Communication breakdowns between jail, hospital highlighted at inquest

Probe into eight drug-related deaths hears from doctor who treated overdose victim

The emergency room doctor who treated Marty Tykoliz when he overdosed May 5, 2014, discharged the 38-year-old back to jail with instructions he should return to hospital if symptoms return.

But that’s not what happened, an inquest into eight drug-related inmate deaths at the Hamilton-Wentworth Detention Centre has heard.

“In the presence of guards, I told (Tykoliz) if any symptoms return he should be brought back to hospital,” said Dr. John Crossley, the emergency room physician working at Hamilton General Hospital that day.

He testified he also asked the two correctional officers what would happen when he returned to jail, and said he was told Tykoliz would go to the segregation unit where he would be checked at least hourly.

At that time Tykoliz, who had been given naloxone — the opioid antidote — by a nurse in jail, was awake and responsive. Crossley didn’t know the drug he had overdosed on was methadone, a very long-lasting opioid.

What was communicated back to staff at the jail is unclear. While there should have still been a nurse on duty when Tykoliz arrived back at jail around 8:33 p.m., he was not seen by a nurse, but was taken straight to segregation Cell 12.

He was not put on an official head watch — which would dictate he’s woken every hour — and an observation report was started, but not filled out overnight.

No one called for an ambulance when just before 6 a.m. the next morning a correctional officer found him speaking gibberish and moving slowly; nor when a nurse took his vitals around 6:45 a.m. and found his blood pressure and heart rate were low.

At 9:08 a.m., he was found unresponsive in his cell.

This time, the naloxone didn’t revive him, testified jail nurse Debbie Heiliger.

He was blue, with a weak pulse and was vomiting a black liquid. He never regained consciousness.

Communication issues between health-care and corrections staff have been frequently highlighted during the inquest so far, including documents not always being filled out and a reluctance to share information, at times.

The large-scale inquest, which began on April 9, is examining the drug-related deaths of Tykoliz, Louis Unelli, William Acheson, Trevor Burke, Stephen Neeson, David Gillan, Julien Walton and Peter McNelis. Their deaths occurred at the Barton Street jail between 2012 and 2016.

When Tykoliz was sent to hospital that first time, Heiliger was also working. She was the nurse who filled out the health-care consultation form with information about what had happened for the hospital. It was handed over to the correctional officers who escorted Tykoliz to hospital. They were supposed to give it to paramedics, who are supposed to give it to medical staff, where a doctor is supposed to fill out instructions for care when the patient returns.

In Tykoliz’s case, like many, that form never came back.

On May 4, the inquest previously heard that a new inmate had arrived on Tykoliz’s 3B Right unit with a “package” of drugs. That inmate, Paul Lutraan, and Tykoliz were caught by a correctional officer with drugs, but Lutraan hid two packages up his rectum and Tykoliz flushed the other.

Yet, the pair were allowed to stay in the same cell.

On Thursday, a security video from the common area was played, showing Tykoliz, only in blue jail underwear, wandering around the range and apparently snorting a powdered substance off a table.

The inquest has heard no one at the jail was actively watching the security camera feed.

Originally autopsy reports suggested it wasn’t clear whether Tykoliz died from the original overdose that came back after the naloxone wore off, or whether he took more drugs. However earlier in the inquest a pathologist and toxicologist said they now believe it’s more likely he took more drugs after returning from hospital.

This issue will be examined later in the inquest, which continues Friday.