She slips off her black high tops and leaves them side by side on the pedestrian bridge. She drops her beige sweater in a heap.

In the distance, where Hwy. 403 begins its long curve down the mountain into West Hamilton, a transport truck comes into view. It will take nearly 30 seconds to wend its way to the bridge.

As it nears, she quickly and without hesitation climbs over the railing onto a narrow ledge. Facing the sky and traffic below, she jumps.

Nicole Jeanine Patenaude, 20, was mentally ill.

This is her story.

Carolyn and Don Patenaude had four daughters in four years: Jeanette, Emily, Nicole and Rebekah.

By the time the girls were all out of diapers, the couple had separated and Carol was raising them alone. It was exhausting but she did it with love and good humour in a small East Hamilton bungalow that doubled as a home daycare.

It was the baby, Rebekah, who was the focus of much of Carol's attention in the early years. She is unable to walk because of cerebral palsy. For a time her mom worried she would be unable to talk.

"Now we're looking for the mute button," Carol teases. Rebekah, 19, will soon enter paralegal studies at Mohawk College. She wants to be a human rights lawyer.

When Carol was coming to terms with the reality that Rebekah needed a wheelchair, Nicole — seemingly the picture of health — was literally climbing the drapes.

"The curtain rod was bent," recalls Carol, 48.

"Nicole was very energetic. Happy-go-lucky. Adventurous. She was a character."

On her first day of kindergarten, she was fearless. "Could she even shed a tear?" Carol says, remembering her own emotional moment watching her daughter head eagerly into St. Eugene School.

A natural athlete, Nicole played T-ball. Jim Roberts coached all the Patenaude girls. (Rebekah's CP didn't stop her.)

"Nicole was always smiling," Roberts recalls. "Full of energy. Talkative. She was the fastest runner I've ever seen at that age. She had a competitive air about her. She wanted to do well."

She was easy to coach, says Roberts. No trouble at all.

By the time she hit Cathedral High School, Nicole had friends and good grades. She did wrestling, volleyball, baseball and cross-country running.

"Her escape was cycling," Carol says. "If she was in a bad mood or needed to get out."

Nicole was a Girl Guide leader. Her Guiding name was "Cupcake," a nod to her sweet tooth.

• • •

The Patenaudes are a boisterous, loving, family.

They finish each other's sentences, make jokes and use pet names. One minute they bicker, the next they are hugging.

The girls call Carol "Wonder Woman." She provided every opportunity and addressed every need.

Like all the girls, Nicole saw a family therapist. Carol was concerned about the impact of the divorce on the girls' mental health, so for years they went to a counsellor.

Carol and the girls had this thing called a "Nicole Sandwich." It involved piling onto Rebekah's lap in her wheelchair, stacking themselves youngest to oldest. The sandwich was invented after her diagnosis of mental illness to surround her with love and support.

• • •

On her 16th birthday, March 6, 2013, Nicole left on a school trip to Europe.

Carol saved to ensure each daughter could go on such an adventure. Jeannette had done it, and now Emily and Nicole were going during March break, although they were on separate trips.

Nicole's class was touring France and Germany for 10 days and she was excited, although nervous about travelling without her family for the first time.

A few days in, Carol missed a call from Nicole. She tried ringing Nicole later that night, but had been given the wrong phone number.

"I guess she waited up for me to call all night," says Carol.

Things weren't going well on the trip. Teachers told Carol that Nicole was acting up. She wasn't participating in activities, didn't want to go on the bus, wasn't eating. She pushed a teacher.

The behaviour was completely out of character for Nicole. Carol got up every night to phone Europe and console her daughter who, she hoped, was just experiencing acute homesickness.

"I knew she wasn't herself."

Nicole complained her legs weren't working. Given Rebekah's CP, Carol asked the teachers to take Nicole to a hospital to be sure she was OK. They told her it wasn't necessary and she ought not to worry.

Meanwhile, according to Carol, the teachers took two other students to the hospital because of stomach aches.

• • •

Carol, Rebekah, Jeannette and her boyfriend Tyler Raynham (now her husband), met Nicole when she returned to Cathedral after the trip.

"She comes off the bus, her head is down, she won't even look at us," says Carol.

In the car, Nicole curled into a fetal position, shaking and silent. She was offered homemade cookies but didn't respond.

"Nicole, talk to me, honey," said Carol. "What's wrong?"

"I don't know," Nicole whispered.

"Do you want to go to the hospital?"

"Yes."

At McMaster Children's Hospital she was examined and sent home. Jet lag, maybe?

Nicole curled on her bed, cocooned in a blanket, shaking. She neither ate nor spoke.

