Broken, fragmented health-care system failed daughter who died by suicide, family of Taylor Pryor says

It was on a clear and warm autumn day in 2018 that Taylor Pryor's life began a spiral toward a tragic end.

She collided mid-air with a fellow soccer player both jumping for the ball during a game with the women's soccer team at the Canadian Mennonite University in Winnipeg.

Taylor didn't lose consciousness, but she sustained a concussion. Soon, everyday tasks became a struggle.

"We knew things weren't right. She wasn't the Taylor we knew," said her mother, Darseen.

"She was there, but she wasn't there. She had a vacant look on her face."

Severe concussion symptoms anger, sensitivity to light and lack of concentration soon began to surface, her family said.

About four months later in February of 2019 she made her first suicide attempt.

In the months that followed, Taylor saw at least 13 psychiatrists and five other medical doctors. Often she waited hours to be seen in one instance it took 70 hours as she was bounced between three different facilities until she was finally admitted. She attempted suicide at least 22 times.

On Oct. 17, 2019 she was discharged against her wishes from Victoria Hospital. She went missing and two days later, searchers found her body in a treed area a short walk from the hospital.

The 21-year-old was mere days away from being admitted to a long-term program.

"I am still having a hard time believing this happened," said Darseen. "I am in disbelief that it did and how she was treated. I was just appalled."

She and Taylor's father, Doug Pryor,say there was no co-ordination or continuity of care, medical staff at times contradicted each other, and a community support plan put in place the last month Taylor was alive wasn't followed.

The family said they decided to come forward with their painful story in hopes of preventing others from falling through the cracks in the medical system like Taylor did.

"I have frustration and anger to how Taylor was treated. It just breaks your heart. She wasn't treated as a person. She was treated as an illness," said Doug.

"We need accountability for what went on," said Darseen, and "some answers as to why this happened."

Happier days

Taylor's family, including her two sisters, describe her as a fun-loving ball of energy who was enthusiastic about life and people. Those close to her say she was a "mover and shaker," someone destined to make a difference.

One video in particular captures what family and friends say was the essence of Taylor a woman of deep faith on fire to change the world.

Filmed while she was doing missionary work in Guatemala in 2017 through the Canadian Mennonite University's Outtatown program, it shows Taylor inviting people to worship as she testifies to her faith.

WATCH | Taylor Pryor talks about her missionary work in Guatemala:

Taylor Pryor in Guatemala

5 years ago

Duration 0:55

Taylor Pryor on her missionary work in Guatemala in 2017. Video courtesy: Jay Siemens

Taylor was taking courses in international development in 2018, with a dream of improving the lives of people and children who were poor and outcast.

But that drive, and her outgoing personality, changed after her concussion.

"We started to see things like anger really come out of her. Her personality changed and so did her language. This was not our daughter," said Doug. "She wouldn't hurt a fly."

Taylor also experienced lethargy, double vision and was having difficulty hearing.

A doctor from Sport Manitoba advised Taylor to stay out of classes for three weeks, and to stop playing sports, driving and using computers.

But she continued to have trouble sleeping and was plagued by headaches. Her life unravelled as she found she couldn't keep up with her studies.

Repeated admissions

In February 2019, Taylor was rushed to Grace Hospital by ambulance from her university residence after a suicide attempt.

After a 17-hour wait, she was transferred and admitted to the psychiatric ward at St. Boniface Hospital.

It was her first admission for an attempted suicide.

She spent two weeks on the ward, before being released and going back to university.

The family decided it would be best for one of them to relocate from Portage la Prairie, Man., to live with Taylor in Winnipeg, to make sure she was safe. Darseen rented an apartment and moved in with Taylor. They got her a dog.

But weeks later, Taylor was forced to drop out of university because she could no longer function or keep up.

Over the next six months, she would be admitted another 13 times at three different hospitals: Victoria, Health Sciences Centre and St. Boniface. Darseen says there were multiple instances when Taylor was restrained, sedated or isolated because she was showing aggressive behaviour.

"She would get violent but it was only in retaliation of what they would do to her wrestle her and hold her to give her a shot," said Doug. "The first thing you would do is defend yourself."

There were also six visits to the Crisis Response Centre, a 24-hour facility for those in mental health crisis.

During it all, at least 13 psychiatrists and five other medical doctors were involved in her care, her family says. And in many instances, she waited hours to be seen, likely because Taylor wasn't classified as a medical emergency, like someone having a heart attack might be, the family says.

