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"I have personally been troubled and saddened by the treatment and living conditions that some of these patients suffered through. In reflecting on everything that I have witnessed, I cannot arrive at one unique point of failure," she said in the report, focusing primarily on the Restigouche Hospital Centre, which provides specialized mental health care in northern New Brunswick.

Both of the province's health networks 鈥� Horizon and Vitalit茅 鈥� used restraints for patients but neither of them had a way to monitor the practice, she said. The investigation identified incidents across both networks in which staff restrained patients for long stretches of time, and didn't always document the use of restraints in patient files. As well, staff did not document how decisions on the use of restraints were made.

In 2019, Charles Murray, the province鈥檚 ombudsperson at the time, found serious problems, including negligence, abuse and unacceptable treatment at Restigouche Hospital Centre. Following Murray's report, a $17-million class-action settlement was approved by the Court of King's Bench in 2023.

In the report released Tuesday, Pelletier included stories from patients who were restrained or placed in seclusion rooms 鈥� described as bare spaces with beds equipped with physical restraints 鈥� at the Restigouche hospital. Their names were changed in the report.

One patient named Francine was admitted in December 2021, and "had been in physical restraints without appropriate interventions and left laying soiled in her urine for an extended period."

The report said the seclusion rooms at the Restigouche hospital have frosted windows and fluorescent ceiling lights that can be turned off or on from outside the room. They have no toilets or sinks. They have a camera, and patients are told to wave at it to get the attention of staff.

However, the report said patients were left in unsanitary seclusion rooms without the means to contact staff.

Adam spent 12 days in a seclusion room in August 2022 at the Restigouche hospital.聽

"He alleged staff sexually assaulted him by pulling down his pants while he was physically restrained in the seclusion room and conversed casually among themselves in French during the intervention, a language he does not speak," the report said.

"Video footage shows Adam urinating at least 20 times and defecating into a cup inside the seclusion room because he was not provided an opportunity to use a toilet."聽

The incident was referred to the RCMP, although no charges were laid, it added.

The report noted patients trying to get attention of staff by yelling, banging on the door, writing 鈥淗elp Me鈥� with pieces of Styrofoam cups or with marks of water on the mattress.

Pelletier's investigation was prompted by 12 complaints from 11 families and patients at the Restigouche Hospital Centre, and was expanded in January 2023 to review the use of restraints in all psychiatric facilities across the province. She said in her report that the practices are a result of collective failure of an entire system that is "under pressure."

"It is also the failure of a society where those who suffer from severe mental illnesses continue to be stigmatized, marginalized and misunderstood."

Pelletier made 21 recommendations and stressed the need for better data collection in the use of restraints and seclusion rooms.聽

"If there's better data available about the use of restraints and seclusion rooms made available publicly, then everybody will be able to to decide for themselves whether or not these practices are improving or not," she told a news conference Tuesday.

Robert McKee, minister responsible for addictions and mental health services, said the health system has already changed the way it operates, including with better training, updated protocols, and closer monitoring of the use of restraints.

S茅bastien Lagac茅, associate vice-president of mental health and addiction at Vitalit茅 Health Network, called the situation at the Restigouche centre "unacceptable" but stopped short of an apology. The health network will accept Pelletier's recommendations in full, he said.

"To those who have experienced these situations, we wish to express our full consideration and our firm commitment to bringing about lasting change," he said in a statement. 聽聽

This report by 好色tvwas first published Sept. 23, 2025.