N.S. jail death report details faulty buzzer
Inmate, 23, died of methadone overdose in 2014
• An emergency intercom in the jail unit of a young Halifax man who died of a methadone overdose had been improperly disabled by guards who regarded it as a nuisance, according to a corrections investigation.
The report says a cellmate found 23-year-old Clayton Cromwell unconscious on April 7, 2014, and yelled at other inmates with an intercom in their cell to press the “red button.”
But there was no response for 10 or 15 minutes, inmates said, and they had to start kicking doors and yelling to get the attention of officers at Halifax’s Central Nova Scotia Correctional Facility.
According to the report, released to The Canadian Press under freedom-ofinformation legislation, the intercom had been cut some time earlier, in contravention of provincial rules.
“They used to have intercoms in there,” a captain is described as telling the corrections investigator. “They were a nuisance for the most part.”
He told the investigator that if someone needed medical attention or had disabilities, they had a special cell with a working intercom, but otherwise inmates “get a hold of us by yelling, banging, waving their towels ...”
The investigator quoted the cellmate as saying he shouted to ask other inmates to use the emergency intercom to get the attention of guards. “They were trying to press buzzers ... I think the intercom only in the handicap cell works,” the investigator quoted the inmate saying.
The investigation report says a followup email from the correctional officer several days after the death indicated that the intercom in the specialized health cell also wasn’t working, and there was no record of the reason for that.
The Department of Justice declined all comment on whether the lack of intercom may have caused a delay in response to the dying prisoner and whether changes have been made in response, citing an ongoing lawsuit from his family.
Devin Maxwell, the lawyer representing Cromwell’s family, said in an interview he feels the disconnected system played a role.
“Disabling the intercom system removed a level of security from the inmates that could have allowed Clayton’s cell mate to contact correctional officers before he died. Nuisance was not a sufficient reason to take that option away,” he wrote in an email.
The report contains disputed versions of when inmates first attempted to get the attention of correctional officers, with some reporting they had been trying since 6 a.m., three hours before the official time of death.
However, closed circuit television showed the first attempts were between 8 a.m. and 8:15 a.m.
Maxwell says the issue of when inmates first tried to alert corrections officials to the overdose “remains an open issue,” but he argues the failure to detect overdose symptoms the day and night before suggests understaffing at the jail and problems in jail procedures.
Cromwell was in the jail awaiting a hearing on alleged probation violations. He was repeatedly described by inmates as a “good kid,” who had been in the unit for a short period of time.
Inmates told the investigator that potent opioids were believed to be on the unit, and inmates gave descriptions of the signs of Cromwell’s overdose through the evening and night of his descent into the fatal overdose.
A guard said inmates were being pressured to “cheek” medication — a term meaning the substance is concealed in the inmate’s mouth. One inmate described how opioids “had been floating around” in the days before the overdose.
The document says that the prisoners were locked in their cells for much of the afternoon before Cromwell’s death due to an unrelated health emergency.
Nonetheless, it appears that somehow Cromwell ended up receiving and taking a deadly combination of methadone and an antidepressant called benzodiazepine, according to autopsy findings. It said medical evidence showed his body wasn’t used to the drug, and a single dose was sufficient to kill him.
Dr. Risk Kronfli, the director of offender health services at the Nova Scotia Health Authority, said a number of measures have been taken since Cromwell’s death to reduce the risk of opioids reaching prisoners.
THEY USED TO HAVE INTERCOMS ... THEY WERE A NUISANCE FOR THE MOST PART.