On September 26, 1995, Zdravko Pukec gained the distinction of being the first person on Canadian soil to be asphyxiated by pepper spray. The debate continues regarding the effectiveness of pepper spray as an alternative restraining measure, and periodically the fatalities are paraded in the media. Those opposed remember the dead, and those who support the deployment of pepper spray point to all the people who have been saved because law enforcement officers didn’t have to shoot them. I want to sidestep the debate and treat Mr. Pukec’s death as a failure of Ontario’s mental health regime. Pukec had wits enough to survive the horrors of a civil war and ethnic cleansing in his native Croatia, yet he didn’t have the wherewithal to survive a psychiatric facility in Whitby, Ontario. Pukec would have been better off living as a contemporary of Charles Dickens when mental illness was criminalized; then, he would only have been beaten from time to time. Now, as we approach the 11th anniversary of his death, it is important to remember the brutal circumstances of his death, to ask why no psychiatric health care providers nor law enforcement officers were called to account, and to hope that things have improved.
Why should I care? Two reasons: 1) Zdravko Pukec was a client, and I had the pleasure of interviewing him just as he was slipping into that soundless chasm that yawns between the criminal justice and mental health systems; and 2) in an irony of the sort that seems to characterize my life, I found myself an in–patient in a psychiatric facility on the day that Pukec was killed. When I read of his death, I was powerless to respond.
In the year before Zdravko’s death, I had been practising law in north Toronto. He had an aunt living not far from my office. She had been living and working in Toronto for 28 years and she had sponsored her nephew so that he could flee his homeland without having to go through the more trying procedure of seeking refugee status. She contacted me and advised that Zdravko had been struck by a car while crossing a street in Kitchener, about an hour west of Toronto. The province had implemented a new no-fault auto insurance scheme, and Zdravko’s aunt was concerned that he had not received adequate compensation. I asked why Zdravko hadn’t called me himself. She explained that the boy’s English wasn’t very good, and besides, there was this other matter … Since his recovery from the accident, Zdravko had gotten into some trouble and so couldn’t speak on a telephone or come to my office. And then, bit by bit, the whole story came out.
Some time after the accident, Zdravko had been walking through a mall and started following a woman who was carrying a large purse over her shoulder. He grabbed the purse and ran, but mall security staff cornered him. He was desperate. He believed that the purse contained a tiny computer (Mac minis hadn’t been invented yet) and was sending signals to his brain, trying to get him to do things he didn’t want to do. He had snatched the purse so that he could destroy the computer and silence the messages that were entering his brain. At his first court appearance, it was apparent to the presiding judge that things were askew in Zdravko’s thinking, and so the judge ordered a thirty day remand to determine fitness to stand trial. Zdravko was shipped off to METFORS (Metropolitan Toronto Forensic Service) which stood on the grounds of the former Queen Street Mental Health Centre in Toronto (now CAMH), and so began his descent into a hell that few of us can ever imagine. I quizzed the aunt: “These things don’t just happen all of a sudden,” I said. “There must have been symptoms before this.” The aunt said that, yes, sometimes he had conversations with the fridge, but it hadn’t struck her as a serious concern because he was otherwise well–behaved, a real nice boy.
I couldn’t very well investigate his accident claim without an interview, so I drove downtown with the aunt and conducted my initial consultation. I was stunned by what I encountered. The holding facility was on the fourth floor of a five–story concrete cube. (The building has since been demolished.) Outside the elevator, there was nowhere to go but to a single reception window. I presented myself to a guard sitting on the other side. I offered my business card and driver’s license with photo ID. After looking at my driver’s license, then looking at me, he pushed a button and I could hear a lock release. Zdravko’s aunt and I passed through the door and sat in a reception area. “That was easy,” I thought. But that was only the beginning. The guard sent a message to the ward and we waited while Zdravko was taken to an interview room. After nearly twenty minutes, two armed guards appeared through another door. They would escort us upstairs. When I passed through this next set of doors, I stopped and gawked. I was standing on the fourth floor, but could look to the roof of the fifth floor. Most of the building was empty except for metal caging. Our escorts led us through a locked door in the caging and up a set of metal steps to a catwalk. We were now on the fifth floor and gazing down into this cavernous space. At the far end of the catwalk was a metal door and beyond that another metal door, and then a tiny ward that housed twenty or so “patients.” With so many secured doors, and armed guards and precautions, I was prepared for the worst. Once the final doors closed behind us, the guards disappeared and we were left to fend for ourselves. “Fend” is the wrong word. A couple men, one in jeans and the other in pajamas, approached, they smiled and said hello and asked how we were. I felt like I’d passed into another dimension, or had fallen like Dr. Who into an alternate universe. Everybody smiled pleasantly, happily, psychotropically. Why, I wondered, was the facility so secure when all the in-patients were so docile? With such bliss, who would ever muster enough gumption to escape?
Eventually, a nurse led us to a narrow room, bare except for a couple of simple tables and some chairs. Zdravko was waiting for us, perched on one of the tables with his back wedged into the corner. He was young, twenty-four, with dirty blond hair that had grown long. There was a sparse growth on his face. He smiled and said hello and seemed to be in good humour. Other reports say that he didn’t speak English. That isn’t entirely true. He spoke passable English, but his accent was thick. With help from his aunt, we were able to converse well enough and stumbled only at one point. I was trying to get Zdravko to set up the accident for me, tell me what he’d been doing beforehand, tell me where he’d been standing, what direction the car had been coming from. There had been a stoplight a little further down the road. Why didn’t he walk to the corner and cross at the lights? Then I asked my question: why did you cross the road? (Like the setup for a bad joke.) He answered: “Because of ze viches.” “Ze viches?” What the heck are viches, I wondered. I turned to his aunt for help. She looked at me like I was a moron. “You know. Ze viches. Zey fly on brooms.” Then I understood. Witches had called him from the other side of the road. They had tricked him and he stepped into the path of an oncoming car. It was while he was recovering from his injuries that he developed the notion that there were wires implanted in his brain and controlling his actions.
