C O M M I S S I O N OF SOCIAL AFFAIRS
 
No: SS - 10369 Division of services of health and social services
(3 9 8 0 6 8)

(A translation of a original document at my best knowledge)

IN FRONT:

Me Lina Bisson Jolin

Sir Serge Bourassa-Lacombe
1 045 rue Lacombe, #206
Sherbrooke (Quebec)
J1E 3E3

              Applicant

c.

Centre Universitaire sante de L'Estrie

              Respondent

DECISION

It is a question of a request presented in accordance with article 17 of the law on the services of on the services of health and the social services (!) to target to obtain the access of the information content to his medical records.

The documentary evidence submit reveal essentially in the following. 

February 11th 1995, the applicant is admit in psychiatry at the Centre universitaire sante de l'Estrie. In course of hospitalization, an prescription of a locked-up in the hospital necessary turns out considering of the refusal of this one to voluntary following the close cure.  

Within the context of this required procedures, two reports of psychiatric clinical examination are submit like the one of Dr Lynn Gaudreault attending physician of the applicant dated March 17th 1995 and hereafter wording :

    "Patient admit 02-11- 95, bring by the police after having shows gesture of violence against an object in front of his roommate + his parents in a context of changing attitude since Dec 94: augmentation of energy, augmentation of sociability, lessening sleep, libido augmentation and appearance of a delusions of grandeur + religious with irritability development + inadequate behaviour; insistence to evangelize his class and/or roommate, very irritable etc.

(1) Law on the services of health and social services, L.R.Q., c. S - 4.2

Initially hospitalization and voluntary taken medication with a relative amelioration, since 03-13-95 refusal of taking treatment claming to be all right.

Patient who remain uptight whit an augmentation of psychomotor activity biggest irritability mist contain (patient said he get up to keep the control and leave the meeting room). Aggressive gesture doing to the medical team like is point by the finger, threatening look, clap one's hands, indirect threat etc. Also patient who present a delusions of grandeur and religious very invading who make him act; lay hands on the patients for their healing etc. Any self-criticism and lack of judgment ++.

Imp: Affective illness bipolarity, manic psychosis + psychotic element, at the moment evidence of dangerousness." (sic)

April 11th 1995, the close cure is clear up following the evaluation of Dr Claude Arbour, psychiatrist physician.

In spite of the recommendations to that effect, he refuse all following in extern also that all medication.

Since, he lead a fight without respite to denounce and emend the injustice commit so much concerning him than concerning the people suffering from mental illness.

As a President-Founder and Controller of SERGE BOURASSA-LACOMBE'S FONDATION, association created at the time of his hospitalization february 13th 1995, he keep up his mission so much in Quebec than in United-States.

For the purposes of this, he submit a voluminous documentation of which the Commission have take knowledge of his describing in details the numerous steps to set about the aim in view to recruit of members and to bring them to appropriate relief, all this dictating by the divine word like that appears in numerous biblical citations reported and commented.

It is also contain the letters addressed to different governmental authorities, Justice ministries, of the public security, Royal Canadian Mounted Police… It denouncing in particular the abuse and injustices commit at his concern.

In this context, September 15th 1995, he require by writing of the respondent the handing over of "his integral file" covering the period of the hospitalization at the psychiatric department from February 11th to April 12th 1995.

December 5th following, the respondent answer to him in this terms:

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"In respond to your letter of September 15 th 95 received to the archives November 16 th 95, we insists to inform you that we can not, unfortunately comply whit your request for now.
 

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In regard of the article 17 of the Law on the services of health, we had contact your attending physician, Doctor Lynn Gaudreault, who consider that, for the moment, This access can be prejudicial to your health. Contrary to, this one stay free to meet you if like it is your desire. Furthermore, like it is mention into the enclosed copy of the letter of doctor Gaudreault, you will be able to remake a request in six months and, at that moment, your attending physician will re-evaluate this access. " In regard of the article 17 of the Law on the services of health, we had contact your attending physician, Doctor Lynn Gaudreault, who consider that, for the moment, This access can be prejudicial to your health. Contrary to, this one stay free to meet you if like it is your desire. Furthermore, like it is mention into the enclosed copy of the letter of doctor Gaudreault, you will be able to remake a request in six months and, at that moment, your attending physician will re-evaluate this access."

Subsequently, April 17th 1996, the respondent deliver him a copy of the hospitalization summary following the recommendations of the Doctors Gaudreault and Yvon-Jacques Lavallee, department Director, after the reappraisal of the file. None satisfied, the applicant maintain is initial request, that is what Doctor Gaudreault she objected against it October 6th 1997, like that is appears in the letter addresses to the in charge to archivies service and worded in this terms:

"We had receive a request from the medical archives service at the effect that Mister Serge Lacombe will desire to obtain an integral copy of his medical file. Following the reading of the document that Sir Serge Lacombe had send to your service, I desire to inform you, that after discussion with my department chief, the Doctor Pierre Gagne, we had acknowledge that for the moment, an prejudice could be cause to Mister Lacombe if he possessed his integral medical file.

So only a summary of the hospitalization could be grant to him."

  From there the present request notably express:

"I desire to receive my medical file #398068 coming from the CUSE formerly CHUS for the period spread out from February 11th 1995 to April 12th 1995 inclusively. I want and expect to receive a conform copy of this medical report. This report should reach me as quickly as possible. It matters little the means of transport who will be use. As a President-Founder and Controller of SERGE BOURASSA-LACOMBE'S FONDATION to permit me to identify the truth and the false. Because it have forgery and the use of forgeries, criminal harassment and assault, physical and chemical torture, furthermore it have having induced poisoning by the medical team on March 13th 1995 which is attempt to murder." (sic)

Testifying in person at the audience, the Doctor Lynn Gaudreault, psychiatrist, related what is following.