In one instance, she had a 70-hour wait between three different care facilities before being admitted into care.

There were many times they would release her and within 24 hours she would be back in the hospital or attempt suicide, or I would call 911.- Darseen Pryor

Those long waits caused Taylor's agitation to escalate, Darseen says.

Waiting in noisy, chaotic ERs was "pretty brutal," she said and staff seemed solely focused on settling Taylor down and sending her home.

"But that didn't work for Taylor. There were many times they would release her and within 24 hours she would be back in the hospital or attempt suicide, or I would call 911."

In one incident,Taylor's sister saved her during a suicide attempt after she left from St. Boniface ER.

In another instance in August of 2019, a passerby found Taylor lying in the middle of the road on William Avenue after she was discharged from the Crisis Response Centre. Police picked her up and took her to the Health Sciences Centre ER.

No plan

Such transitions between units, facilities and from facility to home can be quite risky, said Laurie Thompson, executive director of the Manitoba Institute for Patient Safety.

"Those are points in care we really need to pay attention to in terms of supporting that family and that patient, so they are safe," she said.

Continuity of care is "absolutely critical" to patient safety, said Thompson. Not only does it build confidence between patients and their families with the health care team, it can ensure patients get treated faster and better because medical teams aren't repeating treatments that didn't work. It can also save lives.

"People fall through the cracks. And that appears to be what happened in this situation," she said.

"We didn't even see continuity in the same hospital," said Doug. "On one admission she would have a doctor who would have her meds up here. And she would come in a week later and be admitted again, and the doctor would say no, that it needs to be this and then a different doctor would change it again."

While Doug and Darseen say there were several well-intentioned nurses and doctors in the system who were genuinely committed to helping Taylor, there was one psychiatrist in particular who they believed actually caused more harm than good.

That's why she was in the hospital. She didn't trust herself. She needed protection from herself and they didn't protect her.- Doug Pryor

They say the psychiatrist told them in the presence of a hospital employee that Taylor "needed a place to deregulate, and that place would be jail."

"I was dumbfounded," said Darseen, who herself has worked for almost 30 years as a nurse in health care, including in emergency departments."I honestly had no words for what I was hearing."

That psychiatrist also suggested Taylor may have borderline personality disorder, but there was no consensus. Other psychiatrists were convinced she was severely depressed and anxious.

More than once the family said they were told by health-care professionals that Taylor was responsible for her own safety.

"You have a person who has received a head injury and they aren't thinking correctly. How can they keep themselves safe?" said Doug.

"That's why she was in the hospital. She didn't trust herself. She needed protection from herself, and they didn't protect her."

WATCH | Doug and DarseenPryorsay their daughter lost hope she would get the help she needed:

'Could it have been prevented?'

5 years ago

Duration 0:57

Doug and Darseen Pryor believe their daughter Taylor would be alive today if not discharged from Victoria Hospital in October 2019.

Thompson agrees.

"What we say is everybody is responsible for patient safety. It is not solely up to the patient, in my view. It's a partnership, a team."

The constant stress of not knowing whether Taylor was safe, and where she was, "was just devastating for us," said Darseen.

She and Doug also grew frustrated with the unwillingness of some health-care professionals to share information about Taylor.

"Some were really good, and some [were] just, like, 'We can't do that. We can't give you that information because she is 21. I will have to ask her.'"

They had meetings with members of her medical team at hospitals to discuss her care, and say they felt alienated at times.

"We almost felt like the enemy in some cases," said Doug. "We wanted to help but we didn't feel always invited into that circle to be part of her care."

Last discharge

Taylor's family says the fragmented care sent a devastating message to her. The more people she saw, and the more often she had to tell her story, the worse she got.

She was hanging onto the hope that she might get admitted to the Selkirk Mental Health Centre for dialectical behavioural therapy a type of psychotherapy aimed at helping patients regulate emotions and deal with harmful behaviours.

Though the family was warned about long waits for the program, Liberal MLA Jon Gerrard helped them get an earlier admission reducing a six-month wait to two.

Meanwhile, a community support plan was finally drawn up in September of 2019. Victoria General Hospital urgent care was designated as the place Taylor would be taken in crisis, and she was assigned a psychiatrist and nurse therapist there.

Her parents say they were relieved there was finally a plan in writing but it wasn't followed.

