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Fahey, who is also director of public affairs, was unable to explain why if security coverage was sufficient, the Montreal General often calls upon police to restrain patients who are aggressive but who do not pose a grave danger. He also did not address a question about why the Montreal General deploys 20 per cent less security than Notre-Dame Hospital, even though it has more than double the number of Code Whites.

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Fahey denied that budget cuts played any role in the decision-making over security despite references to the contrary in the documents obtained by the Gazette. Ten days after the near-strangulation, the Code White committee conceded in a meeting that “the current (crisis de-escalation) training is on hiatus” and “attendance has been low due to budget reductions.”

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Behind the scenes, however, the Montreal General had entered into negotiations with police about “how much police intervention will be provided to the MUHC, especially in view of the augmentation of gang wars and protection of these patients while hospitalized,” according to the minutes of a Code White committee meeting last March.

The internal Montreal General documents are filled with anecdotes of violent incidents, and the reports acknowledge the often-unco-ordinated response by Code White team members. One such incident stands out, occurring on July 1, 2017 — two months before the assault on the ER nurse.

The old Royal Vic used to run its own psychiatric ER, but the MUHC chose to relocate it to the Montreal General rather than to the Glen site. That decision coincided with the imposition of the most drastic budget cuts in the MUHC’s history.

As detailed as the workplace commission’s report is about the Sept. 2 attack — especially on the lack of training for nurses in how to deal with highly aggressive patients — it does not address the Montreal’s General’s overall security situation. The Gazette, however, has conducted a broader investigation into the hospital’s handling of security based on a review of hundreds of pages of internal documents as well as interviews with dozens of employees, uncovering a number of anomalies. Among them:

The Montreal General has always experienced security lapses, but the documents suggest the situation deteriorated sharply after 2015. That’s the year the old Royal Victoria Hospital at Pine Ave. and University St. — part of the MUHC — moved to the Glen site superhospital in N.D.G.

Yet during this period, senior administrators insisted that security coverage was adequate. Richard Fahey, the MUHC’s director of human resources, who helps oversee the security dossier, confirmed in an email that union leaders “did share various concerns … about security back in June (2017). The matter was reviewed by the head of the security department and the coverage was deemed sufficient.”

PART ONE: The inside story of how an ER nurse was nearly strangled by a patient.PART TWO: Security gaps at Montreal General as if faces pressure to cut.PART THREE: An MUHC plan to curb escalating violence is drawing criticism.PART FOUR: Hospital violence, staff with PTSD and the need for a solution.

And the violence is not just aimed at the staff. Documents obtained by the Gazette show that patients are sometimes harmed by other patients. On July 18, 2017, a “patient (in monitored care) pulled out his IV & those of other patients, and was destructive to property,” according to Code White committee minutes.

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The workplace safety commission (CNESST) investigated the assault on the nurse as well as a patient attendant who came to her defence. In a report obtained by the Gazette, the commission concluded that the McGill University Health Centre failed to ensure a safe work environment for the emergency-room staff at the Montreal General, and it ordered the MUHC to make substantial improvements under threat of financial sanctions.

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One of the first problems with the relocation was flagged by the interim manager of emergency measures at the time, Pierre Blais. On May 17, 2016, Blais noted that the guards who used to work at the Royal Vic were having a hard time adjusting to their new environment.

Notre-Dame reported 917 such disturbances in 2016, the latest year for which complete figures are available. That number is the second-highest in the city, after the Montreal General’s 1,923.

“Security guards are concern(ed) about dealing with the type of population in the MGH ER,” say the minutes of a Code White committee meeting. “They are now adapting to working in a trauma setting — gang rivalries, violent patients, etc.”

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“A recent incident took place in the emergency room where the police were called and they told security that they will only respond to Code White STAT and/or active shooter, not a regular Code White to assist restraining a patient,” say the minutes of a Sept. 13, 2016 meeting of the Montreal General’s Code White monitoring committee.

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(Commander Danik Guerrero of Station 20 downtown said those negotiations are continuing and he expected to conclude a protocol sometime this year.)

