Inquest hears two supervisors denied request to call 911 before youth’s death

A 17-year-old Kilburn Hall inmate who died of an apparent drug overdose had begged for help and writhed in pain for more than an hour before he collapsed and a supervisor approved calling 911, a coroner’s inquest heard.

The teen, whose identity is protected under the Youth Criminal Justice Act, was pronounced dead at a Saskatoon hospital on July 30, 2015.

Testifying before a six-woman jury at a public inquest in Saskatoon Court of Queen’s Bench on Tuesday, youth worker Peter Gravlin said he recommended calling an ambulance as soon as he saw the teen, but was overridden by two supervisors within 10 minutes.

They apparently didn’t know if they were witnessing a bad drug withdrawal, faking or a deadly overdose.

Each of them phoned psychiatric nurse Pamela Watt at home for advice; she said the symptoms they described were consistent with drug withdrawal, the inquest heard.

In questioning Watt, lawyers at the inquest focused on how to determine the small differences between the signs of someone under the extreme effects of a drug, extremely difficult withdrawal and the effects of an overdose that could be fatal.

Watt said a doctor later told her “There’s a fine line between being high and overdosing.”

Unable to directly assess the patient herself, Watt advised the supervisors to call an ambulance if anything changed in the teen’s condition or behaviour. She noted that blue lips or fingertips and slurred speech would be important signs of circulatory problems.

Gravlin said the supervisors saw the youth’s condition as he did, and told him to watch for the blueness and slurring.

The youth had not slept during a two-week methamphetamine binge preceding his arrest three days earlier, the inquest heard. An addictions worker at the youth facility had warned the assembled staff that the boy’s withdrawal “was going to be ugly,” Gravlin said.

On July 29, the youth told staff he had ingested methamphetamine while at the provincial courthouse that day, but “it was generally thought as not very likely” he could have obtained drugs while in the custody of courthouse security, Gravlin said.

The youth, who had been at the facility before, was known for manipulating staff, including asking to go to the hospital “to have a bit more freedom in his day,” Gravlin said.

Despite that, he was convinced the youth needed medical attention, he said.

“I saw an extreme and very disturbing presentation. He was highly agitated, moved from one position to another, bounced from floor to standing to wall. He was crying out, asking for help, writhing in pain. He was in a state of considerable pain, like nothing I had ever seen before,” Gravlin said.

The inquest is expected to continue today.