Brad Chapman collapsed in the doorway of a Walton St. nail salon in downtown Toronto just before dawn last Aug. 18.

Cocaine, opioids and amphetamines coursed through his body; they were the long-time drug user’s preferred substances. Homeless, the streets were Chapman’s haven for 20 years when he wasn’t in jail. Those dire circumstances for the father of three were a world apart from the middle-class comfort of Etobicoke, where Chapman was raised by a loving family, competed in rep hockey, learned French and played piano by ear.

A security guard making his rounds shortly before 5 a.m. at the Chelsea Hotel, just steps from the nail salon, noticed a man slumped over in an alcove. To the man’s left lay a syringe, spoon and a cigarette lighter; to his right, an empty Crown Royal bottle, a police report would later note. The concerned guard, George Plaier, called 911.

That man, later identified as Chapman, was dying. Chapman would soon become part of Ontario’s growing ghost population: The uncounted homeless dead.

A Star investigation has found that the province and most municipalities across Ontario do not track homeless deaths fully — or at all — and as a result, have no accurate understanding of the scope of the tragedy and how best to solve it. Ontario chief coroner Dr. Dirk Huyer said there is no mechanism under current legislation to track all homeless deaths.

Anti-poverty advocates are calling on the province to change that. They say this under-reporting downplays the problem and prevents the government from properly addressing the root causes.

The City of Toronto, for example, tracks deaths of shelter residents; there have been 217 since 2007. Outreach workers say many others die outside of shelters and are not counted, like Chapman. A volunteer group in Toronto that keeps an unofficial list of GTA homeless deaths, including those of shelter residents and those living on the streets, recorded 295 deaths in the same time period — a difference of 78. The group’s list dates back to the mid-1980s and puts the tally at more than 800.

After the 911 call, police from 52 Division arrived first at Chapman’s side, but couldn’t rouse him and called for an ambulance. When paramedics arrived, Chapman had no vital signs. Police and firefighters performed CPR as the paramedics scrambled to clear his breathing passages, suctioning out vomit while injecting powerful drugs directly into his jugular vein to restart his heart. They frantically worked on Chapman for half an hour, eventually resuscitating him.

The ambulance raced him to Toronto General Hospital, where Chapman was put on life support. The hospital listed him as a John Doe. Police collected his belongings at the scene. Four days later, a police photographer going through Chapman’s effects found a shelter card with Chapman’s name on it, but there is no record of police contacting the hospital with this information, according to a police spokesperson.

Chapman’s family only learned of his grave condition six days later — thanks to a sleuthing hospital spiritual counsellor — and quickly gathered in his 10th-floor room in intensive care. His anguished mother, Cori Chapman, agreed to withdraw life support from the troubled son she loved so much.

Chapman was surrounded by his mother, two siblings, a cousin and his own three children when he died on Aug. 26. He was 43. The cause of death: multi-drug overdose, according to his hospital records.

The coroner’s office reviewed Chapman’s death and deemed no investigation was necessary.

Because he did not die in a city-administered shelter, and his passing was not deemed suspicious, his death in hospital from an accidental overdose on the street put him on no official list.

Like hundreds of other homeless people who have died in Ontario over the last three decades, Chapman has become an invisible statistic.

“Measuring a problem is the first step towards addressing it. And if you don’t measure it, it tends not to be a high priority,” said Dr. Stephen Hwang, director of the Centre for Research on Inner City Health at St. Michael’s Hospital and one of Canada’s pre-eminent experts on homelessness.

“We measure the unemployment rate, we measure inflation, we measure all kinds of things we feel are important to track and keep our eyes on both as the general public and as policy-makers and politicians . . . How can you keep your focus on that if you don’t track it on a regular basis?”

The Star found two main reasons why people like Chapman are not counted by the province: The coroner’s office, which investigates unnatural, sudden and unexpected deaths, has no mandate to track all homeless deaths; and hospitals and social agencies, such as homeless shelters, are not required to report all such deaths to any central provincial registry.

Huyer said his office used to record whether a decedent was homeless or had no fixed address beginning around 1989, but the practice stopped in 2007 because the data was “unreliable.” He said staff may have forgotten to apply the special code used by his office for “homeless/no fixed address,” and the code itself often led to confusion.

“The data collection was not effective or efficient,” Huyer said.

