The House at 600 Sanitorium Road

To understand the transformation of a home for soldiers with tuberculosis into an institution for disabled children that faces a litany of human rights complaints, we need to understand the socioeconomic forces and policy gaps that have kept Canada’s residential institutions open–despite government promises to shut them down.

“I’m sorry.” These were the words heard from victims throughout the day as they testified in a class action settlement approval hearing on June 23, 2021. The case (Yeo vs Ontario) involved the Child Parent Resource Institute (CPRI), a residential institution in London, Ontario that is solely funded by the Ontario Ministry of Community, Children and Social Services.

The survivors, who were in the CPRI as children, were not apologizing for doing anything wrong. They were apologizing to the judge when the trauma of recounting their experiences caused them to cry so much that it was difficult for them to speak.

“I was abused, I was given a dislocated shoulder. [begins to cry] I’m sorry..”

“They put me in a room and ignored me and everything else. It was hurtful, [crying], I’m sorry.”

“I remember being taped on my mouth a lot. And I [sobbing] it was so hard…sorry…”

The Government of Ontario, who operates and funds the CPRI, has never apologized for the abuse that survivors testify they experienced within its walls between the years 1963 and 2011. In fact, the Province’s lawyers resisted early efforts for settlement, requesting the case be dismissed with costs in 2017, cancelling a mediation in 2018 and making it clear that if the case went to trial the Province may succeed in stopping any kind of resolution in favour of the survivors due to factors including the Crown Liability and Proceedings Act (2019) which potentially limits the government’s liability in new ways. In the end, the $10 million settlement did not begin to compensate for the trauma and loss faced by the survivors.

But what amount could? More than 5,000 children and young adults, many Crown wards, had been through the CPRI’s doors and none of them, it seems, have anything positive to say about the place. The CPRI was a site of terror for many. Survivors recall being beaten, restrained, locked in dark rooms, sexually assaulted, drugged against their will and verbally abused by staff. Far from random incidents, the survivors testified that there was an endemic atmosphere of abuse at the institution, like other Ontario residential institutions, such as the Huronia Regional Centre, one of 16 other institutions that have faced similar class actions, all shutting their doors and reaching settlements in the tens of millions.

According to the Motion Record of the Plaintiff:

It is alleged that the [Government of Ontario] had knowledge of abuse of residents at CPRl [and] over a period of some years, no adequate internal safeguards were put into place to prevent or report abuse of residents of CPRI, and no adequate steps were taken to improve the quality of care or living at CPRl. … Witnessed and suspected abuse was not reported. …CPRI failed to screen or train staff sufficiently to protect against abuse of residents or if such screening and training was engaged, the staff ignored said training without consequence.

One survivor told the CBC that he was repeatedly called “worthless” by CPRI staff and witnessed “the repeated and continuous abuse and punishment of residents by CPRI staff and other residents.” The lawsuit alleges that the Province did not fulfill their legal role to take care of the children, resulting in abuse that has “violated their rights and severely altered the paths of their lives,” leading to PTSD, substance abuse, difficulty trusting and forming relationships and more.

In the June 23 hearing, former residents from different decades, who’d never met each other, told similar stories of being put into solitary confinement for countless hours, restrained, forcibly sedated, punched, kicked and sexually assaulted by staff. “Every time I cried because I wanted to go home I would get put in a ‘quiet room’ and I was restrained,” recalled one former resident. Another resident, who was a Crown ward, was taken from an abusive foster home in 2005 and housed at CPRI. “I got [crying] thrown into the walls there, by people who could restrain me for no reason and sexually grabbed…They’re criminals and should be arrested for their life.”

“There was systemic negligence in the operation of the institution,” lawyer Jody Brown of Koski Minsky told CBC, stating that the government failed to ensure patients “were safe from both staff abuse and abuse from other residents.” According to the Statement of Claim, survivors suffered “immediate and long-term mental, emotional, psychological and physical harm…which adversely affected their relationships with their families and the community.”

The Statement also asserted that the government had “prioritized CPRI’s research mandate over residential care and safety” and operated “with callous disregard for the class members’ interest, safety and well-being.”

There have also been criminal cases. In 2013, a CPRI staff member was sentenced to 20 years in prison for attempted murder for assaulting  a 12-year old autistic child, leaving him with permanent brain injuries requiring round-the-clock care. After the child was dropped off at the centre following a weekend at home with family, the staffer (Greg Simard) “took him into the woods and beat, kicked and stomped on him. When he thought the boy was dead, he left him there.” After the boy was found–unconscious and naked from the waist down–he was taken to hospital in critical condition. “He wasn’t moving, he was on a ventilator,” said his father. “We cannot imagine how he survived.” Following his arrest, Simard called the child “a drain on society.”

These incidents are not from a distant past; in fact, the CPRI class action decision covers  survivors as recent as 2011. It is also reflective of a broader pattern of problems in Ontario’s residential system. In 2016, a Report by the Ontario Children’s Advocate found that in three months in the residential care system for disabled children there were 737 reports of physical restraints and at least three deaths. Court documents over the past 30 years reveal a multitude of reports, policy changes, procedure revisions and directions handed down by auditors following inspections, with little follow through to make meaningful change at the CPRI and other institutions. And despite vows by the Province to shut down institutions, the CPRI remains open.

