OHS Canada 25th Anniversary Best Editorial

Shock & Tell

April/May 2008

There were signs. There were concerns. There were mistakes. The death of nurse Lori Dupont at the hands of her former lover and colleague, Dr. Marc Daniel, shows the need to deal with disruptive behaviour and adopt worker protections in a timely manner.

By: Jason Contant

Lori Dupont arrived 13 minutes early for work that Saturday morning, November 12, 2005. Records from the Hôtel-Dieu Grace Hospital, where she worked as a recovery room nurse, indicate that she swiped her electronic access card and entered the post-anesthetic care unit at 8:17 am.

Shortly thereafter -- at 8:38 am -- security cameras show anesthesiologist Dr. Marc Daniel, who had returned from leave to the Windsor, Ontario hospital less than six months before, walking toward the facility carrying two bags and a newspaper.

Being Saturday, there was only a skeletal crew in the unit that day, two nurses, including Lori Dupont, 36. Just before 9 am, as she went about preparing the recovery room for a patient, Dr. Daniel, 50, emerged from behind a pillar armed with a military-style dagger. The six-inch blade entered her back and chest seven times, the brutal attack leaving her in a pool of blood.

When officers from the Windsor Police Service arrived, they requested the hospital's security camera tapes. The captured images showed Dr. Daniel-- wearing green scrubs with dark, bloody spatters on the legs, a black blazer and purple bandanna -- leaving the hospital at 9:07 am. About 45 minutes later, he was found by police inside his car on Windsor's waterfront along the Detroit River. Having already injected himself with anesthetic agents, he succumbed to the overdose three days later.

Some unnerving signs

Lori Dupont's murder was "unspeakably horrendous", the grisly culmination of a series of disturbing events, says Greg Monforton, a lawyer who has filed a $13.5-million lawsuit against numerous senior hospital officials on behalf of her family. The statement of claim, filed in Ontario's Superior Court of Justice in March, 2006, notes that Lori Dupont and Dr. Daniel began a relationship in November of 2002. That relationship ended with his suicide attempt by injection at her home on February 27, 2005.

Within days of the latter, Dr. Daniel had been admitted to the psychiatric unit at the Hôtel-Dieu Grace Hospital, where he stayed for a little more than a week before being released. "As soon as he was discharged from the psych unit, the harassment started," reports Barbara Dupont, herself a retired nurse called to her daughter's home on the day of Dr. Daniel's attempted suicide.

Although her understanding is that Dr. Daniel had threatened suicide in the past, Dupont says he had not made an actual attempt during his relationship with her daughter. After arriving at her daughter's house that day, she discovered syringes and vials of agents used to administer anesthesia. "He had one [syringe] in his arm when I went over. He was unconscious," Dupont recalls. "There were syringes and empty vials at the bedside."

She became aware of Dr. Daniel's increasingly erratic behaviour following the break-up. "We tried to protect her as much as we could," Dupont says of her daughter. "We took precautions. We knew that he was a threat," she contends.

Dr. Daniel's privileges to practise at Hôtel-Dieu Grace Hospital were "put in suspension" until he received medical clearance to return to work after the suicide attempt, reports Colin Johnston, a labour relations officer for the Ontario Nurses' Association (ONA). The time off ran from the beginning of March, 2005 to the end of that May.

Despite being on leave, Dr. Daniel used the hospital pass he still had and "would follow Lori," Johnston claims, characterizing the actions as stalking, following and staring.

Heather Gray, owner and principal of Threat Assessment and Management Associates Inc. in Edmonton, says "fitness to return to work generally comes with an answer that [the worker is] fit to return to work." The concern is the information provided to doctors who are carrying out fitness assessments "comes from the individuals themselves, so they're not going to admit to homicidal or suicidal ideations necessarily," Gray says. An individual looking to regain access to someone on the job may simply "give the answers that are going to get him back in the workplace," she says.