The applicant was under her health care at the time of his hospitalization in psychiatry and at that time she stated a manic diagnosis with psychotic element in a probable bipolarity context.

At the time of the break up the close cure, April 12th 1995, the symptom still persist but without dangerousness element.

A medication and a following turn out to be necessary but the applicant always rebel against it.

Without having treat him as like during those years, she thought that the psychotic progress endure with element of paranoid schizophrenia.

She justified her opinion on the nature of the speech hold by this one at the time of his moves to the hospital in view to obtain is file, on the content of the written works transmit in those occasions and product to support the present; and on the call personally received to his subject be notably the Atlanta Police or Royal Canadian Mounted Police inquire after her in reason of his strange comportment.

Not any outward sign of dangerousity have not nevertheless being or noting, make clear is she.

Moreover, she considering that, in view of that the manifesting delirants elements by the applicant had especially related to the treatment sudden at the time of his hospitalization, the integral access to his file will risk to make worse the symptoms and to provoke a complete disorganization may transform this passivity into aggressively.

A neurotic, that she explain, read his file for understand it whereas the psychotic like in the case in point interpreting wrongly and the case of the applicant, his resentment toward the sudden treatment can overturn against all the people who intervened and the name whose appear in the file knowing as nurses, trainees, residents…

It was offer him the analysis of his file in presence of an expert but this one had refused judging this step useless as convinced to obtain forged replies.

The applicant is as well heared as witnesses.

He declare want that Justice be done to prevent the criminality and the suicide and considering of his file to desire the access for there underline in yellow what is truthful and in orange what is inexact. 

Like as relate in the document produce. He reiterate having being hospitalize and treated against his will. Particularly in drugs was administrated provoquing serious side effects.

His father as well as his teachers as well the attending physicians had want to do a Marc Lepine whereas in reality he is a peaceful man.

He do not want to harm them but simply to expose the injustice and built a better world grace with the medical expertise of which Jesus Provide him.

The foundation that he had created and that he wish at the image of International Amnesty for the people who suffering from mental illness, permit him to fulfill his mission.

Before February 1995, he was never hospitalized or treated in psychiatry and since the end of his hospitalization he had to make the object of not any following or treatment and had always maintain a pacific comportment and adequate entirely consecrated to stop the problems in mental health.

He even went to United-States where he set out to return. He is expected and will having even of employment possibilities according to a written document attesting that and submit to support of the presents. 

Madam Liliane Boucher corroborate the testimony of the applicant and describe him like an engaged man, respectful and accomplishing a work marked with of spirituality consecrated to stop the problems in mental health and to remedy the abuse of which the excessive medication.  

She know him since last Mai 28th, accommodate him since August 13th and she have entirely confidence in him.

Having herself worked as a secretary of a mental health organism, propertied a technician assistant forming in pharmacy and having being follow-up in psychiatry, she his in position to confirm the inadequate of treatment administrated to the ex-mental patient.

She help the applicant to seek his goal, so be it built up a better country by the transfer of the faith. 

Madam Sylvie Poirier submit for her part the following testimony.

She knows the applicant since August 15th 1997 and since he is became her spiritual adviser and her guide.

This one has contributed to the amelioration of her couple life. Herself and her husband are battling with mental health problems, and they had benefit from of the piece of advices and of his power of healing by the prayer.

To her knowledge, he had never use the violence and only positive extricate from his person. 

The article 17 of the aforementioned law applicable in the case in point set out like following:

""17. All user of 14 years old and up have rights to access to his file.

However, the hospital can refuse to him the access momentarily if, from the advice of his attendant physician or of the Doctor pointed out by the General Director of the hospital, the communication of the file or a part of this one could cause probably an serious prejudice to the health of the user. In that case, the hospital, on the recommendation of the physician, determine the moment where the file or the part of which the access hand being refused will able being communicated to the user and advice this one."

It is infer from this so that the right of access is the rule and the refusal the exception following a well precise criterion so be a serious prejudice in consequence for the health of the applicant. 

Therefore, the submit proof did not demonstrate, of the advice of the undersign, such impact. 

Well that this one reveal the persistence of symptoms diagnosed at that time by the attendant psychiatrist, the Doctor Gaudreault, it appear unlikely that the integral file increased the gravity and that a serious prejudice for his health as a result. 

It is in fact, like it appear on the volumentary documentation produced by the applicant to support of presents including detailed narration of his stay in psychiatry, identification of the principals participant and the state diagnosed an administrated treatments, this one have already a thorough knowledge of his file. 

In spite of that, since the break up of the close cure in April 1995, and that, without never have giving to pursue the follow up or the recommended medication, not any dangerousity was not noted neither concerning of the hospital or his staff neither at the outside, but more a behaviour not that aggressive but disturbing.

Considering that not any deep perturbation being not resulted of the access to his summery of file or the personal knowledge that he have in, force is to notice that to acquiesce to the present request risk so little to modify the overcome situation since more than two years and half, so be it: wrong interpretation and negation of data, rancour in resulting, volunteer to restore the justice and increasing militantism in favor of the mental health following his convictions and his own vision.

By those motives, the under sign in consequence : 

RECEIVE the request.

Me LINA BISSON JOLIN
Sainte-Foy, November 20th 1997     [up]

 

M. Normand Legault
Representative of the respondent