Reading time: 3 minutes, 21 seconds
In 1997, Dr. Lori Triano-Antidormi’s 2-year-old son, Zachary, was playing outside with his babysitter’s daughter. A neighbour came outside with a kitchen knife and stabbed him multiple times, killing him.
The neighbour’s delusions led her to believe that the soul of her dead son was mistakenly reborn in Zachary. She believed she needed to stab Zachary to release her son’s soul, so it could be properly reborn in her daughter.
A trial and inquest took place over the next two years. The neighbour was found not criminally responsible (NCR) on account of mental disorder.
Dr. Triano-Antidormi shared her personal story of grief and trauma from her son’s murder to support positive change in her community and forensic psychiatry. She shared the story during the International Forensic Psychiatry Lecture Series. (You can watch a recording of her March 13, 2025, talk online.)
What Went Wrong
The neighbour first showed signs of paranoid schizophrenia in her early 30s. She first entered a psychiatric hospital in her 40s. Police first became involved with her in 1987. They charged her with mischief after she chased her then-neighbour with a knife and shovel.
Dr. Triano-Antidormi’s family was unaware of that history when they moved into the home next door in 1990. At first, they had pleasant interactions and friendly conversations with their new neighbour.
In 1991, the neighbour’s son died. Her delusions became more complex and bizarre. She created a video outlining her delusional thinking that her priest gave her son a communion host tainted with AIDS. She hoped police would charge him with murder.
In 1994, she told her member of Parliament she was going to kill the priest to avenge her son’s death. She was involuntarily admitted to the hospital. However, she was released a month later because she was not “an imminent risk.” The doctor gave her an antipsychotic, not knowing that she did not respond well to it in the past. She was referred for outpatient therapy but never followed up.
When Dr. Triano-Antidormi became pregnant with Zachary, she started noticing changes in her neighbour’s behaviour, which progressively worsened. What began as leaves and cat feces being thrown on Dr. Triano-Antidormi’s porch escalated to her not being able to leave her home without being harassed or threatened.
Police were called when the neighbour:
- was threatening with a crowbar;
- physically fought with her daughter;
- harassed another neighbour’s child;
- followed Dr. Triano-Antidormi, reached for Zachary, and then pushed her; and
- damaged her home’s side door.
Police often dismissed Dr. Triano-Antidormi’s concerns. One said there was no law against being crazy. Another recognized “something was not right.” Some laughed. Most left, providing no assistance.
When Dr. Triano-Antidormi was pushed, the officer charged the neighbour with assault. However, instead of a peace bond, restraining order, or a psychiatric assessment, the judge scolded her for wasting his time. He dismissed the case, saying neighbours should work out their differences like adults, not children.
What Has Changed
The inquest identified many gaps, notably, police officers’ poor understanding of mental health and the lack of information sharing due to misunderstanding of privacy and confidentiality. Unfortunately, when numerous incidents are only seen individually, it’s impossible to see the patterns and recognize the potential danger.
“The jury heard over and over again that, due to the lack of sharing information, there were too many cracks for the mentally ill to fall through,” Dr. Triano-Antidormi said.
The inquest made 60 recommendations, including:
- sharing information among the police, emergency department doctors, hospitals, family doctors, and supportive family members;
- educating police about mental illness and their powers under the Mental Health Act; and
- changes to the Mental Health Act.
Section 17 of the act was amended, so police officers can now act on probable grounds — like reports from Dr. Triano-Antidormi, the neighbour’s daughter, and the other neighbour — not just the behaviour they observe.
The vague word “imminent” was removed from the act to reduce ambiguity.
The Hamilton Police Service implemented all the recommendations, including increased funding to the Crisis Outreach and Support Team (COAST). A partnership with St. Joseph’s Healthcare Hamilton, COAST has officers and mental health workers respond to a 24-7 crisis line.
The two organizations also created a Mobile Crisis Rapid Response Team. These officers and mental health professionals are specially trained to respond in a police cruiser to 911 calls about mental health crises.
Dr. Triano-Antidormi said these programs have diverted individuals in crises from the hospital to more appropriate programs.
These and other partners now operate in a community hub — called Zachary’s Legacy — so they can more easily collaborate and provide support to individuals experiencing mental health crises.
“It goes without saying that I would rather have Zachary with me. But given that obviously could not be possible, I am very thankful and grateful that … Zachary’s death was not in vain,” Dr. Triano-Antidormi said.
Written by Virginia St-Denis and approved by Dr. Lori Triano.