Trail of concerns

The statement of claim cites instances of disruptive behaviour by Dr. Daniel at the Hôtel-Dieu Grace Hospital in April of 2005, including blocking Lori Dupont from entering a doorway, following her while she was working, leaving compromising photographs of her on her vehicle in the hospital parking area, and telling both her parents that he planned to distribute the pictures. "A mere month and a half after Lori and her mother saved his life, he's posting partially nude photographs of her on her vehicle and not being held to account by the hospital," Monforton relays, incredulous.

An internal report of a hospital review carried out following the murder notes that, in March of 2005, Lori Dupont advised that she had concerns Dr. Daniel would attend the unit despite being on medical leave. At an April 8 meeting, held to discuss the concern, hospital officials offered her a security escort both to and from the operating room, and assigned her a parking spot immediately adjacent to the security office on the first floor of the parking deck. (Hospital spokesperson Kim Spirou reports that "six months later, she refused to park in that space.")

In essence, says Monforton, hospital officials were "helping her avoid [Dr. Daniel]. They were not confronting him or, in any way, disciplining him," he contends.

Beyond the parking spot and escort, hospital officials also helped Lori Dupont make an application for a peace bond. That had been postponed twice, says Barbara Dupont, but a hearing had been scheduled for December, a month after her daughter's death.

At the April 8 meeting, the hospital report notes, Lori Dupont was encouraged to file formal complaints with the police services in both Windsor, where the hospital is located, and in Amhertsburg, the nearby town where she lived. She declined to do so.

She was reluctant, Johnston says, "and that goes back to a generalized fear that many nurses have" about complaining against doctors.

Concerns seemed to have become more and more obvious to more and more people. On August 11, 2005, the hospital's internal report cites a physician who stated the hospital was "an uncomfortable environment. Marc Daniel is on the edge. He stares at Lori Dupont. Something is not right with him." Another doctor indicated, "some day Marc is going to come in here and go postal."

A sad review

Over nine weeks, beginning last September, members of a coroner's inquest jury heard about a number of disturbing signs from more than 50 witnesses. "There were multiple complaints from the nurses regarding Dr. Daniel's disruptive behaviour starting in 2000," notes the coroner's verdict. These "included damage to equipment, fracture of a nurse's left ring finger, verbal abuse, unprofessional behaviour in front of patients and refusal to work with a specific nurse."

Medical staff by-laws should "support a culture that does not tolerate physician disruptive behaviour and make it easy to address concerns and ensure timely resolution of the issues," it advises.

Staff, in general, seemed "uncertain how to go about filing a complaint or addressing the situation effectively within the realms of the workplace code of conduct."

This resulted in "a great deal of frustration on the part of the nurses who were trying to protect Lori and help her," says Barbara Dupont, solemnly. "All they heard was, 'We'll take care of this.'"

Hôtel-Dieu Grace Hospital had records of formal complaints against Dr. Daniel from two different nurses. On June 7, 2004, a nurse complained of being "harassed and discriminated against by Dr. Marc Daniel," the internal report says.

Another complaint prompted a meeting on November 4, 2004. Dr. Daniel completed a memorandum of agreement and was placed on a year's probation, effective January of 2005.

The assessment committee's recommendation for Dr. Daniel to return to work, following his suicide attempt, was based on interviews with the doctor himself; there was no documentation of input received from operating room nurses, hospital administration or Lori Dupont, the verdict notes.

"When abuse and/or harassment are issues and third parties have their safety and well-being threatened," it goes on to say, "there needs to be clear releases of information that let the perpetrator know that effective treatment involves accountability and comprehensive and coordinated treatment services."

Barbara Humphrey, a partner with Stringer Brisbin Humphrey LLP in Toronto, suggests that "the issue is making sure physicians understand [and are held] accountable to their obligations as participants in a workplace community, whether it's violence, whether it's harassment, whether it's bullying."

A number of steps have been taken to address the potential for violence, Spirou reports. "This is an issue that did occur here, but could happen at any workplace, especially any hospital."

Among other things, an intimate partner violence component to Hôtel-Dieu Grace Hospital's workplace violence prevention program, tailored to physicians, was launched last August, Spirou says. The component is believed the first of its kind at a hospital in Canada. "Nobody wants to see a tragedy of this kind repeated again," she says.

