Inmate showed overdose signs before found without a pulse
‘I did not get the feeling ... that we were in a crisis situation,’ nurse says in video shown during inquest into jail deaths
“MAYBE I WAS THE LAST one that even talked to him,” the voice says, before pausing.
The woman speaking is Ruth Ann Day, a now retired Hamilton Wentworth Detention Centre nurse, in an audio-recorded interview played Friday at the inquest into inmate Marty Tykoliz’s overdose death.
Indeed, it appears her interactions with him inside segregation unit Cell 12 around 6:45 a.m. on May 6, 2014, was the last time he spoke with anyone, before falling asleep and then becoming unresponsive.
Tykoliz would be discovered without a pulse in his cell shortly after 9 a.m. and, despite being given two shots of the opioid antidote naloxone, he never regained consciousness and was pronounced dead around 2 a.m. the following morning after being taken off life support.
Day was the first nurse in that morning at 6 a.m. and was trying to prepare medicine for inmates going to court when she received a message to check on Tykoliz. A correctional officer was concerned about him after returning from hospital the night before.
The retired nurse was not available to testify in person at the inquest,
which is also examining seven other drug-related deaths inside the jail between 2012 and 2016.
Inside the cell that morning, Day said, “Tyk, it’s me,” she recalled. He sat up and said, “What do you want?”
He told her he was OK, she said in the audio recording. But his blood pressure and pulse were very low. Both are signs of an overdose. The emergency room doctor he’d seen the day before, Dr. John Crossley, had said in the presence of correctional officers that Tykoliz should return to hospital if symptoms returned. But it’s unclear if this was communicated.
Instead, Day said: “I did not get the feeling ... that we were in a crisis situation.”
She left Tykoliz in the cell and claims she told another nurse who arrived later that morning to keep an eye on him. But no other nurses saw him until he was found without a pulse more than two hours later. Day said she was “shocked.”
After the nurse left, correctional officer Anthony Byrne, who was working in segregation that morning, started a new observation report and wrote “head watch” under the reason, he told the inquest Friday.
A head watch can only be ordered by medical staff and has its own specific form; under a head watch, correctional officers are supposed to wake an inmate every hour and make sure he or she can follow simple conversation.
Yet there appears to have been no formal followup.
When breakfast was delivered around 7:20 a.m., Tykoliz appeared to be sleeping.
Byrne testified he was concerned that Tykoliz hadn’t touched his breakfast and around 7:40 a.m. went into his cell and tried to wake him. He says Tykoliz half-opened his eyes, snorted and fell back asleep.
The last log on his observation report shows Tykoliz was snoring at 8:20 a.m. — the inquest has heard snoring can be an overdose symptom, but one that medical experts say on its own doesn’t offer a clear signal.
More than 40 minutes went by before Byrne found Tykoliz unresponsive at 9:03 a.m.
For Marty’s sister, April Tykoliz, listening to all witnesses recount everything that led up to her younger brother’s death has been “emotionally draining,” she said outside the hearing.
Throughout she has been shocked to hear how easily drugs get in, how they circulated right under the nose of correctional staff with little being done, and by the communication gaps between health care and other staff.
But it was Friday’s testimony, of her brother slipping away without anyone helping, despite clear warnings he was overdosing again, that stands out.
“What’s the most on my mind, that’s bothering me is how could ... you see somebody has low blood pressure, you’re aware of what happened to them the day before? How do you walk in there for literally minutes, walk out, slam the door and nobody goes to see him for hours, then he’s found dead?” April said. “It’s beyond comprehension to me.”
The inquest resumes Monday.
Throughout April Tykoliz has been shocked to hear how easily drugs get in, how they circulated right under the nose of correctional staff.