To whom it may concern,

I have written to the medical examiner already on a person level as you see below. I am still requesting an inquest into her death in order to make changes in a broken system. But now I am asking for an inquest into all the opioid deaths as we are in a crisis and losing to many. I would Like if people wrote the medical examiner to ask to call an inquest so that changes have I be made. I also hope that the human rights commission will help in my fight. 
if you want to write the medical examiner please look at what was written below. It has to benefit others if they call an inquest. So please sign my petition and please write the chief medical examiner ( address is below) use my daughters name is you have no others asking them an inquest. Please help my fight to help others with addiction please write the medical examiner and call for an inquest into the death of people who died from opiates  and you can use my daughters name if you want or can be in general so please sign My petition and write a letter to the medical examiner I think they want change as they are probably sick of doing an autopsy every three days in Manitoba on a young person who has died from opiates 

my letter:

October 10, 2019

Office of the Chief Medical Examiner

210-1 Wesley Avenue

Winnipeg, MB R3C 4C6

 

To the Chief Medical Examiner,

 

Re: Request for inquest into the death of my daughter, Destiny Dawn Taillieu (November 4, 1995 – November 4, 2018)

 

I am writing this letter to request a formal inquest into the death of my daughter, Destiny Dawn Taillieu.  Destiny died from an accidental fentanyl overdose on November 4, 2018 at the age of 22 years.  My daughter struggled with various mental health and substance use issues throughout her adolescence and young adulthood.  Over the course of her life, there were many opportunities for more effective intervention that may have changed her trajectory.  Particularly concerning are some of the events that occurred in the weeks leading up to her death that I will detail below.  Additionally, over the past several months, I have become involved with a number of different advocacy groups that are fighting to make change in our mental health and addictions systems.  After talking to many different individuals who have lost loved ones to the current opioid crisis, I realized that Destiny’s story is not the exception, but the rule.  I believe that a formal inquest into her death will help to identify important gaps and problems in the current mental health and addictions service delivery systems that need to be addressed if we want to prevent and reduce deaths associated with substance use and other mental health problems.  

 

At the time of her death, my daughter was considered a vulnerable person as she was diagnosed with mental illness around 14 years of age.  During adolescence, Destiny was diagnosed with borderline personality disorder, suffered from a number of anxiety issues/phobic types of behaviours with obsessive-compulsive components, and engaged in eating disordered behaviours.  She also started to experiment with drugs (e.g., marijuana, prescription medications, ecstasy), likely in an attempt to self-medicate for some of these issues.  She did see a pediatrician and several mental health professionals during her teenage years, and also received lots of support within the school system.  Destiny was always an extremely smart and determined young person. I believe that the supports she received during her high school years, particularly from professionals working within the school system, really helpedDestiny throughout high school and it seemed that she was back on the right track.  Ultimately, Destiny was able to graduate from high school a year early (in 2012 at age 16 years), and embarked on her university career.  In addition, Destiny was posthumously awarded her Bachelor of Arts degree in Criminology on October 16, 2019.  A major issue with the current mental health and addictions systems is that these same types of supports are not readily available to young adults.  In my opinion, the lack of supports and treatment options available for individuals with comorbid mental health and addictions problems, as well as many missed opportunities for more effective intervention, directly contributed to my daughter’ death.

 

I should also mention that Destiny was exposed to many different traumas over the course of her short life (e.g., sexually abused by an uncle at a young age, absent father for most of her life, death of her grandmother who was like a second parent in 2008, sexually assaulted by a peer in high school, the homicide of her cousin’s uncle [Gary Godson] in 2015, the suicide of a family friend [Jaedra Winter] in 2015, the homicide of a high school friend [Joshua Bentley] in 2014, and the sudden death of another friend/former co-worker [Dustin Gamble] in the weeks just before her death).  I do not believe that any of the services made available to Destiny during her struggle to stay sober ever adequately addressed the traumas she experienced or how these traumas may have contributed to her continued substance use.  Destiny’s experiences highlight the need for a more holistic, integrated, trauma-informed mental health and addictions system of care.  Something that is markedly absent from the current systems in place.