The Gazette sent Fahey of the MUHC a series of detailed questions about the handling of security at the Montreal General. He did not respond to a direct question about why, for more than two years, the Montreal General did not appear to follow its own emergency security policy for overnight coverage.

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Despite Blais’s warning, the problems grew worse. The Montreal General continued to assign three overnight guards for the entire hospital despite the fact that the MUHC’s own security policy demands the presence of at least four guards in cases where a patient has arrived wounded because of a gunshot or stabbing.

Following the nurse attack last Sept. 2, MUHC officials repeated the same explanation, stating that they were simply following a directive issued by the provincial health ministry. However, a spokesperson for the ministry told the Gazette that no such directive exists.

Not so, the MUHC responded in a Nov. 22 statement, insisting that “clinical and safety considerations prevailed over budget considerations.”

For the basis of a fair comparison, the Gazette drew upon the figures of Notre-Dame Hospital, which also has a psychiatric department and was recently part of a university teaching health network like the MUHC, the Centre hospitalier de l’Université de Montréal. The Gazette also examined the statistics of other Montreal hospitals, including the Jewish General and Maisonneuve-Rosemont, but those institutions log fewer Code Whites.

A guard must remain at all times at the main desk near the Cedar Ave. entrance. As a result, two of the three overnight guards were left to patrol the hospital. Yet the MUHC’s security policy stipulates that during emergencies involving gunshot and stabbing victims, “at least three guards are required for the effective control of all access points in order not to compromise the response of the medical team until the patient is transferred to the operating theatre.”

Under threat of financial penalties by the workplace commission, the MUHC has now agreed to invest in Code White training and other security measures, but serious concerns nevertheless linger among staff.

The report by CNESST followed repeated warnings over two years by staff to senior administrators about an escalating number of violent incidents since the ER’s expansion and a lack of resources to fix the problem. During this period, the Quebec health ministry forced the MUHC to make tens of millions of dollars in cuts to its operating budget — cuts that affected everything from secretarial services to security.

“In inpatient psychiatry unit,” the committee observed, “patient was very aggressive, threatening & destructive to property. Code White response team was unable to contain him, the police were called, patient threatened police, additional police assistance was required and an intervention was performed with Taser and K9 officer.”

“It’s up to the institutions to determine their needs in terms (of the number) of security agents,” Noémie Vanheuverzwijn said by email.

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The MUHC oversees the Montreal General, a Level 1 Trauma Centre with a mandate to treat those injured in car accidents and gang-related violence, among other life-and-death emergencies. In 2015, the MUHC expanded the Montreal General’s ER to take care of psychiatric patients, but decided not to add an overnight security guard in the locked psychiatric ward.

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That compares with about 800 hours of security coverage per week at the Montreal General, even though it has more than double the number of Code Whites and is close to downtown bars, often receiving heavily intoxicated drinkers after last call on weekends. The Montreal General’s security statistics include the addition of the overnight guard in the ER psychiatric ward after the nurse attack last Sept. 2.

Mounting concerns about the lack of overnight security were raised directly with senior managers at a meeting of the MUHC’s Joint Occupational Health and Safety Committee in July 2016. Mathieu Jetté, head of emergency measures at the MUHC, explained that the “security guard coverage/budget is established by square footage” — and not the number of patients or the severity of cases.

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The Gazette has reviewed documented cases of gang members clashing with ER security in the midst of patients and other visitors. In one case, an ER coordinator sought to calm down an enraged gang member by allowing him to accompany her to the operating-room floor where his fellow gang member was undergoing surgery.

The Montreal General Hospital reports far more violent incidents involving patients and visitors than any other acute-care hospital in Quebec, yet it provides markedly less security than comparable health institutions, a Montreal Gazette investigation has found.

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That is still the case even after the Montreal General boosted security following the near-strangulation of a nurse by a patient in the psychiatric emergency department in the early-morning hours of Sept. 2, 2017. That incident triggered a national outcry and highlighted the grim reality that health-care workers are victims of violence to a much greater extent than in any other profession.