Protocol and human error to blame, not ‘inability’ to treat rape victim in French

“One can and should criticize the protocol itself, but this was never a story about an English hospital refusing to serve a patient in French, no matter how irresistibly sexy those headlines might be for the Journal de Montréal.”

A francophone victim of sexual assault in Montreal had to go to three different hospitals before being seen, the Journal de Montréal and La Presse reported last Friday. 

During the sentencing for a rape committed by Martin Jolicoeur in the summer of 2020, Quebec Court Justice Alexandre Dalmau stated the victim was first taken by police to the Montreal General but refused an exam because her mother tongue was French. She was then taken to the CHUM, where she was also turned away because they didn’t have a rape kit. Officers finally took her to the Notre-Dame Hospital, where an exam was finally performed, two hours later.

“Rape victim: the General Hospital refuses her … because she’s francophone” was the headline the Journal de Montréal ran with.  

La Presse ran with a more subdued “Quebec launching an investigation against the Montreal General Hospital,” later updating their original story with more details.

A francophone patient, a victim of rape no less, refused care in Quebec’s majority language, and then shuffled from hospital to hospital? Unacceptable. I can’t fault anyone for being outraged and shocked by such a story. But, as initially reported, the story focused on language alone (unfairly focusing on the Montreal General’s supposed inability to help her and completely ignoring the CHUM’s apparent failure to do so, as well) while too many elements were missing in order to provide important context. The initial reporting wasn’t inaccurate per se, but it was incomplete. And one major element missing was the fact that a long-standing protocol has been in place in Montreal that would have directed hospital personnel to do exactly what they did that night. 

Protocol meant to protect survivors

“In the late 1970s, it was decided that Montreal needed more structure and organization in terms of who was treating sexual assault victims,” explains Deborah Trent, the Executive Director of the Montreal Sexual Assault Centre. “If I’m not mistaken, the initial request came from the police themselves, who wanted to know where to take the victims.” 

Trent says the protocol was a way to “share the load,” a way to ensure that people of different cultural communities and different linguistic backgrounds would have access to services in an environment where they would feel the most comfortable and ensure the services would be provided.

According to her, the regional health board decided that there would be four designated centres in the city of Montreal, and that they would be divided by age (two pediatric hospitals: Sainte-Justine and the Montreal Children’s) and linguistically. 

Since 1996, in the Montreal-Centre region (where the 2020 incident occurred) there’s been a tri-partnership with three organizations: the Montreal General Hospital, the Montreal Sexual Assault Centre and, until this past September, CLSC Metro of the CIUSSS Centre-Ouest. That role has now been taken over by Clinique Medic-Elle.

If you’re over 18, Clinique Medic-Elle treats patients Monday to Friday, 8 a.m. to 5 p.m., except on statutory holidays. Outside these hours, the Montreal General Hospital emergency department is mandated to provide services to English-speaking patients, and the emergency department at Hôpital Notre-Dame to French-speaking patients. 

“This arrangement is well known to all those involved in the management of these cases.” reads a statement from the McGill university Health Centre (MUHC), which oversees the General Hospital.

“That’s the protocol that has been in place for all these years,” confirms Trent. “What was put in place at the end of the ‘70s is still pretty much in place today.”

She says it’s a protocol the SPVM, 9-1-1, Info-Santé and the provincial violence help line are all aware of.

So, how is it that the police officer was not aware of this protocol? Why would he take her to, not one, but two hospitals that were not designated to help her? First to the Montreal General (a bilingual anglophone institution that media reports have all focused on) and then to the CHUM (a francophone institution that also sent her away, but no one seems to be focusing on). Why was the police officer’s failure to follow protocol an almost-forgotten element of the story? 

In a statement issued to CityNews, the SPVM clearly says “the victim was taken to the nearest designated hospital.” 

Only she wasn’t. 

Since they knew the victim only spoke French, they should have known to take her directly to the designated centre, which was Notre-Dame Hospital. 

More questions than answers

So, what actually happened? If a longstanding policy exists that all parties are supposed to be aware of, why did the police officer take the victim to the wrong hospital? Were they “refused” and “turned away” or were they merely redirected as per protocol? Once there, did the hospital incorrectly refer them to the CHUM and, if so, why did the police officer go there, if the protocol clearly indicated where a francophone victim should be directed? As a long-standing designated centre that treats and refers survivors daily, would the General not be aware the CHUM has neither the rape kits nor the expertise to conduct a rape test? No protocol is, of course, immune to human error, but much remains unanswered.

One thing is certain: with linguistic tensions being what they are in this province these days, reporting on a long-standing protocol in such a way so that it’s interpreted by so many as a “refusal” or “unwillingness” to treat someone in French is lamentable. It predictably generated a tirade of anti-English reactions, as if the English-speaking community or English-speaking institutions (which are fully bilingual and treat everyone) have anything to do with a protocol the regional health board implemented 40+ years ago. 