 

Although Destiny rarely drank alcohol during high school (perhaps because she recognized how our family struggles with addictions issues), by age 18 she started drinking and rapidly developed a problem with alcohol.  Shortly after, she knew that she needed help with her drinking and, on her own, went to her first Alcoholics Anonymous (AA) meeting (even though she has an aunt who has been in recovery for the past 20 years), went to the Addictions Foundation of Manitoba (AFM) for an assessment, and checked herself into the chemical withdrawal unit at the Health Sciences Center (HSC) in the spring/summerof 2015.  From there, she completed the 30 day residential treatment program through the AFM.  After this program, she remained very active in AA and maintained her sobriety for just over a year.  

 

In early 2016, Destiny met an individual at AA who was also sober, and they began dating.  His drugs of choice were OxyContin and heroin, and when he relapsed, he also introduced Destiny to these drugs and intravenous drug use.  Although we were not aware that Destiny had also been experimenting with prescription opioids in high school (e.g., stated in her sobriety that morphine, Percocet, etc. were her drugs of choice), she had never injected drugs (including heroin) until early in 2016.  At the time, we were desperate for immediate help, but this was not available through the publically funded addictions treatment system.  Wait times for potentially life-saving residential treatment for addictions in the publically funded system were, and continue to be, completely unacceptable, particularly for women.  People are dying while waiting for a treatment bed.  At the time, I really feared for my daughter’s life, and paid for a private rehab (Kelburn Recovery Centre) at a cost of $23.050 for the 30 day program.  As a single parent on disability, I had to borrow the money to cover the cost of the program.  In my opinion, we truly live in a two-tiered mental health and addictions system – if you can pay, you can access immediate help, but if you cannot pay, you can sit on waiting lists for months.  As a parent, it makes me so angry that private, for-profit treatment facilities are closing (e.g., Whispering Pines in June 2019) or laying off staff because of a lack of demand (e.g., Aurora Recovery Centre in September 2019) in the midst of a public health crisis.  Many people cannot afford $20,000 or more per month for treatment. If the public system (i.e., government funded) cannot handle the demand for life-saving treatment (e.g., AFM wait times for residential treatment were206 days for women and 52 days for men in January 2019), then they should be subsidizing the costs of beds in the private system in order to reduce wait times and, ultimately, save lives.

 

In July 2016, she accidentally overdosed on fentanyl.  This really scared Destiny, and she was again able to maintain her sobriety for about a year without re-entering a residential treatment program. But, as is common with the disease of addiction, she relapsed in the fall/winter of 2017.  That was really the beginning of the end.  However, from the time she became an intravenous opioid user until her death, she never stopped trying to get help.  A major issue is that many of the outpatient mental health programs will not allow an individual to participate unless they are sober, but it is almost impossible for an individual to stay sober without concurrently addressing their mental health issues.  Over the course of her last year, Destiny also presented at the HSC Emergency Department several times a month, as well as the Crisis Response Centre on almost a weekly basis for many different issues (e.g., suicidal and self-harming behaviours, seizures, substance use, sexual assault).  Most disturbing is that Destiny would often be discharged within hours after a suicide/self-harming incident or an overdose event with no real supports or follow-up plan in place.  Although Destiny did not die by suicide, the failure to address suicidal types of behaviours effectively in our emergency departments is not an isolated case as evidenced by other suicide deaths that have occurred in the province (largely crystal meth users) shortly after discharge from our emergencydepartments.  Again, highlighting that Destiny’s story is likely not the exception, but the rule.  