To understand why, we need to go back to the beginning.

The sanitorium, repurposed

The CPRI is located on the site of the original Queen Alexandra Sanitorium, at 600 Sanitorium Road in London, Ontario. The Queen Alexandra opened in 1910 as a tuberculosis treatment facility for locals and later for soldiers returning from the war. A stately series of buildings with a large wooden home as its centerpiece, the sanitorium was located on a high bluff overlooking the Thames River. In 1910, tuberculosis sanitariums were seen as a way to treat patients with fresh air, rest and a healthy diet.

When antibiotics were discovered as a new way to treat tuberculosis, TB sanitoriums lost their patients. Many Canadian sanitoriums were demolished. Others were repurposed and redeveloped as residential institutions. This shift enabled provinces to maintain the economies of the institutional spaces, including local jobs, since many were located in remote areas without much industry.

These segregated institutions were familiar in the Canadian landscape which had also included Indian Residential Schools and almshouses, all defined by  abuse, neglect and disease. As the Queen Alexandra hospital was coaxing Londoners back to health with vitamins and fresh air, Canada’s large residential institutions for the “feeble-minded”—like its residential schools for Indigenous children–were riddled with the disease, a result of overcrowding and neglect. At Ontario’s Huronia institution, named A Hell on Earth by its survivors, residents were buried onsite in unmarked graves.

Though provincial governments promised as early as the 1960s to close institutions and provide community living opportunities, the CPRI (among others) remained open. The old Queen Alexandra, which had first transformed into The Beck Memorial Sanatorium (1949) and then the Child Psychiatric Research Institute in 1960 (CPRI) remained open under Ontario Government control.

The class members’ Factum alleges that for decades the Crown “prioritized CPRI’s research mandate over the residential care and safety of the class members”. The misuse of research at the institution is alleged to be a key factor leading to the “deprivation of healing opportunities” for patients. According to the Factum: “The Crown conducted its affairs with callous disregard for the class members’ interest, safety and well-being. In all the circumstances, the Crown breached, and continues to breach, its fiduciary duty and duty of good faith owed to [patients].”

Policymakers have not only faced pressure from researchers but also from labour unions. In the US in 1975, the American Federation of State County and Municipal Employees, which represented workers in large institutions, issued a pamphlet called Out of Their Beds and Into the Streets calling for a moratorium on institutional closures near the very beginning of de-institutionalization. That same year, the Ontario Public Service Employees Union announced that they intended to launch a similar fear campaign. Pressure from organized labour translated into multi-party support for large residential institutions.

It wasn’t until 2018 that Saskatchewan closed its last institution. In Manitoba, two large residential institutions remained open decades past when policymakers had promised to close them. One of these institutions, the Manitoba Developmental Centre (MDC), has finally announced plans to close its doors and relocate its 133 residents to community living by 2024.

Although many factors explain why MDC has finally closed, one stands out: the class action.

Certified in May 2020, the MDC class action is much like Ontario’s institution-related class actions. Lawyer David Rosenfeld, who represented survivors of the CPRI, Newfoundland Indian Residential Schools and the MDC among others, told me it has been “very difficult” to bear witness to the accounts of the survivors.

Through connecting and documenting victims’ experiences by means of the courts, the class actions are a catalyst for something that decades of activism struggled to achieve: getting governments to acknowledge wrongdoing and shut the institutions down. Class actions against Ontario institutions in 2009 resulted in more than $100 million in settlement dollars, and a mandate to close institutions. In 2013, a class action against several Ontario institutions was settled for $35 million and a formal apology was issued by Premier Kathleen Wynne.

“Public apologies achieved through litigation are exceedingly rare,” notes Rosenfeld, “However, based on our experience and discussions with class members, an apology can have a significantly beneficial impact to survivors.”

In the June 23 hearings, some CPRI survivors also called for the province to acknowledge wrongdoing by covering costs for therapy they required for the years of abuse they had suffered at the CPRI and as Crown wards. Another common hope: that the CPRI would close its doors, for good.

Yet, in 2018-2019, 115 youth resided at the CPRI. The Province has not given any indication that it plans on closing the institution.

A paper trail of broken promises

Why did it take so many years for these abuses to come to light? In part, it’s because of the nature of institutions. As segregated spaces, institutions foster abuse because there is no opportunity to safely report it, nor to escape it. At the CPRI, “communications between residents and family members were made difficult if not impossible,” according to the Statement of Claim. Survivors told their legal counsel that they felt “afraid to report injuries or abuse out of fear of assault or repercussions by staff.” When they did complain, according to the Statement, their concerns “were ignored or not investigated”. The Statement also asserts that the CPRI “failed to report allegations of sexual abuse and moreover often punished those residents who came forward with such claims.”

