She was restrained by hospital guards and later died. A security camera was 'purposely turned' as it happened

Six months since her sister's life was cut short after being restrained by security guards at a Toronto hospital, Denise Warriner says she's haunted by an image she can't unsee. 

That image, contained in surveillance video from Toronto General Hospital, was gathered as part of an investigation by Ontario's coroner and has not been released to the family or the public. But after months of demanding to see it, Warriner finally did.

A coroner's report obtained by CBC News reveals Stephanie Warriner had been "sitting calmly" in the hospital's lobby when a group of guards approached, and that a security camera was "purposely turned away" for more than two minutes as the guards restrained her.

The next time Stephanie appears on camera, she's unconscious.

"She's in a transport wheelchair and she is completely dead weight. She's slumped," Denise Warriner told CBC News.

"She's so tiny and her legs are dangling, and as they're pulling the wheelchair down this hallway to Lord knows where... her feet are just bouncing off the floor."

Stephanie, 43, died in hospital 16 days after the incident. It took 11 days for the hospital to contact her family, who had believed at the time that Stephanie, who struggled with bipolar disorder and substance abuse, was missing. 

Now the coroner's report is raising more questions about what happened to Stephanie, and what should happen next. Toronto police continue to investigate, and as previously reported by CBC News, two staff were let go in the wake of the incident with two others disciplined. But Warriner wants to ensure what happened to her sister never happens to anyone else.

"There's no words to encapsulate the heart-wrenching pain of observing someone you love have the life taken out of them," Warriner said. "And I think about, 'Did she know this was the end?'"

'Loved hard and cared deeply'

Stephanie was the younger of two sisters — sensitive, spunky and wore her heart on her sleeve. But over the years, she struggled with substance abuse and was diagnosed with bipolar disorder. She also suffered from chronic obstructive pulmonary disease or COPD, associated with smoking. 

In March, after a break-up, she found herself living in a shelter. Then, in April, Stephanie was diagnosed with COVID-19, leading to a series of admissions to Toronto General. At the time of her death she weighed just 125 pounds. 

"She had her battles, but at the core, she was a really sweet, kind, loving, quirky, off-the-beaten path, artistic woman who loved hard and cared deeply," Warriner said.

According to the coroner's report, after a series of negative COVID-19 tests, Stephanie returned to the hospital on May 10 with a cough and shortness of breath, and also appeared confused.

Seconds after interaction began, camera moved

On May 11, she left the emergency department to get something to eat and was sitting "calmly" in the lobby at 6:38 a.m. when she was approached by several guards, one of whom confronted her "from up close," resulting in a yelling match, according to the coroner's report.

"This female guard then forcefully lifts her out of the chair into a standing position before walking her a few feet over and forcing her face first with a lot of strength against a wall," says the report, which drew from witness statements, a police summary and a human resources investigation by the hospital.

Another guard then steps in, the report says, and the two wind up on the floor with Stephanie.

What happens over the next two-and-a-half minutes isn't captured on camera.

"Details surrounding this part of the altercation are unclear as the video camera had been purposely turned away at 6:38:34 a.m. by another security guard who was watching," the report says.

One guard reportedly attempts to put Stephanie "forcefully" into handcuffs as she kicks and screams "before she was lifted up from the floor in the standing position described as 'dead weight' and transferred into a wheelchair, where she is noted to be blue and unresponsive," the report continues.

The security footage resumes at 6:41 a.m., showing Stephanie in a wheelchair being pushed into a service elevator. She is resuscitated, the coroner notes, but because of an approximately 10-minute "downtime," she develops a brain injury from which she never recovers. 

The report concludes Stephanie died from a brain injury resulting from a lack of oxygen "due to restraint asphyxia following struggle and exertion," with her underlying COPD a possible contributor. The combination of pressure to her chest, while lying on her stomach along with exertion during the incident could have led Stephanie to stop breathing, the document continues.

No clear way to label deaths like Stephanie's, coroner says

The report goes on to say there is "no national consensus" on how to classify restraint-related deaths involving law enforcement. 

While some recommend they be deemed homicides, others suggest categorizing them as "undetermined" particularly where multiple contributing factors might exist, the report says.

The manner of death in Stephanie's case, it concludes, is "undetermined."

As first reported by CBC News in July, two hospital staff were let go as a result of the incident and two others were subjected to "internal disciplinary action."

A spokesperson for the University Health Network (UHN), of which Toronto General is part, would not say whether the four employees were security staff or medical professionals, or specifically what form of discipline they received. 

"This matter is under investigation by the Toronto Police Service and we are co-operating with that investigation, as we did with the Coroner's Office," UHN spokesperson Gillian Howard told CBC News, adding results of all investigations are shared directly with patients or someone designated as their decision-maker. 

"UHN does not comment on individual patients, nor on matters of individual employment," she added.

As for the police investigation, Denise Warriner says she has not received an update from the Toronto Police Service since Oct. 28, and has yet to hear whether any charges will be laid.

"There needs to be a message sent that use-of-force cases are not going to be ignored, that there is accountability," she said. 

'Where is the humanity?'

In July, a spokesperson for Toronto police said investigators were awaiting the results of a full autopsy and that the case was in its early stages. 

Asked for an update on the case, spokesperson Connie Osborne said, "We have received the Coroner's findings and will review any comments or recommendations as part of our ongoing investigation."

Meanwhile, for Stephanie's family, it's the little memories that bring comfort amid their grief — like her fierce concern for an elderly person or special needs person on the bus or train, who needed a seat.  

"I saw this lovely, very pregnant woman, and did you know that nobody moved for her?," said Warriner, recalling how Stephanie would ask people to move if they wouldn't give up their seats for those who needed them. "I don't understand why people don't see that," she would say.

"She had a heart," Warriner recalled.

It's that type of heart that she wishes the guards would have shown the day Stephanie was restrained.

"Dealing with a challenging population every day could weigh on you," she said. "But you took that job, you took an oath, you took a responsibility.

"Where is the humanity? Where's the compassion?"