INQUEST: Day 3
Elgin-Middlesex Detention Centre (MORRIS LAMONT, The London Free Press)
Editor's note: The inquest into Jamie High's death is expected to last all week. Reporter Randy Richmond will be Tweeting live from the proceedings. Scroll down to the bottom for the feed.
No one could help Jamie High the final moments he lay dying on the floor of a segregation cell at London’s provincial jail because there weren’t enough correctional officers in the unit, an inquest into his death heard.
A shortage of nurses also prevented a mental health specialist from doing what he wanted to help the St. Thomas realtor, the inquest heard Wednesday.
Understaffing — along with overcrowding — have often been cited in recent years as contributors to problems at the Elgin-Middlesex Detnetion Centre (EMDC), a frequent flashpoint for troubles in Ontario’s correctional system.
Besides the staffing shortages, the four-women, one-man inquest jury into High’s death also heard the following on the third day of the inquiry into his death:
— From the time he was found standing naked on his top bunk and soaking wet with sweat the morning of Dec. 22, 2014, to the moment he was found lifeless in his jail cell Dec. 23, his behaviour was deemed due to suspected drug withdrawal.
— That behaviour – lying on the floor, muttering to himself, staring into space, unable to answer questions — was so frequent, it came to be considered normal.
— Information about High’s conditions might have been passed from health care staff to correctional staff, but only verbally.
— Staff had no training to recognize or manage alcohol withdrawal.
— High’s death may have been preventable: He died of delirium, a syndrome a pathologist testified is often treatable while the underlying causes — and there are many — are often curable.
As another exhaustive day of inquiry wound down, High’s family left the inquest while two short videos — seconds in length — were played.
The videos showed High being taken by wheelchair to a room at EMDC for a video appearance at St. Thomas court Dec. 23.
In the video, High sits quietly under a white heavy gown that covers him from neck to knee, arms on his lap. Once he looks to the side, but mostly he looks ahead or down. It’s the last image of him alive.
Many of the issues raised at the inquest — lack of training for health care and correctional staff, communication gaps within the jail over inmates’ health and treatment — have been raised dozens of times abefore at inquests over the past nine years in Ontario.
Mental health nurse Mike Moretti raised another common issue — staffing shortages.
Moretti checked High twice the day he died, once in the cell about 8:21 a.m. Dec. 23, and once through the window shortly after 9 a.m, and attributed his condition to drug withdrawal.
But Moretti said he never had the time to consult medical charts or take other steps to get a true assessment of High.
“I was hired as a mental health nurse. . . to take certain steps. I went through three superintendents, three program managers and one health care manager requesting that I want to do the job that I was hired for,” he said, his voice thick with frustration.
Instead, he became an overpaid medication dispenser, he said.
“I could have went in there (High’s cell) as a true mental health nurse,” he said.
Time and time again, “That didn’t happen so it was a time for me to resign and I left.”
“I feel guilty,” Moretti said. “I really do.”
Moretti was one of several people looking after High in his final hours.
Then-security manager Tim McFadden was called down to segregation about 7:45 a.m. Dec. 22, and found High “standing on his bunk, naked and sweating profusely.”
He talked High down, suggesting the court appearance could lead to his release that day, McFadden said.
But he didn’t talk to anyone about High’s mental or physical health.
“I saw a very anxious man. I talked him down. And he came to be, in my opinion, just another offender,” McFadden said.
High left for court and got back around 2:20 p.m., complaining of an infection.
Nurse Deb Barnes testified he had no infection but he was anxious.
“He was upset because he thought he was getting out at court.”
The evening of Dec. 22, High “was a little bit off,” correctional officer Matt Hopkins said.
He called the jail’s health care department about his concerns, but was told High was withdrawing from something and such behaviour was expected, Hopkins testified.
The next morning, Dec. 23, he was told by other officers High “slept through the night and really there was no change,” Hopkins said.
He didn’t check the actual logs of the overnight period, which showed High spent a restless night pacing his cell.
Hopkins called health care again at 8:21 a.m because High “appeared to be unresponsive and lying on the floor.”
Moretti came down in the middle of dispensing medications, found High on the floor and asked if he could help, and if High had been taking street drugs.
To each question, High gave an angry, “No!”
Moretti said he had no idea High might be in withdrawal from prescribed medications or alcohol.
Shortly after 9 a.m., after High had come back from a video appearance in court, Moretti checked him again and saw High walking in his cell. Moretti decided to put High at the top of the list to see a psychiatrist at noon that day.
Correctional officer Hopkins still had concerns about High, but by then the strange behaviour “became the norm for that inmate.”
On one of his regular 10-minute checks, at 10:30 a.m., he saw High on the floor, naked and not noticeably breathing.
One of the three segregation officers had been called out to do a search and the other had stepped out for a bit, leaving him alone, Hopkins said.
At that same moment, two other inmates were in crisis, threatening to hurt themselves and covering the windows.
When his partner returned, he checked on High and found him with no vital signs.
Staff tried to revive High but he never came back, declared officially dead at hospital at 11:30 a.m.
The cause of death was delirium, with a possible factor an enlarged left heart chamber, pathologist Dr. Elena Tugaleva testified.
“There is some uncertainty to cause of death in this case.”
Delirium is a clinical syndrome that usually has an underlying medical condition, or history of drug use, or withdrawal.
Delirium can kill by a heart rate jumping or becoming irregular, she said.
The syndrome can often be treated while the underlying condition is cured, she said.