Carol decided to take Nicole back to hospital, but couldn't rouse her. She called 911.

The scene that unfolded still upsets Rebekah.

Her thin, five-foot-five sister kicked and punched paramedics and battered police.

Nicole was handcuffed and loaded into the ambulance.

"She was screaming 'I don't want to go,'" remembers Rebekah.

Emily came back from Europe eager to exchange travel stories with Nicole. Instead, she learned her sister was having a breakdown.

"I didn't know how to process it," she says. "I expected we'd talk about the Eiffel Tower."

• • •

Nicole was admitted to the children's mental health ward at Mac. She stayed six weeks, the first of many hospitalizations.

While there, Nicole hid in the closet and under the bed. She kicked, bit and punched staff. She pulled taps from the bathroom walls. She cut herself with anything she could find. Once, she used a deodorant lid.

She was put in restraints. Nicole said the straps around her arms, legs and chest made her feel safe.

Sometimes, amid the chaos, the old Nicole surfaced.

"I'm sorry," she said.

Then she was gone.

• • •

Doctors warned they were going to send Nicole home, and Carol begged them not to.

Nicole didn't want to go home. She said so repeatedly.

Carol didn't know if she could handle her daughter. Her violent outbursts were hard for trained staff to manage. How would she do it?

What about the daycare kids? It wouldn't be safe to have Nicole around them. The daycare was the family's only source of income.

Most of all, the family knew Nicole wasn't well.

"Professionals think they know what's best, but they don't listen to the families," says Jeannette. "Yet it's the family who knows them and must care for them."

One day Carol heard a car outside the house. Nicole got out of a cab. The hospital had sent her home.

• • •

Carol describes Nicole's mental illness as "a concoction."

It is Borderline Personality Disorder combined with Impulse Control Disorder and a dash of anxiety and depression. Maybe.

Many of Carol's questions remain unanswered. That school trip, was it a trigger? Did the family miss signs of mental illness before that?

"Until then, I only noticed normal, teenaged problems," she says.

• • •

Nicole wasn't home long before she was readmitted to hospital.

And released.

And readmitted.

Lots of medications were tried.

The family runs through some of the more memorable episodes in Nicole's saga.

There was the time Carol took Nicole out of Mac for some fresh air and Nicole climbed a tree on campus and wouldn't come down. Firefighters were called.

Or when she grabbed her social worker in a headlock at the hospital and threatened to smash her head in with a fire extinguisher. Security guards tackled her, police were called and she was charged.

Like many desperate families, Carol hoped the criminal justice system might help Nicole get treatment. She was locked up at Syl Apps, a youth detention facility in Oakville.

"Syl Apps is absolutely amazing," says Carol, with genuine appreciation for what it did for Nicole. "She was thriving at Syl Apps."

Nicole attended school there and learned to cope with her illness.

Every week the family made the trek by bus (they don't have a car) to visit Nicole. They gave her a blanket that says "I Love You" on it with a big heart. It was meant to "hug" her even when they couldn't.

"She loved it there," says Rebekah. "She was happiest there."

Kinark, the agency that operates Syl Apps, declined to comment for this story.

On Nicole's 18th birthday, she was discharged from Syl Apps.

She was an adult by law, says Jeannette, but she did not have the mentality of an adult.

• • •

Nicole moved into Charlton Hall, a home for troubled girls. But she assaulted a staff member, so she didn't stay long.

Next came a series of group homes, interspersed with hospital stays, which were now at the West 5th Campus of St. Joseph's Hospital in Hamilton, the city's adult mental health unit.

"All the group homes have really tried to help Nicole," says Carol. "They tried and they were compassionate, not only with Nicole but with our family."

The hospital, however, cut the family out of the loop. Now that Nicole was an adult, her mom was no longer her legal guardian. Carol was not told when her daughter was admitted to hospital.

• • •

"Mommy, I want to be normal again," Nicole said.

Her goal was to have an apartment and a boyfriend.

She got a job delivering flyers, but after a few weeks she was back in hospital and lost her route.

Contact with her family became sporadic. They often didn't know what was going on in her life, though they let it be known they loved her and missed her.

"She didn't want us to be disappointed in her," said Carol. "But I told her, 'I love you and I'm heartbroken because you're in pain.'"

Nicole got a tattoo on her right forearm. A blue and purple butterfly with the words, 'Stay Strong.'

In an undated poem she wrote, Nicole likens herself to a butterfly:

Because everybody has their struggles,

Everybody has their troubles.

I am winning because every day, every moment is a new beginning.

I am soaring over whatever is in my way.