Also, suggestions for Dr. Peter Jaffe, a workplace violence expert who testified at the inquest, to train physicians regarding the revised policy, and for the hospital to review security measures in situations where staff/employees are exposed to dangers on the job from other staff/patients or visitors is under way, notes a statement from the hospital.

With the Lori Dupont tragedy, says Doris Grinspun, executive director of the Registered Nurses' Association of Ontario (RNAO) in Toronto, "it went to an extreme, but the reality is nurses suffer the highest level of aggression."

Need for change

Changes were regarded as necessary by the inquest jury, members of which made 26 recommendations for, among others, Hôtel-Dieu Grace Hospital, the College of Physicians and Surgeons of Ontario (CPSO), the ONA and Ontario's ministries of labour and health:

• the Public Hospitals Act (PHA) should be reviewed to address the process for the early identification of disruptive physician behaviour, including timely and effective disciplinary actions;
• a review of the Occupational Health and Safety Act should be undertaken to examine the feasibility of including domestic violence (at the hands of someone on the job), abuse and harassment as factors warranting investigation; and,
• the "current system of repetitive hearings" for physicians should be replaced by a system that allows doctors the opportunity for an immediate hearing before an external tribunal.

One can see from the recommendations, says Humphrey, that physicians should not be regarded as having "any special class or status in terms of being insulated from [workplace] standards."

The jury further recommended that Dr. Jaffe be asked to conduct a review and revision of the hospital's violence prevention program. "The whole theme is looking at missed opportunities," he says. "Probably the most important thing we've learned is not to minimize psychological and emotional abuse. I think, for many people, when they think about violence prevention, they're looking for knives and guns and that's a mistake," Dr. Jaffe says.

"Access to weapons is a significant factor, but there are lots of cases where there's a long-term pattern of harassment, stalking and controlling behaviour that may end in a tragedy," he says.

Depression, too, is a key sign. People often "see someone simply being sad or they might harm themselves, but they don't see them as being a danger to others," Dr. Jaffe adds.

A real maze

Confusion about how to go about suspending or revoking a doctor's privileges or licence proved a sticking point. A worker concerned about disruptive physician behaviour can issue a formal complaint against the doctor through the CPSO. The possible outcomes include a "formal sanction or suspension or revoking their actual licence to practice completely," the college notes.

But the issue of privileges is governed under the PHA through an individual hospital's medical advisory committee (MAC), says Johnston. As per the act, the hospital has the authority to pursue suspension or revocation of a doctor's privileges, beginning with a hearing process within the hospital. A doctor may appeal, but is permitted to continue working with privileges, Johnston says.

There will be cases where physician behaviour cannot or will not change, despite best efforts at the local level, the CPSO acknowledges. "In these cases, the college will be required to investigate the conduct and disciplinary proceedings may result."

Grinspun suggests that "unless we tackle the underlying power structure that exists in health care organizations -- hospitals mainly, but not only -- nothing really will change."

The RNAO is calling for changing MAC to become an interdisciplinary advisory committee, meaning all health care professionals who work in an organization have equal voices on issues relating to patient care and healthy work environments, Grinspun says.

In essence, Johnston adds, doctors are now deciding "among themselves whether or not they are going to discipline one another. There's a real problem."

Culture clash

The "culture of physician dominance" can have worrying effects, says Grinspun. "I've had that experience [unwanted sexual advances] myself in my career," she says. "I simply just walked out of the room. I remember the head nurse at the time -- this was 30 years ago -- screaming at me, 'Get back in the room.'"

Monforton reports a repeated theme at the inquest was that Dr. Daniel had to be treated with kid gloves because if hospital offi- cials "in any way, improperly revoked or suspended his privileges, it would result in dire financial consequences to the hospital."

ONA vice-president Vicki McKenna does not point a finger at all doctors. "But, quite frankly, they yield and continue to play a major part in parts of the hospital's structure and have a free pass in a lot of ways," McKenna says. "How many flags do we need to be raising?"

