Inmate’s death not likely preventable: report
A public fatality inquiry determined a former Charlottetown woman with a long criminal record died of a cardiac event that was most likely unpreventable.
The report, released last month, follows a five-day inquiry in January into the death of Jolee Mary Acorn, 36, of Calgary who was found unresponsive in her cell in the healthcare unit of the Calgary Remand Centre (CRC) on Aug. 10, 2014.
Acorn, who had a criminal record on P.E.I. that included convictions for possession of stolen property, fraud, theft, and assault causing bodily harm, was arrested on Aug. 6, 2014, by the Calgary Police Service for a number of charges.
She was admitted to the Calgary Remand Centre the following day and was remanded into custody without bail.
She remained in custody until her death three days later.
On Aug. 9, 2014, correctional peace officers (CPO) noted Acorn was complaining of drug withdrawals and escorted her to the medical area of the CRC.
She claimed that she took morphine and heroin daily prior to incarceration. Alberta Health Services (AHS) transferred Acorn to the CRC infirmary and placed her on a narcotic withdrawal regime as per physician’s orders.
Acorn was admitted to the infirmary unit and placed in a cell.
Shortly after midnight on Aug. 10, AHS documented that Acorn had vomited in the sink and on the floor of her cell. She was given Gravol and encouraged to lie down and rest.
Acorn exited her cell later that morning at 8:13 a.m. and interacted with a nurse who took her blood pressure three separate times.
A correctional peace officer accessed Acorn’s cell at 10:35 a.m. and found the female inmate unresponsive. He initiated a medical emergency code.
Several efforts were made to revive Acorn. None were successful.
She was declared deceased at 11:47 a.m. on Aug. 10.
The inquiry found that in July 2012, Acorn was seen by a cardiac specialist and assessed as possibly suffering from a relatively rare heart condition of Wolff Parkinson White syndrome.
On her admission to CRC, Acorn provided little information about her health to the admitting nurse. At some point during her stay at CRC, she did inform the AHS staff that she had a cardiac issue that could cause irregular heartbeats, but there were no discussions between Acorn and AHS staff about Wolff Parkinson White syndrome (WPW).
Dr. Tera Jones, the medical examiner, determined the cause of death to be a fatal cardiac event most likely due to WPW. She also confirmed that Acorn’s drug use was likely a significant condition contributing to her death.
The report concludes “it is highly unlikely that Ms. Acorn’s death was preventable.’’
Several recommendations were made for the prevention of similar deaths, including education for all corrections nursing staff on the physiological effects of opiate withdrawal and to specifically include assessing fluid volume loss and replacement as well as nursing management of the patient generally.