I am like a butterfly flying away.

Though Nicole may not have thought of it, her tattoo also evokes the philosophy of The Butterfly Effect. It's the idea that one small event — or maybe one person — can change things in a way that cannot be predicted.

• • •

In August 2015, Nicole was referred to lawyer Courtney Hamara at Sullivan Festeryga LLP.

She had a youth record and now adult charges relating to an assault on staff while at West 5th.

She entered into a peace bond, but, when in crisis, wound up assaulting another worker and being charged with a new assault as well as breaching her bond.

"She was always very remorseful," says Hamara. "She did worry about what the consequences would be."

Hamara says Nicole could have benefited from a designated Mental Heath Court, had there been one in Hamilton. An MHC is about treating low-violence offenders. "I really liked Nicole," says Hamara. "She was very sweet."

• • •

From January to November 2016, Nicole lived at Elm Villa, the residential care facility where she would meet her boyfriend, Justin Hind.

Tanya Hannigan runs the home and has fond memories of Nicole.

"I just always enjoyed talking to her. She was fascinating. Wise … She had ambition."

Hannigan hoped Nicole would have a career helping others one day. But there would be mountains to climb.

"Nicole had major struggles … She was a soul crying out for help. The combination of her different illnesses added up. She was struggling with a darkness inside her."

• • •

Thanksgiving was the last time the whole family was together.

Dec. 11, Nicole phoned her brother-in-law, Tyler, to say she loved her family but wouldn't be joining them for Christmas. She was sparing them the burden of her company.

Around the same time, Nicole was admitted to the West 5th Campus. She remained a patient there for the rest of her life.

The Scrabble game the Patenaudes bought Nicole for Christmas is still at her mother's house, unopened.

• • •

Every year, on each daughter's birthday, Carol has their photo taken at a portrait studio.

There are gaps in Nicole's. No photo at 16, because she was away and then in hospital. Also in hospital at 18.

On her 20th birthday, March 6 of this year, Nicole called her mom and sisters from the hospital to say she was sorry and she loves them.

• • •

Dr. Peter Cook is chief psychiatrist at St. Joe's. Peter Bieling is head of mental health and addiction services.

They oversee the staff who cared for Nicole during her final five months in hospital. With Carol's permission, they agreed to speak about Nicole's care and her suicide.

Nicole's mental illness was "complicated and profound," says Bieling. She grew up inside institutions. The goal for her care team was to get her well enough to live in the community.

"It appeared to be going well," says Bieling. The team helped her secure an apartment on May 1 and was working up to discharging her. No date had been set yet.

"So many agencies were wrapping around her and getting her ready," says Bieling.

• • •

Nicole tried many times to kill herself.

She used her bra to hang herself from the closet and from a bedpost. She bought a knife and stabbed herself in the neck. She overdosed on allergy medicine.

Her family wasn't informed by the hospital about her adult suicide attempts.

"She wakes up in the hospital after overdosing with nobody there for her," Carol says angrily. "You're going to let a mentally ill young lady, who almost died, wake up by herself with no support?"

That legal issue is one of the thorniest that Cook and Bieling must navigate: the rights of patients vs. the rights of their families. In the end, adult patients win.

"We were obligated to protect the privacy of Nicole," says Cook. "She was an adult."

While involving the family is a part of treatment wherever possible, if a patient does not want their family involved, the hospital must respect that wish, says Cook.

Confidentiality between patient and doctor is "sacrosanct," says Bieling. Nicole did not want to share her medical information with her family.

From her poems, journals and conversations with her family, it appears Nicole's decision to shut them out wasn't because she didn't love them. Indeed, it seems to have been because she loved them so much. She considered herself a burden.

"I know that I'm hard to love," she posted on Facebook.

On May 11, Nicole was on a pass from St. Joe's. She dropped by Elm Villa, her former lodging home, for a half-hour visit with Hannigan.

Nicole had marks on her arms and neck, and Hannigan was concerned. She knew Nicole had a history of self-harming — cutting, head banging and strangulation. That pain was a way of diverting the pain from inside her head.

Hannigan recalls Nicole's final words: "I'm young. I can do anything."

A selfie on Nicole's phone, taken May 12, is a close-up of her neck. Long red marks are visible across her throat.

• • •

Nicole met Justin Hind when they both lived at Elm Villa.

"She seemed very nice," Hind, 23, remembers. "I was afraid to talk to her."

But Nicole made it easy. She was outgoing and fun and they had much in common, including their struggles with mental illness.

"She made me get out of the house and do stuff. We'd go for hikes."

Nicole was Hind's first girlfriend.

