviewed during the research for this article. The psychiatrist recounted a consultation with this patient whose carers had placed her on psychotropic medication. While chatting with her about her situation and medication regime she suddenly stopped the conversation and remarked: “You can’t doctor a soul with pills.”

If the adults involved in Joshua Durnford’s short and unpleasant life had known and understood the truth of these words, it is more than likely that Joshua would be alive today.

He might even be happy.