WRHA returned autistic man to agency 'unable to manage him'

Despite warnings from health professionals, the Winnipeg Regional Health Authority returned an autistic man to an agency that was having trouble supporting him.  Eight months later, he was dead.

The WRHA had hired Teskey & Associates in January 2014 to provide support services to Ronald Wilderman, 57, so that he could live in the community.

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After seven months under the contract with Teskey & Associates, a doctor wrote: "this current living situation can't handle patient any longer in this capacity" and "staff feel unable to manage him."  

Wilderman had Asperger syndrome and a childhood brain injury. His complex behavioural issues made him a poor fit for existing programs and — after being evicted from the Salvation Army — he ended up homeless.

As a last ditch effort to get Wilderman off the streets, the family signed him over to the Office of the Public Guardian and Trustee, which in turn put him in the care of the Winnipeg Regional Health Authority. The WRHA then hired Teskey & Associates to provide services to him on a daily basis.

A social worker's report said at that time Wilderman was suffering poor health, poor hygiene, homelessness and anger issues and that his mental health "severely deteriorated" in recent years.

Files in Wilderman's medical records state the WRHA felt Teskey & Associates was "able to provide suitable housing with necessary supports for the client in the community."

$312.50 per day, 12 hours of support

The agency originally charged the WRHA $112.50 to provide Wilderman with four hours of support services a day, ranging from developing social skills to taking medication. However, by July, the agency bumped that up to $312.50 a day for 12 hours of support services because of his worsening behaviour.

In the year leading up his death, numerous reports from the WRHA and Teskey & Associates indicate Wilderman had escalating violent outbursts toward agency staff, was refusing medication and showed erratic public behaviour.  

On one occasion, when staff entered his apartment he attacked them with a curtain rod. Notes in his medical records question whether the support services in place for Wilderman were adequate.

Finally, in mid-August 2014, Teskey staff brought Wilderman to the Health Sciences Centre because they were unable to deal with him any more.  Wilderman's medical records from that time noted, "He has reportedly not taken meds for two months."  

Wilderman spent the next six weeks in hospital to stabilize his diabetes, take care of his diabetic ulcers, and assess his behavioural issues.  An entry in his medical chart dated August 26, 2014 said, "An alternative  placement is needed to meet his need".  A few days later, another entry said staff discussed the "current placement not meeting his identified need and the need to sort an alternative placement."

However, on September 24th, Wilderman was discharged from hospital and returned to Teskey & Associates. He died eight months later of complications from diabetes.

"What we want as a family is an inquest and inquiry, into his death," said Wilderman's sister, Elizabeth Rosenberg. "We can't bring my brother back; nothing changes what happened. But what we want to do is make sure it doesn't happen again."

An autopsy report said Wilderman was found in his apartment on the evening May 31, 2015 "with obvious signs of death." It's unknown exactly how long he lay dead in his suite.  While the WRHA was paying Teskey & Associates to provide him with 12 hours of support services every day, it was not explicitly stated in their agreement what those services were to entail. The autopsy report noted his body had mild decomposition.

The Office of the Chief Medical Examiner told CBC News a review of Wilderman's case is ongoing and a decision on whether to call an inquest has not been made.

Rosenberg is angry with Teskey & Associates and the WRHA because the family learned of many of Wilderman's violent incidents only after her brother died.

"There were lots of lapses of notification, even though my brother was there, my eldest brother Jim was there every week, visiting Ronald and the family was involved in Ronald 's care, we weren't notified of lots of incidents that had occurred," she said.  "I only found them out by reading these reports."

Since her brother's death, Rosenberg has been on a mission for answers.  She says answers she has received from Teskey & Associates don't match up with the information in her brother's health records.

"They [Teskey & Associates] said that Ronald was 90 to 95 per cent compliant in taking his medications, which is completely contradictory to all medical reports received," she said.  "With the blood sugar levels from the medical reports that Ronald had, it's a huge red flag that his behaviour would have been affected. They were off the charts."

'Slow but positive progress'

Answers that Teskey & Associates recently provided to the family said the agency had reported to the WRHA that they were making "slow but positive progress with Ronald."

"We still strongly feel that there was a severe lack of reporting of the difficulties they were having in caring for my brother," said Rosenberg, adding that her family was involved with Wilderman on a regular basis and available to be consulted.

Teskey & Associates declined an interview but did send a statement to the CBC I-Team.

"We cannot comment on the specific incidents you are referring to by reason of the applicable privacy legislation, including PHIA (Personal Health Information Act)," wrote Harris Teskey, when asked about Wilderman's family's concerns. "We regularly review our procedures relative to the individuals we support to ensure that they are being delivered in the best way and means possible."

The WRHA now requires all special contracts to spell out exactly what services are being provided to clients and is reviewing its contracts with the agency.

"If we're going to be providing a per diem, we need to know what we're paying for," Cloutier said. "We need to do far better due diligence about what is indeed happening with these clients."

The province, which also has clients with Teskey & Associates in separate contracts,  is no longer referring clients to the agency while the WRHA review is underway.

Wilderman always crying for food: neighbour

Wilderman's neighbor, Patricia Powell, who lived across the hall in the same apartment building, told CBC News Wilderman was "always crying for food."  

The diabetic's care notes reveal his food needed to be locked up to prevent him from gorging.  Powell was worried he was not being given enough to eat.

"I felt so bad for him," she said. "He screamed all day long for food, proper food."

The WRHA said its contract with Teskey and Associates was so unclear it didn't specify whether the agency was responsible for providing Wilderman with meals or not.

"I didn't know I could be more upset but I am," said Rosenberg reacting to the neighbor's account. "Why is this organization still being allowed to care for these individuals? You can't tell me that this is the level of care that is expected."

Teskey & Associates told CBC it does not provide care or supervision for its clients but it does supply supports to help them live in the community.

In an email statement, the agency said, "We are committed to our clients and the supports we provide to them, and strive to serve them and the community in the best possible way that we can. We stand behind our work."

Rosenberg said she brought her concerns to Manitoba's Protection for Persons in Care Office but was told Teskey and the other agencies charged with caring for 300 high-risk clients was not covered under its mandate.

"There has to be auditing. Either it's by WRHA , either it's by a separate agency that maybe needs to be formed for these people that all fall between the cracks because that's probably the majority of these individuals: that's their story." she said. "They've fallen through all the protection safety nets that we have in place."

To contact the CBC I-Team, email [email protected] or call the confidential tip line at 204-788-3744.