"I told her every day that I loved her," he says. "I texted her every morning so she knew she had someone who cared about her."

When Nicole was in hospital, Justin visited twice a week. He saw she cut her wrists and neck. Sometimes she talked about suicide.

"I told her never to do it. And to call me if she was thinking about it."

• • •

Tuesday, May 16, is the last day of Nicole's life.

At 9 a.m. she sends a text to Hind: "Love you lots. Sorry I couldn't get back to you sooner. Had a bad week. Hopefully I'll be better soon."

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Hind texts and calls her throughout the day, but never hears back.

Nicole gets a "therapeutic pass" from West 5th.

Different levels of passes allow increased freedoms.

Level 1 means the patient must remain on the secure in-patient unit. Level 4 grants visits to the community.

Nicole had Level 4 passes before with success, according to Cook and Bieling.

Nicole starts her day out by going to her bank and paying her phone bill. At 9:29 she checks out a book at the library.

At 10:30 she meets with a member of her care team at Fortinos on Main Street West.

"How are you feeling? What is your mood like?" are likely questions, says Cook. Nicole would be asked about her plans for the day.

Part of that conversation is a risk assessment, says Cook. Is the patient a risk to themselves? To others? Are they vulnerable to harm from others?

Cook and Bieling say they were unaware of the red marks on Nicole's neck. They say it was not unusual for her to self-harm, so perhaps the care team member sees the marks but does not consider them a suicide attempt.

Another possibility is the big sweater Nicole has with her. It is a turtleneck. Yet it is a warm day.

Nicole goes to the apartment she has taken in West Hamilton. A week earlier, on another pass, she went there with Hind and played board games. It was a happy day.

This time at the apartment, Nicole writes a suicide note: "For everyone who tried to help, thank you."

She records a video on her phone. It is time stamped at 11:29 a.m.

Those goodbyes will be found by police.

The mystery of what Nicole does for the next four and a half hours haunts her mother, reducing her to tears when she thinks of that deep, dark gap in time.

Was Nicole teetering on the brink of a decision? Was her pain unbearable?

Nicole leaves her phone and identification in her apartment, carrying only the apartment key.

She makes her way to the wide, smooth pedestrian bridge that is a 15-minute walk away and part of the Hamilton-Brantford Rail Trail.

At about 4 p.m. Nicole stops on the bridge above the down-bound lanes of Hwy. 403, takes off her shoes and drops her sweater. Police will tell Carol and her three remaining daughters that shedding clothing is a common thing for jumpers.

Police will describe Nicole's sweater as "neatly folded," and that troubles the Patenaudes. Did someone else fold her sweater? Was someone with her?

Eventually, when they see a picture taken by Hamilton Spectator photojournalist Barry Gray — he shot it before police arrived at the scene — they see the sweater is not folded, but rather crumpled in a heap.

It is a relief to them.

"That," they say, "is so Nicole."

Two passersby see Nicole climb over the railing. They call 911 and later tell OPP detectives the young woman was gone in a heartbeat. She didn't linger on the ledge. She just turned out into the sky and jumped.

Carol and the girls believe Nicole waited for a transport truck.

"The world was too much for her," says Carol.

• • •

The OPP closed the 403 in both directions for hours.

Motorists near the pedestrian bridge got out of their cars and sat on guardrails, waiting.

The official word from police was that a pedestrian was struck by a truck. Nothing about suicide.

Traffic backed up for miles. It took drivers two and half hours to crawl from the Ford plant in Oakville to downtown Hamilton.

Jeannette, 22, was on a bus, coming home from York University. It was her next-to-last day before finishing her teaching degree.

She wondered what was causing the traffic jam.

• • •

Nicole was identified by her tattoo. Police ran it through the Canadian Police Information Centre (CPIC) databank and came up with five people with similar butterflies on their forearm.

At 10:30 p.m., just as she was preparing for bed, Rebekah answered the phone. A police officer said it was about Nicole and they were on their way over. When they arrived they said a woman, who may be Nicole, had been struck by a truck.

It was the next day, when fingerprints confirmed Nicole's identity, that her family learned she had jumped. And that it was suicide.

Carol and the girls did not see her body at the funeral home. It was too broken. She was in a body bag, her old I Love You blanket wrapped around it.

Everyone took turns hugging what was left of Nicole.

After her body was placed in a casket, ready for cremation, Carol, Jeannette, Emily and Rebekah said their final goodbye.

"We Nicole Sandwiched the casket," says Emily.

• • •

This was not the first time suicide touched Tyler's life. When he was 10, his older brother died by suicide. He was 23.

