Jury suggests jail review detox program, help staff access medical records
The Saskatoon Correctional Centre should make it easier for its medical unit staff to access inmates’ health records, a coroner’s jury recommends.
The six-member jury found Thursday that Gerald Wayne Joseph Burnouf died at the jail from an undetermined cause at 6:31 p.m. on Oct. 8.
Correctional staff should indicate what signs of life they observe when a person is under medical supervision and should have annual formal training on recognizing the signs of drug use, withdrawal and treatment, the jury recommended.
They also recommend the jail have an addictions expert review how the methadone program is used in the jail and look into using suboxone instead.
Burnouf, 49, was from Ile a la Crosse and was in Saskatoon on Oct. 1, 2016, when he went to St. Paul’s and Royal University Hospitals. He was sometimes known as Gerald Laliberte. Burnouf was likely in withdrawal from methadone after his supply ran out on Sept. 30, the inquest heard during three days of evidence.
He was admitted to the hospitals eight times in five days.
During that time, he took methadone from an unknown source, and methamphetamine. He saw psychiatrists three times and was diagnosed as being in a drug-induced psychosis.
Despite that, he seemed to fall between the cracks.
Burnouf ’s doctor sent a methadone prescription for him to a drugstore near St. Paul’s hospital on Oct. 3, but Burnouf never had it filled.
He was taken into police custody Oct. 6, and went to jail Oct. 7, while apparently suffering side effects of anti-psychotic and sedative medications he received at the hospital.
Two nurses at the jail tried to find out if Burnouf had a prescription, but couldn’t access the information. Royal University Hospital was not allowed to share the information without consent from Burnouf.
Forensic pathologist Dr. Shaun Ladham said he was unable to find the cause of death. He and addictions expert Dr. Peter Butt told the inquest drug use was probably a contributing factor.
Butt said Burnouf received “suboptimal treatment, system-wide,” and that there is a lack of commitment to make the improvements needed.
Institutions that deal with people withdrawing from opiates should have protocols to manage detoxification or they place people at risk, he said.
Lawyer Neil Robertson presided as coroner over the inquest. Lana Morelli was counsel for the Coroner and James Steele was counsel for the Ministry of Corrections, Public Safety and Policing.