The past half-century of audits of the CPRI and other institutions shows a disturbing pattern of broken promises by various Ministries to reform them. Typically, an inspection would trigger a task force report and/or audit. (Major audits were prepared in 1975, 1979 and 1980), with several in the 1990s by the Office of the Auditor, Ontario. Auditors would visit the facilities and report violations, then issue guidelines for reform. The Ministry in charge of the institution would then promise make changes but fail to keep its word. Several years later, another auditor’s report would repeat the same findings and recommendations, noting that institutional leadership had not enacted the promised reforms.

Auditors themselves seemed frustrated with this pattern. One of many examples is a 1995 review by the Auditor General of Ontario, stating:

“…We made similar comments in our previous audit in 1990. At that time, the Ministry indicated that a peer review process would be established to review the quality of care. The Ministry has not established an ongoing review process to aid it in monitoring the quality of care [and] the Ministry-operated facilities were not subjected to health and safety audits, nor were the statements of good practice applied to these facilities.”

The Auditor also noted that “In 1990, the Ministry indicated ‘a pilot project to examine the benefits of an overall peer review process’. …At the time of our audit in February 1995, the Ministry had not schedule any further peer reviews at its facilities.”

Given the audit trail, it is hard to accept the Province’s claim that during the class period, “the Crown, [and its] employees… met and often surpassed the standard of care for the delivery of services to the children and youth who were admitted to CPRI.” It is a remarkable claim that could only be believed if the testimonies of hundreds of survivors are not believed.

Taking on survivors’ credibility was a strategy of the Crown’s lawyers, who engaged Dr. Tim E. Moore from York University’s Psychology Department as an expert witness on memory and children. “Having been asked to review the affidavits sworn by several class members,… Dr. Moore concluded that there were indications of confused facts and other errors in …recollections of their experiences at CPRI.”

Yet the affidavits of survivors, who were unknown to each other, share many themes. The affidavit of James Chadwick, who was nine years old during his year-long stay at CPRI in 1986, reflects the recollections of many survivors:

I was hit by the staff at CPRI on many occasions. Sometimes when staff thought I was behaving badly, three of them would grab me, force me to the ground and sit on me. I was nine years old at the time and the people sitting on me must have weighed 180 pounds or more each. It’s always scared me because it seem to happen for no reason at times. …Staff forced me to take a lot of drugs when I was at CPRI. These drugs made me feel sleepy. I did not want to take them, but the staff forced you to take them. …Living at the CPRI was a really scary place to live for a nine year old. I never had any control over what I wanted to do or where I could go.

The defense touted a level of community support for the CPRI that is also debatable. For example, counsel for the Province claimed that Inclusion Canada, a non-profit that advocates for community living, had praised the CPRI as “setting the standard” for similar institutions. But Krista Carr, Inclusion Canada’s Executive Director, told me:

“Despite our best attempts, Inclusion Canada has been unable to determine the source of the apparent endorsement of CPRI as attributed to the Canadian Association for Community Living [Inclusion Canada’s former name].

“Inclusion Canada is unequivocal in its statement that persons with an intellectual disability have the right to live fully and inclusively within community. Inclusion Canada does not support facilities that congregate, isolate, and/or marginalize persons with intellectual disabilities.”

Part of the Ministry’s efforts to rehabilitate its image has been adopting new language, describing the CPRI as using a “sanctuary model,” with “program development in trauma-informed care, complex special needs and autism”. It has also renamed its units as “cottages”. But by accounts of residents and others, it has remained a space of isolation for its vulnerable residents. T.R., a resident in 2014, told me he had to earn weekly phone calls to his parents in 25 cent increments based on “good behaviour”; his parents soon removed him from CPRI. A social worker who went into the residences in the 2010s told me: “What made me sad [was] seeing the children crying for their families.”

Despite the colourful cartoon murals and inspirational slogans on its cinderblock walls, the institution remains a space where children are isolated from their communities, longing for home.

An institution, by any other name…

In 2014, a proposal to change the street name of Sanitorium Road was brought before the town council. Michael Dawthorne, chair of London’s accessibility advisory committee, introduced the change because he was concerned about the negative connotations of the street’s name. “We felt that the elimination of this name…would be a big step forward to reducing stigma within the city of London,” he said.

The majority of the Council disagreed and voted to keep the street’s name.

Perhaps there’s a hidden wisdom in the Council’s decision. For decades, the Province was audited, sued, exposed, publicly chastised and asked to take accountability. Yet its residential institutions didn’t change. By design, they have segregated disabled people from their families and communities and exposed them to violence that has plagued the institutions from the beginning to the present day. The children at the CPRI and other institutions were–and are–among the most dispossessed and powerless people in Ontario: the developmentally disabled, Black, Indigenous and children of colour, poor and juvenile wards of the state. The Province was legally obliged to care for and protect them as much as any other children.

And yet in the courtroom, it was the victims who apologized for the grief that made them weep while speaking, the impact of trauma they could not contain. There is no apology from the provincial government. There is only silence —no tears.

PDF with citations: The House on Sanitorium Road_2021

Thanks to the Board at Autistics for Autistics for support and feedback during the writing of this piece.