After the thirty day remand had expired, the attending psychiatrist completed a form 14 under the old Mental Health Act (committal papers); it was clear that, in his present condition, Zdravko could not be released into the general population. He seemed like a nice enough person, but he was unpredictable. From METFORS, they shipped Zdravko to a psychiatric ward in London, Ontario. A few months passed and then I got another call from his aunt. Zdravko had gone blind. She was convinced the psychiatrists had given him the wrong meds. All these powerful psychotropics had made him blind. She asked me to investigate. I phoned his psychiatrist in London and asked what was going on, and he advised that Zdravko had retinitis pigmentosis. Both my cousins have retinitis pigmentosis, so I realized immediately that this had nothing to do with mental health issues or meds. For Zdravko, blindness was inevitable and unrelated to his other health issues. Zdravko’s aunt would have none of it. I hate phone calls like this. I had to tell her about the diagnosis and what it meant, but she was not prepared to listen to me. I was a lawyer, not a doctor. I would have to sue them for making her Zdravko blind. She was inconsolable, so I let her yell and scream until she had nothing left to say.
There was little more I could do for Zdravko Pukec. In the circumstances, the accident compensation had been reasonable. As for his mental health, well, that was unfortunate. And the retinitis pigmentosis? A damn shame. But, really, what had that to do with me? Or me with it? So I let the matter pass.
That winter, things did not go well for me. Work was stressful. Lingering concerns had reasserted themselves. Increasingly, I found it difficult to get moving in the morning. I couldn’t concentrate. Sometimes I was filled with rage, and then the rage would dissipate into a profound sadness. Yet everything I felt struck me as utterly disconnected from the circumstances of my life. Every week, things got worse. I stayed indoors. I wanted nothing to do with other people, not even with my own children. There is a point in clinical depression when you find yourself weeping for no reason at all, when you are overcome by immeasurable grief and all for nothing. But there is a point beyond this. Your emotional life becomes so profoundly thwarted that you feel nothing at all. There is simply nothing. At that point, I was confronted with a choice: either go to a hospital, or let a psychiatrist sign a form 14 and force me to go to a hospital. I could not believe this was happening to me. I was the person who had it all together. I was the person everybody else relied on. I was the person who always gave strength to everyone else. How could I be the needy one?
I spent most of the fall of ’95 in a psychiatric ward, gradually crawling out of the hole I had fallen into. It was between admissions, in the first week of October, that I read the article, really only a paragraph: Zdravko Pukec had been killed. It was on about page 27 in the newspaper. Ignominious. Trivial. A footnote in someone else’s debate.
From what I understand, Zdravko had sensed the onset of a psychotic episode and so had advised the staff at the Whitby facility. (What does a psychotic episode look like to a blind man? Did Zdravko not wonder at the irony of it all? That in blindness, he could have his vision, but only the vision of a certain sort?) The staff managed to effect partial restraint, whatever that means, then called police for assistance. A coroner’s inquest cited as his cause of death: “cardiac arrest associated with acute psychosis, physical restraint, positional asphyxia, exhaustion and stress due to pepper spray.” But I have a theory. I think the real cause of death was an equal measure of ignorance and stupidity—ignorance in assuming that Zdravko’s mental illness somehow gave permission to treat him cavalierly, and stupidity in failing to ask if this was an appropriate situation for the application of pepper spray.
Here is how I think death occurred. When the police officers arrived on the scene, the Whitby staff had already managed to restrain some, but not all, of Zdravko’s limbs. He did not pose a danger to anyone else (because at least one limb was already restrained); this negated the need for pepper spray. The staff told the police officers they needed to subdue the patient. The key word is “subdue.” I conjecture that the police officers assumed that pepper spray functions the same way RAID functions when you spray a wasp. If the wasp is still twitching, you keep spraying until it stops twitching. But pepper spray is not toxic. There is no active ingredient, as there is in RAID, which will “subdue” the person being sprayed. Pepper spray doesn’t “subdue” anything. Pepper spray induces a reflex: hands go to the eyes and so can’t be used to hurt anybody. But if the behaviour you are trying to control is thrashing, there is only one way to end the thrashing, at least only one way with pepper spray, and that is asphyxiation. It wasn’t pepper spray which killed Zdravko, but it’s persistent application. This is only a theory and I have no way to confirm it, but I think it’s a reasonable theory.
Although I didn’t talk about it with anybody, I took Zdravko’s death quite personally. The police had killed one of us, and for no good reason that I could discern, except the obvious one—he was different, he was strange, he needed to be controlled. In the year following Zdravko’s death, I had three more hospital admissions, each for more than a month, and then I decided that I had had enough. I knew I would never need to return to a psychiatric ward. One day I caught myself wandering from room to room, sitting down and chatting with the other people on the ward, listening to their stories, reaching beyond myself and acknowledging that my reality—which only months before had shrunk to a point of nothing—was only as large as the due I gave to those around me, especially to those who seemed different or strange, especially to those who seemed most out of control.
Photo Credit: US Department of Defense – Public Domain