Warkworth in­mate died of Tylenol over­dose, coro­ner’s jury finds


COBOURG-An ac­ci­den­tal Tylenol over­dose was the cause of death of 34-year-old Warkworth In­sti­tu­tion in­mate Jeffrey Yse­bert, a coro­ner’s jury de­cided on Thurs­day.

Yse­bert died at Peter­bor­ough Re­gional Hos­pi­tal Cen­tre on Jan. 11, 2015 af­ter be­ing trans­ferred from Camp­bell­ford Me­mo­rial Hos­pi­tal.

He had been found crouch­ing over his cell’s toi­let be­ing vi­o­lently ill on Jan. 8, 2015.

Yse­bert ad­mit­ted to prison staff he had taken about 25 ex­tra-strength Tylenol be­cause of se­vere shoul­der pain. The in­mate had been wait­ing al­most a year for a re­fer­ral for a shoul­der ul­tra­sound so treat­ment could be pro­vided.

The coro­ner, Dr. Jen­nifer Tang in­structed the five-per­son jury in Cobourg ’s main court­room that they must de­ter­mine the cause of death and that they may pro­vide rec­om­men­da­tions so such a sit­u­a­tion will not hap­pen again.

Yse­bert was serv­ing a five-year sen­tence for a jew­elry store rob­bery in Strathroy, Ont. in 2012.

Dr. David McMil­lan, an ICU spe­cial­ist, tes­ti­fied that Yse­bert was lu­cid upon be­ing ad­mit­ted to the Peter­bor­ough hos­pi­tal and ad­mit­ted hav­ing swal­lowed the pills shortly be­fore be­com­ing ill. The blis­ter pack of 30 pills is dis­trib­uted through health care at the prison but it was un­clear if they had been pre­scribed for Yse­bert or if he had ob­tained them through other sources, court heard.

Foren­sic pathol­o­gist Dr. Micheal Pol­la­nen said that an au­topsy re­vealed the ac­etaminophen over­dose killed the in­mates liver from which he died. Ac­etaminophen is the generic name for Tylenol.

The Tylenol cre­ated a toxin that the in­mate’s liver could not with­stand, court heard. He de­vel­oped hep­ati­tis and liver fail­ure as a re­sult. Be­cause of a his­tory of prior drug abuse, Yse­bert would have been an un­likely can­di­date for a liver trans­plant, court heard.

OPP Det. Const. Daniel Peters tes­ti­fied there was no in­di­ca­tion of crim­i­nal ac­tiv­ity lead­ing to the in­mate’s death.

The jury agreed with the rec­om­men­da­tions put for­ward by coro­ner’s counsel that any drugs ad­min­is­tered by the Cor­rec­tional Ser­vice of Canada should set out a max­i­mum daily dosage and the harm­ful ef­fects if too many are taken and that CSC dis­trib­ute no more pills than the max­i­mum daily dose.

The jury came up with two additional rec­om­men­da­tions: That dur­ing hourly ob­ser­va­tion of in­mates in their cells, staff also note any ap­par­ent dif­fi­cul­ties ex­hib­ited by in­mates and that CSC look to in­creas­ing ef­fi­ciency in hav­ing in­mates seen by out­side med­i­cal spe­cial­ists and hav­ing spe­cial­ized tests un­der­taken.

In­quests are manda­tory when a pris­oner dies in cus­tody.

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