“Outside normal hours (nights, weekends and holidays), it is our duty to inform French-speaking victims that Notre-Dame is the designated hospital,” continues the MUHC statement. “However, under no circumstances do we refuse to treat anyone who prefers to stay at the Montreal General Hospital, regardless of language.” 

Was the patient given the option or not, or did someone fail to inform them? Did the patient and/or the police officer misunderstand the directives given? Did someone at the hospital fail to provide the correct directives? There are many questions to be answered, but what was originally presented as a linguistic issue is quite clearly and fundamentally a protocol issue.

Anachronistic and outdated? 

Is it, perhaps, time to reassess a protocol that was implemented so long ago? 

“There’s no question it needs to be reviewed,” says Trent. “It’s already in motion. There have been efforts in place since this past year to create a committee to look at this, and question if the protocol still makes sense. Like anything, it needs reassessing after so many years.”

Speaking under condition of anonymity, a healthcare worker who works at one of the designated centres told me they also share concerns. 

“Implementing healthcare directives based on language, such as directing English-speaking patients to the MGH and French-speaking ones to Notre Dame, seems anachronistic in the context of our increasingly multicultural society,” they said. “It’s essential that healthcare services remain inclusive, equitable and accessible to everyone, regardless of language preference. This approach could potentially introduce barriers to access, and I’m equally troubled about the possible implications.”

Hal Newman, a former paramedic who writes The Last Ambulance, a blog about the crisis in Quebec’s pre-hospital care system, wrote on Twitter that “the protocol […] has never made any sense and only serves to deepen the sense of violation for rape victims.”

In addition, he told me “ultimately, we need multidisciplinary teams who can provide seamless care for victims of sexual assault and domestic violence.”

The healthcare worker speaking anonymously also said it’s unfortunate when institutions become targets of public disapproval for decisions made at higher levels, which they may have little control over. 

“I worry about the potential backlash these institutions may face,” they said, “despite merely following a given directive; it’s a delicate situation where they may bear the brunt of public discontent while the actual decision-making authority lies elsewhere.”

“The Montreal General has been called to task since Friday and it’s as if they don’t provide service in French,” says Trent, “which is not true. If an English-speaking victim of sexual assault showed up at the Lakeshore or Notre-Dame, they would also be redirected elsewhere.”

If the Montreal General alone has been bearing the brunt of much discontent since the news surfaced last Friday, it’s largely due to the way the story was reported, including sensationalistic headlines. The particular slant presented by the police officer during the hearing didn’t help matters much. 

“Unfortunately, because the woman spoke French, the General decided to refuse her care and decided to redirect us to the CHUM, where they didn’t have a rape kit, and who then sent us to Notre-Dame,” said the police officer assisting the victim that night during his testimony. 

There is an enormous difference between a patient being redirected to the appropriate resources as per a long-standing protocol that aims to provide the best specialized service to the survivor and someone deciding to turn someone away from an institution (making it appear they had a choice) because of the language they speak.

The MGH didn’t decide anything. They followed protocol. The same way the CHUM also followed protocol by redirecting her to Notre-Dame. And while the police officer testified that they were sent to the CHUM by the General, a statement by the MUHC’s general director Dr. Lucie Opatrny denies that. That was also in the original statement provided to media but was never shared by the outlets who originally reported the story.  

“We would like to clarify that the triage nurses in our emergency department,” reads the statement, “are all well aware of the long-standing entente of many years that specifies that Hôpital Notre-Dame is the designated centre providing care at night and during weekends and statutory holidays for victims of sexual abuse who speak French. As such, a patient would not be redirected to the CHUM by the MGH. Furthermore, the MGH ER does not refuse to provide care if patient wishes to stay at the Montreal General Hospital.”

Not language discrimination 

The medical professionals I spoke to say the protocol is not language discrimination, but rather a directive that aims to ensure better quality of care for the patient. A sexual assault exam is very delicate and traumatic, so efforts are made to ensure that its conducted in the language of the victim.

“Dividing the work across four hospitals that could develop, over time, proper expertise is an important part of the vision of providing this service,” explains Trent. “We want these centres to have specific expertise and knowledge. You don’t want to spread it out, you want to concentrate it.”

Healthcare workers treating victims have received training and developed expertise that makes them able to understand the issues and trauma that someone who has been sexually assaulted is going through. “They are able to understand what it means to press charges,” she says. “They have the knowledge and training to be able to gather forensic evidence properly. This is a legal tool if the victim decides to press charges, so it has to be gathered appropriately so it can be presented in court. If it’s gathered inappropriately, then it’s not useful. If the person is going to share difficult things with you, you want to make sure that person can do so in the language they are most comfortable with.”

