Autopsy didn’t reveal cause of man’s death in jail cell
Gerald Burnouf was in Saskatoon without his methadone when he went to hospital emergency rooms eight times in five days.
Two days later, the Ile a la Crosse man died in a jail cell.
Addictions expert Dr. Peter Butt told a coroner’s inquest Wednesday he sees Burnouf ’s death as a result of systemic bias against people addicted to drugs.
Burnouf, 49, died Oct. 8, 2016, at the Saskatoon Correctional Centre, within hours of insisting he had a prescription for methadone and being told he didn’t.
“This was a repeated cry for help,” Butt said.
A person with schizophrenia would have been kept in hospital under comparable circumstances, he added.
For some unexplained reason, no one, including Burnouf, seemed to be aware that a methadone prescription had been waiting for him at the drugstore across the street from St. Paul’s Hospital since Oct. 3.
He was admitted to St. Paul’s once and Royal University Hospital twice between Oct. 1 and 3, and five times more over the next four days. The admissions lasted between three and 18 hours each. He saw psychiatrists and was referred to Larson House detox centre, but would have to wait about 36 hours, leaving him without help during the withdrawal.
“We’ve got a problem with the way we treat substance abuse system wide,” Butt said.
“I think he got sub-optimal treatment, system wide. We can do better, we have the information … ( but there is a) stigma, a lack of commitment to make change.”
Butt said people work within systems and with the resources they have.
Forensic pathologist Dr. Shaun Ladham testified that he could not explain what caused Burnouf’s death.
The 49-year-old man’s body had non-toxic levels of methamphetamine, often called crystal meth, and methadone, which helps addicts manage addictions recovery.
Nor did Burnouf die from withdrawal from his prescribed methadone, since he somehow obtained some in the days before he was taken to the Saskatoon Correctional Centre, where he died less than 36 hours after his arrival.
Jail video showed Burnouf gesticulating as he asked a nurse for methadone. He appeared to take the ibuprofen and Gravol she gave him and then lay on his cot and pulled the blanket up to his chin.
He didn’t move again and was found not breathing about two hours later. Burnouf’s cell mate told an investigator he heard the man snore once, loudly, about 20 minutes before a guard found him unresponsive.
Institutions that deal with people withdrawing from opiates should have protocols to manage detoxification or they place people at risk, Butt said.