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.