In many cases of stalking, Gray notes, there are warning signs at the beginning of a relationship. These include moving too quickly "on the first date, talking about marriage or past relationships and how horrible these people were," or giving someone a cell phone or pager so the two can reach one another.

"At first, it seems as if the attention is romantic and it's flattering to many people who haven't found that perfect person. Before they realize it, it's become a nightmare."

Dr. Jaffe estimates that about three-quarters of homicides are preceded by "as many as 10 warning signs," such as stalking, harassment, prior emotional or physical abuse and depression. "There tends to be a pattern over time. Usually people know what's happening, but they're often uncertain what to do or whether to get involved," he reports.

In cases where criminal charges have been laid, or the person attempts to obtain something like a peace bond, "it changes the balance of power and that is offensive to the individual who's doing the stalking," Gray says.

"If somebody has never been stalked, they have no idea what kind of pressures come to bear on that person. They feel completely ill-equipped to do anything to stop it," she says.

Armed by language

The ONA is hoping to better equip nurses against disruptive physician behaviour by having associated language incorporated in its collective agreement, McKenna says. The intent is to put in every hospital in Ontario mechanisms "that would protect nurses from disruptive physician behaviour."

Gray says, "We know from these tragedies, not just the horror of it, the loss of life involved in this case, but in many, many cases people's lives become unravelled and they try to deal with it on their own. They need their employers to assist them."

Spirou emphasizes "it's important for us, as the hospital, to take some significant time to review these very thoughtful recommendations." As for the Ontario Hospital Association, president and CEO Hilary Short notes "we intend to discuss the recommendations with our health care partners before moving forward."

Because the health care system has undergone such a significant transformation since the PHA was proclaimed in 1931, Short says, "an updated, modern, legislative framework for hospitals is needed, one which not only reflects the current environment, but also facilitates system change and integration."

Monforton adds the hope is that adopting recommendations will correct the systemic problems that "culminated in this terrible tragedy."

The ONA supports the call to review the OH&S Act and include domestic violence from someone on the job as warranting investigation. "We are committed to making these recommendations go forward and we will not be silenced," McKenna says.

Humphrey says due diligence obligations can be applied in the context of workplace violence. But she believes the Lori Dupont case will "fuel more interventions legally in terms of imposing greater responsibilities on employers in terms of preventive steps [for] workplace violence."

Humphrey expects legislative initiatives in Ontario within the next year. "It was such a blatant case that there were risks to this employee," she says, noting there were reports of abuse and threatening behaviour from both Lori Dupont and other nurses.

Barbara Dupont has formed a group to push for adoption of inquest recommendations. So often, these sorts of suggestions "just become words on a piece of paper," she says.

Having some measure of good come from the murder is "the least we can hope for," Dupont says. "It will be some consolation."

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EARLY MARKERS

Following the provincial inquest into Lori Dupont's death, the College of Physicians and Surgeons of Ontario (CPSO) released a guidebook on how to manage disruptive physician behaviour. Certain behaviours should "heighten your concern about an individual's professionalism or well-being," the guidebook advises, including the following:
• referring emotionally, often to anyone who will listen, to personal upset over recent events originating in the workplace or in personal life;
• failing to show respect for others in the workplace and/or for patients;
• suspecting the actions and motivations of others, and holding grudges;
• making frequent references to other incidents of violence in a way that implies these could be replicated in this workplace if provoked;
• threatening to harm self or property;
• evading, intimidating, threatening or challenging those who confront said workers over disruptive behaviours;
• making unwelcome romantic overtures to people within the workplace;
• stalking/obsessing over fellow workers;
• expressing a fascination with weapons;
• taking risks that threaten the safety of patients and co-workers; and,
• monitoring the behaviour and activities of others, often maintaining records

Source: College of Physicians and Surgeons of Ontario, "Guidebook For Managing Disruptive Physician Behaviour," released December 20, 2007

Jason Contant Is Editor Of CANADIAN OCCUPATIONAL HEALTH&SAFETY NEWS.