A body imaging scanner should be installed at Kilburn Hall and more nurses should be staffed at the youth facility during daytime hours, a jury has recommended at the coroner’s inquest into the death of a 17-year-old inmate.
The recommendations are two of six left by the jury for Saskatchewan’s Ministry of Justice following the five-day inquest. The identity of the teen, who died in custody in July 2015, is protected by a publication ban.
The inquest, which began Monday at Queen’s Bench Court, heard he smuggled crystal meth into the facility and cried for help, asking staff to call 911, when he began overdosing. Some workers tried to help him but supervisors didn’t call 911 because they thought he was in withdrawal and didn’t need an ambulance. He died about three hours later.
The other four jury recommendations call for Kilburn Hall staff to receive continuing education on medical emergencies such as drug withdrawal and overdoses, for staff tasked with supervising youth to be provided more training on taking vital signs of residents, for the youth facility in Saskatoon to create or modify an emergency response plan, and for the facility to identify critical policies.
A spokesperson for the province’s justice ministry called the recommendations well thought out and solid.
“We’ll take a look at them and see what we can implement, what we may have to put more though in to and what’s going to take a bit of budget in order to do that,” Drew Wilby told reporters after the inquest.
“I think they’re compressive and I think they will go a long way in helping something like this from happening again.”
The lawyer representing the teen’s family said they would like to see follow up with the recommendations. They’re happy with them but would have liked to see a few more, including activate charcoal — which can help absorb drugs during an overdose — be kept at facilities and that parents or guardians be notified if an inmate is put on one-to-one supervision.
“It’s been very difficult (for the family),” Ammy Murray said. “There’s been a lot of sadness. There’s been a lot of frustration.”
A youth worker at the facility testified at the inquest the teen told her he took something and was overdosing around 10 p.m. on July 29, 2015.
She told her supervisor Dale Larocque to call 911, but he testified he chose not to because he thought the teen was going through withdrawal and didn’t see any indication an ambulance needed to be called.
Larocque said Thursday he was confident with the way a team of nurses and supervisors handled the situation at the time and that it was a group decision to not call 911.
“I was very comfortable with how we went about it and the decisions that were made,” Larocque testified.
He said a nurse told him to watch for signs of the teen’s lips and fingertips turning blue, slurred speech or the teen becoming unconscious before calling an ambulance.
The inquest heard Larocque assigned a staff member to a one-to-one watch of the teen around 10:45 p.m. That staff member also recommended that Larocque call 911.
When Larocque’s shift ended at 11 p.m. he told supervisor Robert Johnson, who was taking over his shift, about the teen’s condition and told him about the warning signs from the nurse. Meanwhile, two staff members tried their best to comfort the teen and believed an ambulance should be called.
“They felt bound by the decisions of the two supervisors and continued to advocate to call an ambulance,” coroner Neil Robertson told the jury in his instructions Friday.
At 11:56 p.m., an ambulance was called after the teen was found unresponsive and frothing at the mouth. Nobody entered the teen’s cell between the time the ambulance was called and when paramedics arrived — about 10 minutes, according to Johnson. He said staff at the youth facility became frantic.
When paramedics arrived, the teen was seizuring and unresponsive, the inquest heard.
He was officially pronounced dead just after 1:15 a.m. July 30 at Royal University Hospital. Through their lawyer, the teen’s family expressed their gratitude to the staff who tried to help the teen.
“It was traumatic on everyone who was involved,” Murray said.
She said while it’s been difficult, the family says it feels like a weight has been lifted and they’re happy the story is now public.
The full recommendations read:
1. That body imaging scanners be installed at Kilburn Hall.
2. That there be an increase in on-site nurses at Kilburn Hall during waking hours being 7 a.m. to 11 p.m. 7 days a week. This can be accomplished with a combination of registered nurses as well as licensed practical nurses.
3. That all staff at Kilburn Hall receive continuing education regarding medical emergencies which include, but are not limited to, drug withdrawal and overdoses.
4. Kilburn Hall staff responsible for supervising youth are provided with additional training on taking the vital signs of residents both manually as well as with any automated equipment available at Kilburn Hall. These staff members should also demonstrate competence of these skills yearly at a minimum. *To clarify, this would include all staff at the Youth Facility Care Worker level and up.
5. That Kilburn Hall create (or modify if already created) an Emergency Response Plan specific to medical emergencies and review it annually with all staff. Document to contain current emergency contact numbers which include but are not limited to EMS – 911, Healthline – 811, Poison Control #.
6. That Kilburn Hall identify or determine a set of key critical policies, at the ministry and/or facility level and require all staff to review annually.