He stressed that his office can only investigate deaths under three broad areas defined by the Coroner’s Act: sudden or unexpected, such as a heart attack with no witnesses; unnatural, such as a drug overdose; and deaths in which the deceased was under the care of certain social services, such as group homes or psychiatric facilities.

Huyer said his office would investigate the death of a homeless individual only if their death fell under one of the categories he is required to investigate under the act.

“Even if we had a definition that was universally accepted of homeless, we still wouldn’t be involved in those cases where they died of a natural disease process in the hospital,” said Huyer.

Cathy Crowe, a long-time street nurse and a distinguished visiting practitioner at Ryerson’s Politics and Public Administration Department, said she isn’t surprised by Huyer’s stance, “but at the same time, that doesn’t mean you don’t have accountability or responsibility to look at the issue with eyes wide open and figure out a way to proceed.”

Crowe said the coroner’s office should track and examine the circumstances around homeless deaths just as it has done for other categories, such as winter sports deaths, cycling deaths and pedestrian deaths.

“The Office of the Chief Coroner should be held accountable for not counting or investigating a tragedy of literally decades of homeless deaths,” said Crowe. “They say they speak for the dead to protect the living — but do they in all cases?”

In contrast, the British Columbia Coroners Service collects homeless death data and recently made this public in an online report covering years 2007 through 2014. A spokesperson for the service said this information is shared with the public, agencies and government ministries “to inform policies and legislation.”

Cheri DiNovo, NDP MPP for the Toronto riding of Parkdale-High Park and a longtime advocate for the homeless, said social service agencies in the city that work with the homeless would be happy to be part of a provincial death reporting system.

“It’s not hard to figure out if somebody’s homeless or not,” said DiNovo. “Where there’s a will, there’s a way.”

She says the provincial government should require that cities, hospitals and social service agencies report to a ministry or the coroner when they learn of the death of a homeless person.

“Without statistics, you can’t make wise policy decisions,” she added. “The government says it’s going to address homelessness. Well, how can you address homelessness if you don’t know its effects? Death is one of the effects of homelessness.”

***

A beautiful brown-eyed boy, Brad Chapman was adopted at the age of 9 months by Cori and Peter Chapman, who feared they could not have children of their own.

“He was just delightful and brought so much joy and love into our home,” recalled Cori Chapman, a registered nurse who became a program director at Credit Valley Hospital before she retired.

The Chapmans knew their son’s biological mother was a drug user, but Brad, who had been in a caring foster home, “was a very healthy baby and was meeting all the milestones,” Cori Chapman said.

The Chapmans soon had two biological children: daughter Leigh and son Peter. The early years were busy and fun. There were summer trips to a family cottage in Alberta, where Brad — always active — loved to swim and fish.

By about Grade 4, Brad’s behaviour became problematic. Though intelligent, he struggled with school work, even with tutors helping him, and became socially isolated from classmates and friends. He was assessed as “hyper,” a common term 30 years ago, and prescribed Ritalin.

However, the “catastrophic” break in Brad’s life occurred when he was 12 after his father, Peter, abandoned the family.

“My dad left all of us, he didn’t just leave the marriage. So for Brad it was just catastrophic. It was a wound he could never recover from,” said his sister, Leigh Chapman, a registered nurse. “Brad felt so rejected.”

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Group homes, crisis interventions, therapy and drug use increasingly became part of Brad Chapman’s world as Cori, now a single mother, tried desperately to help her eldest son during his vulnerable teenage years. He began spending time on the streets during this time, never returning home for long.

Chapman became a young father, just 20 when the first of his three children were born, but he couldn’t hold a job as a general labourer and split with his common-law wife.

A growing list of petty crimes, mostly involving loitering, theft and drugs, led Brad in and out of jail, a cycle that would last until the end of his life.

***

For 30 years, calls to comprehensively track all homeless deaths — including recommendations from a coroner’s inquest jury, Toronto city councillors, social workers, affordable housing advocates and the medical community — have been largely ignored by the province. This, despite research by Canadian and international experts that has found being homeless can dramatically reduce a person’s life span, especially for men much like Brad Chapman.

Canada’s largest city, however, has in recent years made an attempt to gather at least some of those statistics.

