Year 2 Highlights 2017/18

Fair access for Ontarians with mental health and addictions problems

A doctor listens to a young man who looks troubled


A young adult with an eating disorder, who recently transitioned from youth to adult care, was admitted to hospital for a related medical condition.

The hospital experienced challenges dealing with patient’s eating disorder while treating the medical condition and arranging an appropriate plan for discharge. Patient Ombudsman received a complaint from the parent who was concerned that the hospital would discharge the patient without the necessary supports in place to manage the eating disorder. The young adult also had a disability that affected their ability to participate in local programs for adults with eating disorders.

The complaint highlighted the lack of specialized care for complex patients with eating disorders and the challenges faced by young adults who transition from youth to adult care.

What we did

Patient Ombudsman, with consent, connected a specialized provincial program for Eating Disorders with the hospital care team to consult about the patient’s unique needs. The care team at the hospital worked with the patient and caregiver on a specialized care plan to support a safe discharge back to the community.


A patient with a serious addiction problem and a history of life-threatening overdoses was admitted to the forensic unit at a hospital for assessment.

The patient had been trying, without success, to get help with the addiction for some time. While on the forensic unit the patient and family requested a referral to the hospital’s addiction program, but the family reported that the request was refused by the forensic unit physician.

The patient attempted to self-refer to the addictions program but was unable to make the call because the hospital’s main switchboard and internal phone numbers were blocked on the forensic unit’s patient phone.

Shortly after being discharged from the forensic unit, the patient overdosed and required a critical care admission at another hospital.

What we did

After receiving a complaint, Patient Ombudsman confirmed that forensic patients cannot dial internal telephone numbers from the patient telephone and access is monitored for the safety of patients and staff. However, patients can access internal hospital numbers by making a request with their nurse. This information is not routinely shared with patients.

Patient Ombudsman suggested that the forensic unit post a notice to let patients know that they can request nursing assistance to connect to other units at the hospital. The hospital agreed to act on the suggestion.

Patient Ombudsman was not able to investigate the clinical decisions of the patient’s care team, but provided a referral to the appropriate regulatory college.

Patient Ombudsman received over 290 complaints from patients who identified that they had mental health and addictions challenges and from the loved ones of those who struggle with a system that often does not work for them. Close to 50 complaints involved a direct intersection with the healthcare system and the justice system. The healthcare journey for many of these complainants began in police custody after being detained and held under the Mental Health Act.

Waiting for services

We received over 50 complaints about patients who were waiting for or unable to access treatment. Specifically, patients and their loved ones complained about lengthy wait-lists for treatment or housing supports, lack of access to or capacity in specialized treatment programs, travel involving long distances in some geographic catchment areas and a shortage of service providers.

Many of these complaints involved complex processes that resulted in complainants not being able to obtain a referral or a feeling the referral itself was ‘lost’ or not well communicated back to the patient.

Patient Ombudsman helping complainants navigate a complex system

Patient Ombudsman also received complaints about programs and services that are outside of our jurisdiction.

Our team takes the time to both thoughtfully and compassionately work with complainants who disclose they live with a mental illness to provide information, research services, make courtesy calls to health sector organizations and refer complainants to the appropriate regulatory colleges to launch complaints and access services.

Quality of care concerns

A notable number of complaints received to Patient Ombudsman from patients living with mental illness or addictions involved the quality of care they experienced in health sector organizations. Many complainants felt a lack of courtesy or respect from members of their healthcare team. A few complaints ranged from extreme circumstances of alleged abuse, to a possible misuse of restraints or isolation.

Parents and families with concerns

Through the complaints we received, we are seeing the complex journeys of those transitioning from youth or pediatric services to adult mental health services. We heard compelling stories from parents and other caregivers who worried about their loved ones’ safety and well-being. A common trend are the parents of young adults who come to Patient Ombudsman seeking help for their children who struggle to connect to specialized services.

Improving our services for complainants with mental health and addictions concerns

Patient Ombudsman recognizes that mental health can play a pivotal role in many of the interactions we have with Ontarians who are using our service. Many of our complainants continue to share with us the impact on their mental health that a negative healthcare experience can have.

Our office is working to improve our service to better accommodate the needs of complainants who are both experiencing distress and those impacted by mental illness.

Patient Ombudsman is enhancing our capacity by connecting with stakeholders in the mental health and addictions sector to share the stories we are hearing from complainants. Patient Ombudsman is investing in the education of our staff with strategies on how to work meaningfully with vulnerable people experiencing mental health concerns and even to those who come to our office in distress.