System failed teen who died of OD, worker testifies

A 17-year-old inmate of Saskatoon’s Kilburn Hall youth detention facility who died of an apparent drug overdose “was failed that night,” a staff member testified at a coroner’s inquest.

The teen, whose identity is protected under the Youth Criminal Justice Act, was pronounced dead at Royal University Hospital on July 30, 2015.

Angela Silva, on the witness stand Wednesday before a sixwoman jury at a public coroner’s inquest in Saskatoon Court of Queen’s Bench, said the teen begged her to believe him when he told her around 10 p.m. that he had swallowed two grams of crystal methamphetamine about 15 minutes earlier.

His mouth was “chattering ” and he was very agitated, she said, adding the boy told her, “I’m overdosing. I took too much … I need an ambulance … I’m going to (expletive) die. Do you realize this?”

Silva said she immediately told supervisor Dale Laroque that the teen was asking for an ambulance, but after Laroque phoned a nurse he said they would call an ambulance if the boy’s fingers or lips turned blue. She said she made the same request to the supervisor who took over after the 11 p.m. shift change, with the same results.

She described a frustrating, desperate vigil with the teen as his condition deteriorated and he begged for help. He co-operated by sitting near the food hatch so she could reach through, but he shook too hard for her to read his pulse, she said.

She has seen many people coming off drugs, but the teen’s condition that night was different from the usual lethargy and vomiting, she said.

She saw the boy’s body shaking as he was on the floor, begging for his life with his eyes rolling back in his head, Silva testified. She said she felt helpless to intervene beyond insisting to supervisors to call an ambulance. It would have been insubordination to disobey a superior, she said.

“I could have lost my job … I’ve struggled with that,” she testified, visibly struggling to hold back tears. She has been on leave from her job since the incident, she said.

The teen deteriorated “extremely” in the two hours before he collapsed and became unresponsive, when staff called the ambulance, she said.

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

Silva said the boy “should not have had to die in an institution where we have the capability of having help.”

“People come to jail and their freedom is taken away, but their human rights are not supposed to be.… He was failed that night.”

Emergency room physician Dr. Elsa Lubiantoro testified by phone Wednesday. She said the teen was in cardiac arrest when he arrived. Paramedics and ER staff administered epinephrine trying to restart his heart, used other drugs and did chest compressions, but were unable to revive him, she said.

There is no reversal agent for methamphetamine but medical staff can manage the effects, such as elevated heart rate and seizure. She doesn’t know if the teen could have been saved if he had been brought in sooner, Lubiantoro said.

Supervisor Dale Laroque began his testimony Wednesday and is expected to be questioned further on Thursday.