Coroner’s inquest makes recommendations to improve safety of inmates25 October 2022
SAINT JOHN (GNB) – A jury at a coroner’s inquest has made recommendations to improve the safety of inmates in New Brunswick’s correctional facilities.
An inquest into the death of Derek James Whalen was held Oct. 17-20 at the Saint John Law Courts. Whalen died accidentally on May 3, 2020, following an incident at the Southeast Regional Correctional Centre in Shediac.
The five-member jury heard from 21 witnesses and made 23 recommendations.
The following recommendations were directed to the Corrections Branch of the Department of Justice and Public Safety:
· Draft a policy dealing with inmates in unsecured rooms or areas within the facility.
· Ensure handheld cameras and/or body cameras with audio are functional for all incidents.
· Draft a policy to require the use of body scanner and trace detecting devices upon admission into the facility.
· Ensure one correctional officer per functional area is trained on using an electronic control device.
· Provide access to the Wrap or similar products on-site as an alternative to handcuffs/shackle restraints.
· Ensure correctional officers have the prerequisite skills to identify critical illness and provide effective lifesaving basic interventions. Correctional officers should be trained and remain up to date with their Medical First Responder courses. All correctional officers must have an up-to-date first aid training and it should be documented.
· Adopt a “cuffs on, cops off” principle to ensure that inmates are not lying flat on their stomach any longer than necessary.
· Return spit hoods as a tool to be used when an inmate is spitting at an officer along with required training and monitoring of use.
The following recommendations were directed to Horizon Health Network:
· Provide nursing access to critical medical history through the electronic health record and the Social Services data systems.
· Ensure a policy is in place that supports standard operating procedures regarding an evidence-based approach to overdose, toxicology and excited delirium.
· Mandate the collection of vitals physiology, including pulse rate, respiratory rate, oxygen saturations, blood pressure, blood glucose and temperature as part of a methodical assessment for safety and stability. These physiologic measurements if found to be abnormal, should be collected to allow the identification of a trend.
· Mandate the collection of clinical data using an organized primary survey or ABCDE assessment and document on the patient report form. The form’s usage should be audited.
· Write a curriculum for nurses working in correctional facilities based on need.
· Draft a policy to allow registered nurses in correctional facilities to administer chemical restraints.
· Provide nurses with education to perform, at a recognized and approved level, a primary survey to guide subsequent actions and assist in the identification of threats to life. Educational options are: Emergency Medical Responder, Advanced Cardiac Life Support, International Trauma Life Support, Medical First Responder.
The following recommendations were directed to both agencies:
· Draft a policy to direct that equipment inventory and maintenance interval records are kept and visible to management, and have these records reviewed annually.
· Secure provincial access to rapid online medical support that will provide access to clinician guidance to on-site nursing staff and/or correctional officers when required.
· Draft a policy to mandate nursing attendance to all 1099 codes (which means: officer needs assistance) to mirror the Horizon Health Network Policy on team composition at “code white” or potentially violent patients. Ensure staffing levels to support this response at all times.
· Adopt the use of a challenge response checklist to identify excited delirium during all 1099 events.
· Offer training for nurses and correctional officers with case base discussions on recognizing drug overdose, excited delirium, use of force, positional asphyxia, addiction & team-based simulation training in realistic operational environments utilizing low fidelity mannequins (CPR/AED). Should be part of onboarding and then annual refresher.
· Social workers, mental health personnel and addiction services should be available to inmates and staff.
· Recognize that excited delirium, or other signs of distress such as difficulty breathing, should be treated as a medical emergency. The policy should direct that internal medical service and Emergency Medical Services be called early in the incident. In times when nursing staff are not available, 911 should be called right away.
· Incident management training should be completed province-wide for correctional services to ensure that the span of control and chain of command are established.
These recommendations will be forwarded to the appropriate agencies for consideration and response. The responses will be included in the chief coroner’s annual report for 2022.
An inquest is a formal court proceeding that allows for the public presentation of all evidence relating to a death. It does not make any finding of legal responsibility nor does it assign blame. However, recommendations can be made aimed at preventing deaths under similar circumstances in the future.