Much has also been made about the CHUM not having rape kits, and while the shortage of rape kits has indeed been a longstanding documented issue for years across Quebec, and across Canada, in this particular story their presence or absence was irrelevant. 

“If that second hospital was not a designated centre,” says Trent, “they would not be able to do the intervention. Whether or not they had rape kits (and they shouldn’t have any since they can’t administer them), it didn’t matter. Rape kits are not in all hospitals. They are only in designated centres.” The CHUM would later confirm that in a statement. 

“If you’re taken to an emergency room and you need care because you’re injured, then of course you should be treated,” says Trent. “But this is a specialized intervention. If you were badly burnt, not all hospitals have a burn unit. Designated centres are the same thing. It’s not about checking a box. It is about the whole intervention that is looking at a total person. A person who has emotional needs, medical needs and has forensic-evidence-gathering needs. And in order to check that box, you have to know what you’re doing.”

Trent says they’re used to fielding questions from across the province because people are trying to ensure they fill out the forms properly, so they don’t compromise an investigation if charges are levied against the aggressor. 

“It’s not appropriate to say, ‘Anybody can do it.’”

The difficulty is also amplified by the challenge of finding people willing to work in the field. “We have to make sure we have enough people to cover a 24/7 basis, make sure we have councillors and psychosocial help on call,” says Trent. “Is it easy to achieve? No. It’s tricky. It’s hard. We have to make sure they’re trained, and not everybody wants to work on call. It’s not an easy job. You’re sometimes on call for 16 hours. It’s hard work and people can’t do it forever. We have to constantly ensure we have enough people.”

Trent doesn’t understand why the victim was not taken directly to the designated centre that corresponded to her language, but doesn’t rule out human error. 

“Police should know this,” she says. “Is there more work that needs to be done to ensure everyone knows? Yes. Does it happen? Are people not directed to the right place? Or do people just walk in because something happened to them and it’s their neighbourhood hospital but not a designated centre and they’re redirected? Of course. I think it happens periodically, and if someone was poorly directed, we make sure to follow up with whomever directed them, so they understand the protocol, so it doesn’t happen again. Do we need to do more work on making sure that the proper message is out there? Yes. Do we have to repeat it all the time? Yes. Because new people come into triage, new ambulance drivers, so it has to be repeated over and over again.”

Prioritize the sexual assault survivor

The MUHC has launched its own internal review. In the meantime, the OQLF is investigating the “availability” of French services at the General.

It’s hard for me to understand what exactly the OQLF is investigating when the protocol has been in place and in clear sight of everyone for the better part of 40 years. “All Quebec hospitals should be able to offer care in French,” stated Minister Jean-François Roberge, even though there is nothing indicating an unwillingness or inability to offer care in French, only steps taken to follow the protocol. The Montreal General acted in the exact same way the CHUM did. This was never a language issue, but a problematic protocol applied incorrectly that unnecessarily retraumatized the victim.

“It’s unfortunate and disappointing that elected officials are making this about defending French supremacy instead of defending survivors,” Marlihan Lopez, cofounder of Harambec (a Black feminist advocacy organization) and Community Outreach and Engagement at the Simone de Beauvoir Institute at Concordia told me. 

“Survivors face so many barriers to accessing health and social services. The experience this francophone survivor had is unacceptable, and revictimizing at a time where they needed support. The reality is anglophone minorities in Quebec that are survivors also face barriers accessing these services on the daily. If they are Black, Indigenous, of colour, trans or disabled — a member of other underserved groups — they also face other systemic barriers to getting support services.”

Yet, the way the story was framed as a language story directed the way the story was researched, and the sources contacted. The president of Impératif français and the président du Mouvement Québec français were approached, as if the hospital had maliciously withheld treatment in French and it was not a pretty obvious case of someone (or several people) dropping the ball. 

The real questions to ask, are, Is this really the best protocol? How do we best serve all victims of sexual assault in Quebec, regardless of language? In a majority francophone province, shouldn’t all designated centres ensure that French-speaking victims are seen? Should police officers require more training, so they actually know where to take victims and not schlep them from institution to institution, making an already traumatic experience even more traumatizing and exhausting? 

If a rape victim in Quebec is shuffled from hospital to hospital to hospital due to a protocol, the protocol needs to be reassessed. One can and should criticize the protocol itself and I’m sure more will be revealed as multiple investigations unfold. But this was never really a story about an English hospital refusing or being incapable of serving a patient in French, no matter how irresistibly sexy that story might be for some. ■

Read more weekly editorial columns by Toula Drimonis.