"When we would call paramedics, they would tell us that [Victoria Hospital] was not in their region. 'We have to take her to the Grace,'" said Doug.

On Oct. 16, 2019, Taylor was taken to Victoria hospital for the last time. It was almost a year after her concussion. She was seen by psychiatry and kept overnight.

Later on the 17th she was discharged even though her family said Taylor did not want to leave. She was four days away from being admitted to the Selkirk treatment centre.

A social worker stated that Taylor was 21 years old and was free to go without her mother, Darseen says. Taylor walked out and scaled a fence on Pembina Highway, between Markham Road and Thatcher Drive.

Her mother tried to follow in her car, but lost sight of Taylor when she went into a wooded area at the University of Manitoba.

It was the last time she saw her daughter alive.

She wanted to live. She wanted to go to Selkirk. [But she] was at the end of her own self.- Darseen Pryor

Over the next two days, police along with members of the community, the Pryors' church and the university scoured the area for Taylor.

"It was a parent's worst nightmare," said Doug. "To lose your daughter and not know if you are going to find her or not to find her alive or not."

Her body was found by one of the searchers.

The Pryor family believes Taylor would be alive today if she had been kept at Victoria Hospital for the four days before she was set to be admitted to the Selkirk treatment centre.

"She wanted to live. She wanted to go to Selkirk," said Darseen, but her daughter "was at the end of her own self.

"There are many times we would hear her cry out, 'I can't do this anymore. I can't do this anymore.'"

Who is responsible?

The Pryor family blames an underfunded health-care system that they say is profoundly broken, with departments and wards operating in silos.

"And the sad part is, Taylor is not the only one. There will be more Taylors," said Doug.

There have been similar cases in the past, too.

As they were trying to get help for Taylor, the Pryors connected with the Bricker family, whose son Reid died by suicide in October 2015, shortly after being released from the hospital he went to for help. It was the third time in 10 days Bricker had been discharged from a Winnipeg hospital following suicide attempts.

In a written statement sent to CBC, the Winnipeg Regional Health Authority says its quality improvement and patient safety program is currently conducting a comprehensive review of Taylor's case.

"All aspects of Ms. Pryor's care are included in the review process," the health authority said. "Ms. Pryor's death is a tragic and devastating loss and our sympathies continue to be with her family and friends."

She was a world-changer. And even though she isn't here with us right now, she will continue to change this world so others won't have to suffer the way she did.- Doug Pryor

But Doug and Darseen think Taylor's death should be investigated as a critical incident.

Under Manitoba legislation, a critical incident is when a patient dies or is seriously harmed by an unintended issue related to their care in hospital such as mistaken medication dosages or breakdowns in communication resulting in serious harm.

Doug and Darseen met with the patient relations officer at Victoria Hospital. They obtained medical records from them, as well as St. Boniface and the Grace. They are still waiting on documentation from HSC and the Crisis Response Centre.

They have also met with the head of patient safety and quality improvement with the WRHA and plan to meet with an independent psychiatrist who can help them understand what happened in Taylor's last couple of days, and other incidents leading up to it.

The family also sent a written request to the Office of the Chief Medical Examiner, asking for an inquest into systemic issues such as why patients with a history of suicide attempts are stabilized and released with no where safe to go, why effective treatment approaches aren't available in a timely manner all in hopes of preventing a similar death in the future.

In December, Manitoba Health Minister Cameron Friesen reached out to the Pryor family, saying he wanted to hear about what changes they recommended. They met with him in January.

While their faith in the health-care system has been shattered, they have a new glimmer of hope that the system will be changed -- and that Taylor's life-long mission of making a difference will be realized.

"We believe Taylor is going to continue to change this world. That is what she wanted. That's who she was," said Doug.

"She was a world-changer. And even though she isn't here with us right now, she will continue to change this world so others won't have to suffer the way she did."

WATCH | Marianne Klowak's report on Taylor'sstruggle:

'It was a parent's worst nightmare'

5 years ago

Duration 4:12

Broken, fragmented health-care system failed daughter who died by suicide, family of Taylor Pryor says.

If you're experiencing suicidal thoughts or having a mental health crisis, there is help out there. Contact the Manitoba Suicide Prevention and Support Line toll-free at 1-877-435-7170 (1-877-HELP170) or the Kids Help Phone at 1-800-668-6868. You can also text CONNECT to 686868 and get immediate support from a crisis responder through the Crisis Text Line, powered by Kids Help Phone.