• • •

The butterfly had an effect.

Carol, the girls and Tyler want the truck driver to know they think of him.

They know there was nothing he could do. In fact, they are grateful.

They know he saw her face as she fell from the sky. They can only imagine how this affects him.

"We really hurt for him," says Emily, 21.

It is a miracle to them that the driver was able to stop without causing an accident.

The truck didn't kill Nicole, says her family. Her illness did.

Nicole could not have imagined the way her death reverberated through the world.

Her old baseball coach, now with family members of his own coping with mental illness, was devastated to hear the fleet-footed girl with the big smile had killed herself.

"I was in shock," Roberts says. "It took me a couple of days to come around."

Hannigan, the lodging home operator, replays their final conversation, looking for clues.

The lawyer, Hamara, had to appear in court after Nicole's death to officially close her case. It was very emotional for her.

Nicole's death is "very difficult for the staff" at St. Joe's, says Dr. Cook. They were very fond of her.

Hind, Nicole's boyfriend, was crushed.

"It was the first time I cried in a very long time," he says.

And, 15 km away from where Nicole jumped, a 10-year-old girl in Waterdown named Jasmin Hanif was fatally struck by a car. Police say her death was caused, indirectly, by traffic diverted off the highway closed for Nicole's death investigation and rerouted through Jasmin's neighbourhood.

"I don't blame Nicole," says Shakeel Hanif, Jasmin's father. "I blame the system. More resources need to be put into mental health care."

Hanif support's the Patenaude family's decision to tell Nicole's story.

"The story is the smartest and most beneficial thing to do for the public right now," he says.

• • •

The Patenaudes want you to know Nicole was deeply loved and deeply troubled. They want you to know something about her beyond the fact she is the one who jumped off the bridge.

They see no shame in mental illness or suicide. They believe talking about it is the only way to break down stigma, educate and let other families know they are not alone.

Carol is disappointed the OPP didn't ask if they could tell the public that Nicole's death was a suicide. Instead, the news release simply said a woman was struck by a vehicle. (Even when directly asked if Nicole's death was suicide, the OPP would not confirm and did not seek direction from Carol.)

Police have closed their investigation of Nicole's death but the coroner's case is ongoing. St. Joe's is reviewing their work to determine if anything could have been done differently.

How can a doctor or nurse or social worker know a patient's suicide is imminent?

"That's the Holy Grail question," says Bieling.

• • •

Last year, three people died by suicide while in-patients at West 5th Campus.

The hospital saw almost 24,000 unique mental health patients last year.

The cluster of suicides led the hospital to order both an internal and outside review, which is being conducted by a former chief coroner for Ontario and the retired head of psychiatry from a major hospital. It was expected to wrap up in February, but the hospital is still waiting.

Meanwhile Nicole took her own life. And on June 25 another patient died by suicide at West 5th, St. Joe's has confirmed.

Carol would also like to see a Coroner's Inquest called into the suicides of West 5th patients. That, she believes, may be her best chance of getting answers and preventing similar deaths.

• • •

The video is one minute and two seconds long.

Nicole shot it with her phone, likely in the apartment she never got to live in. Her face fills the frame. Her dark hair is short and tousled. Her dark eyes are big and penetrating under thick brows. They peer straight into the camera.

On her neck are angry, red marks.

Her voice is barely a whisper. At times, her words are inaudible. It is as though she doesn't have the strength to speak them aloud.

It is hard to imagine anyone could possibly look sadder than Nicole in this moment. This is a woman in agony.

"Hi. If you're watching this, it means I killed myself. I have been thinking of suicide a lot, a lot lately. I want to get out of this world. I have tried three times in three days … I want to get out of this world. In all fairness to everyone … My family will always be number one. I'm sorry for … pain to everyone. I'm sorry it's over. I think it needs to happen. I left this for my loved ones — family and friends. I'm sorry it has to end this way."

If you need help Youth Wellness Centre

905-522-1155 ext. 31725

COAST (Crisis Outreach and Support Team)

905-972-8338

Barrett Centre

905-529-7878

Contact Hamilton

905-570-8888

Salvation Army Suicide Crisis Line

905-522-1477

Telecare Burlington

905-681-1488

Distress Centre of Hamilton

905-525-8611

Kids Help Phone

1-800-668-6868

Suicide Prevention Community Council of Hamilton

spcch.org

Canadian Association for Suicide Prevention

suicideprevention.ca

- BERTON: How a tragic photo became a difficult story

- Nicole's Story: Beyond blame and toward understanding

- Nicole's story: Deeply loved and deeply troubled

- Clairmont: Lives left behind