Since 2007, the City of Toronto has kept track of deaths related to city-administered shelters (those occurring in the shelter or soon after leaving it to be admitted to hospital, for instance). The names on this list are kept secret for “privacy” reasons, a city spokesperson told the Star. Not even family members of a deceased individual can find out if their loved one is on the list. Deaths unrelated to the 59 city-administered shelters are not officially tracked.

Right now, only a volunteer group of street nurses, pastors and front-line outreach workers is attempting to keep a full list of homeless people in the GTA who have died. The group’s list dates back to the mid-1980s and now sits at more than 800 people. Many people are named, many are John and Jane Does. Most are men.

The list, called the Toronto Homeless Memorial, is posted outside the Church of the Holy Trinity just west of the Eaton Centre.

Last year, the Ontario government struck a panel of experts to study ways to end homelessness across the province. The Expert Advisory Panel on Homelessness, made up of affordable housing advocates, doctors, researchers and co-chaired by the deputy premier, Deb Matthews, recommended the province adopt a definition of “homelessness” and end chronic homelessness within 10 years. None of the panel’s 23 recommendations call for the counting of homeless deaths.

A spokesperson for Matthews said in an email the government’s plan to end chronic homelessness will include “municipal and community partners” to determine how best to expand data collection, “which may include homeless deaths, to better understand the consequences and complexity of homelessness.”

Homelessness researcher Dr. Stephen Hwang, who was a member of the province’s expert panel, said the tracking of homeless deaths could be useful in monitoring whether government programs are working to prevent certain causes of death, such as drug overdoses. To be useful, reporting of deaths by hospitals and other agencies would have to be mandatory, he said.

***

As Brad Chapman continued to spiral downward, Cori Chapman beseeched her son to attend drug and mental health counselling. She often took him to appointments herself when he agreed to go.

Ben Fedunchak, a criminal defence lawyer who represented Chapman for 12 years, says his client knew he had a drug problem, and would use jail as a self-imposed treatment plan to get clean and reconnect with relatives.

“Most of the time he would just basically go into custody, ask for solitary confinement and go through the process. I think it was because he was trying to cold turkey himself away from the drugs,” said Fedunchak. “He was a very bright guy and when he was off the drugs, you couldn’t meet a nicer human being. But the drugs get into you and you go through a personality change.”

Leigh Chapman said her brother was more like himself while in jail.

“It was a good place for him. He cleaned up. He read books. My mum sent him Indigo orders and she got the newspaper delivered to him,” she said. “He wrote letters to his kids. He was remorseful.”

She wept when she described her brother’s quick return to his old ways when freed from jail.

“He’d be let out and get back on the streets and get sucked right back into this vortex.”

Leigh Chapman said her brother used Toronto’s city-administered men’s shelters as a last resort; he feared the violence and thefts he had experienced at these shelters and preferred living on the street. She said he was beaten so badly in a city shelter (the family doesn’t know which one) in February 2015, he ended up in St. Mike’s for treatment.

Brad Chapman’s street life was, in part, born of despair.

“One of the things that really created a problem for him was the lack of hope,” said Fedunchak. “You don’t know where you’re going to be sleeping, you don’t where you’re going to be eating, you don’t know if you’re going to get a job.”

***

By Aug. 25, Toronto General Hospital’s “John Doe” was deteriorating.

With all tests pointing to brain death, the hospital contacted the public guardian to outline a plan to remove the patient from life support, according to Chapman’s medical records. The public guardian asked hospital staff to make a last attempt to identify the man.

Soon after, the hospital learned of Chapman’s name, but neither hospital staff the Star spoke to nor Chapman’s family know how his identity was discovered. Hospital records obtained by the Star contain no clues as to how the mystery of John Doe was solved.

Armed with only a name — Brad Chapman — Derek Strachan, a spiritual care professional at the hospital, found Chapman’s mother, Cori, after making a flurry of phone calls to police, ambulance dispatch and a nearby hospital that had admitted Chapman earlier in the year.

Strachan’s detective work allowed Chapman’s distraught family to assemble from across the province within 24 hours to be with him when he died.

“It was so meaningful for all of us to have been there at the end with Brad (and) say goodbye to him, to see him,” said Cori Chapman.

“Even the hospital staff said, ‘Isn’t this just amazing?’ ” she recalled. “He was John Doe for the last six days and now, he’s Bradley Chapman and he has a room full of family.”

Tracking homeless deaths, a timeline