 

All of these contacts provided the opportunity for more effective (and compassionate, non-judgemental) intervention.  In particular, the lack of compassion and poor treatment that Destiny received from health care personnel on many of these occasions speaks to the high level of stigma that people struggling with mental health and addictions face even within the system that is supposed to help.  For example, at the Health Sciences Centre, I overheard a nurse referring to Destiny as “that addict with the dog”.  Another example is that one time when Destiny was taken to the Health Sciences Centre for suicidal behaviours by ambulance (so had no shoes, coat, or purse in the middle of the winter), rather than helping her, they told her to walk over to the Crisis Response Centre for help (in -30 degree weather).  Another time, she was discharged from the emergency department despite the fact that she had a seizure right in front of staff just after discharge – it seemed like it was too much trouble to readmit her and actually try to figure out what was actually wrong. These are only a few of the examples that I personally witnessed, but have heard similar stories from other families who have also lost loved ones to substance-related deaths. As a nurse myself, it should have been a red flag to health care personnel that she needed help.

 

In September 2018, Destiny moved back to my house in St. Adolphe.  At this point in her life, she was desperate for help for her addiction.  From October 2 to October 14, 2018, she completed detox at the Main Street Project hoping to transition into a residential treatment facility.  Again, wait times for publically funded beds were extremely long at the time.  However, she was able to obtain a bed date for December 15, 2019 at Tamarack Recovery Centre (as was sponsored by a donor).  She never made it to her bed date.  Although she attended AA meeting to try and maintain her sobriety after leaving detox, she relapsed shorty a few days after being discharged.  

 

Although her drug class of choice was opioids, she occasionally used crystal meth as well.  During this relapse, she went missing for a couple of days with my car.  I had to make a missing person’s report and also reported my car stolen to the police at the time.  The police found her wandering the streets downtown with no coat, shoes, phone, or car on October 19, 2018.  Because it was the Winnipeg police who found her (and she lived in St. Adolphe), they told me to pick her up from them in St. Norbert (as they were unable to drive her out of town).  When I picked up Destiny, it was obvious that she was under the influence of drugs as she was hallucinating, acting paranoid, and not even sure who or where she was (i.e., crystal meth type psychotic behaviours).  As a result, I had to call for a wellness check once we were home, and both paramedics and a RCMP officer were dispatched to my house.  The responding RCMP officer suggested obtaining a court ordered mental health hold as he could also see that Destiny was not mentally stable at the time (so he took her to Bethesda Hospital in Steinbach, MB).  So I went to the Winnipeg Courts and received a 7 day mental health hold (signed by a judge) and brought the order to the Steinbach hospital (October 19, 2018).  She was discharged from the hospital within 48 hours (October 21, 2018 at 10:00am) even though it does not appear from her medical records that she was seen by a psychiatrist or clinical psychologist.  They actually wanted to discharge her on October 20, 2018, but I was unable to pick her up as my car was still not found. In addition, the decision to discharge Destiny was made shortly after finding syringes in her room at the hospital.  Staff likely viewed her as a nuisance (e.g., she was also caught smoking in her room) rather than as someone in desperate need of help.  Again, Destiny was discharged with no real follow-up plan other than pamphlets outlining some of the resources available.  Two weeks later she died of an accidental fentanyl overdose (overdosed on November 3 and died on November 4, 2018 at the St. Boniface hospital). She was with her ex-boyfriend (he had put a temporary restraining order against her while she was in detox in October), and he was with her at the time of her overdose.  From what he said, they thought they were buying heroin that day (not fentanyl), so Destiny’s death is likely also related to the problems of the tainted drug supply.

 

 

I am asking for this inquest as our government is largely ignoring the opioid crisis, and people (including many young people) are continuing to die. I have written all levels of government and am disappointed in their lack of response.  My daughter’s journey through addictions might have been prevented if we actually treated addictions and mental health like any other life threatening disease. There were many missed opportunities to help her. This is happening to families and people struggling with addictions every day in our province.  Over the course of the past year, I have talked to many other people who have also lost loved ones due to substance use and almost all of them have stories very similar to my own.   I believe an inquest into her death would highlight the many gaps in services and potential life-saving points of intervention that could better facilitate access to treatment and prevent more deaths. Findings from an inquest might force politicians and other decision-makers to act in order to better address the current public health crisis related to substance use, which will ultimately save lives.

 

Thank you for your consideration, and I look forward to hearing from you soon.

 

Sincerely,

 

 

 

Shelly Taillieu