'Left to fend for himself': Man killed by police had no access to mental health care, judge finds

When DavidMcQueen was fatally shot by police in 2016 after opening fire on his own neighbourhood, his life had spiralled into a "horrendously difficult and overwhelming" mental and physical health crisis, according to a Calgary judge whose fatality inquiry report was released Tuesday.

The inquiry took place in December 2018 and June 2019 before provincial court Judge Sharon Van de Veen. The purpose of the hearing is to identify changes which could be made in order to help prevent similar deaths in the future.

In the months leading to McQueen's suspected goal of "suicide by cop," Van de Veen heard the 53-year-old had lost his vital home health care, his beloved dog Bear died, and he had become paranoid.

McQueen was in such a state of despair he had protested Alberta Health's lack of home care support by sitting in his own feces for 31 days, leading to a month-long hospitalization for infectedwounds in 2015.

It was the first of two timesthat year he had staged such a protest.

• 'He didn't give them a choice': Caregiver reacts to report clearing police in disabled man's killing

'Left to fend for himself'

At the time of hisdeath, McQueenwas all alone after two home care programs had terminated services.

"It appears that Mr. McQueen was left to fend for himself the last week of his life, which he would have been unable to do," wrote Van de Veen.

McQueen, a quadriplegic since a diving accident in 1994, had many health problems, including that his hands had become "clawlike."

Although Van de Veen acknowledged McQueen could be belligerent and difficult with health care workers, she noted he was "clearly a person in anguish" and said his state of mental and physical health caused him "significant suffering."

The last year of McQueen's life was full of hardships. He was hospitalized four times.

In May 2015 McQueen was taken to hospital with second-degree burns after he used ablow dryer as a heater.His longtime caregiver Isabelle Templeton testified McQueen was often very cold.

Another source of distress for McQueen was his broken wheelchair. Parts were missing and it would sometimes place him in a lying position.

He couldn't get it fixed because he owed the vendor agency money, though the chair was "crucial" to McQueen's well-being.

"His wheelchair was the only thing keeping him from being bedridden 24hours a day, seven days a week," wrote Van de Veen.

Beloved dog dies

In January 2016, Bear had died of cancer afterMcQueen spent all his money on treatments. In fact, he was so broke, Templeton bought supplies out of her own pocket.

McQueen suffered from numerous wounds that required regular, specialized care and dressings. Between McQueen's credit cards and his AISH payments, he didn't have enough money to cover groceries and supplies.

The compassionate and loyal woman also answered his calls for help at night, even though he had lost his funding to pay her salary.

Templeton told the judge that McQueen had been "very depressed" over his deteriorating condition.

McQueen was part of Alberta Health Services' Self-Managed Home Care Program which allowed him to be cared for in his own home.

But the program does not include mental health services and there is no evidence McQueen received any treatment in the last years of his life.

McQueen loses home-care funding

In August of 2015, McQueen was terminated from the program when he failed to provide audits for the funding he'd received. Home Care had tried to help McQueen but he didn't provide the required supporting documentation and he cancelled appointments.

An outside agency was contracted to provide care to McQueen but his relationship with its workersdeteriorated to the point of termination.

The program gaveMcQueen one last chance. He had until Jan. 15, 2016 to supply the documents and would again receive funding to hire his own caregiver.

The only person McQueen trusted

McQueen wanted Templeton, whom he'd known for 16 years, to continue as his caregiver. She was the only person he trusted.

The deadline passed and McQueen did not hand over the documents. The judge said his failure to cooperate was likely because of his deteriorating mental health.

Once again, the program terminated its relationship with McQueen. With nofunds to hire a caregiver, the impact, wrote Van de Veen, would have been "profound."

"This would render him virtually unable to dress, bathe, tend to his wounds, tend to personal hygiene or prepare food for himself. Staying in his home could not have been a long-term viable option for Mr. McQueen."

"[McQueen's] tragic reaction to his crisis and emotional disturbances led to his death at police hands," said Van de Veen.

McQueensays goodbye toTempleton

The inquiry heard from 16 witnesses; police, health care workers and Templeton.

Around 4:30 p.m., on Jan.24, 2016, McQueen began shooting into his Huntington Hills neighbourhood from inside his home.

First he hit a bus, shattering the window and causing glass to spray into driver Sean McNabb's face.

McNabb called police while McQueen continued to shoot out the front and back of his house. In 30 minutes, he fired 30 to 40 shots including several that struck an armoured police vehicle.

When Templeton called McQueenduring the incident, he told her his house was surrounded by police.

"I will not go back to hospital. They did not help me," he told her.

Judge's recommendations

McQueen told Templeton not to come over. He then said goodbye and hung up the phone.

Ninety minutes afterMcQueen opened fire, he was shot in the head by a CPS sniper after tear gas forced him out of his home.

An Alberta Serious Incident Response Team investigation found CPS officers' use of force justified.

In an effort to prevent similar deaths in the future, Van de Veen identified four recommendations in her final report:

• Alberta Health Services carry out an independent study to examine the glaring gaps in the mental health system which contribute to police commonly being first responders to people in crisis.
• Expansion of the recent collaborative partnerships attempting to bridge the gap between mental health services and police services.
• Alberta Health Services facilitate access to mental health professionalsin cases involving vulnerable patients like McQueen.
• A liaison be established between Home Care and the Vulnerable Persons Registry to ensure updated contact information of vulnerable people. The police did not have correct telephone numbers when they responded on Jan.24, 2016. Despite their intention to communicate with McQueen, there was no opportunity for police to de-escalate the situation.