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Inmate's death in 2009 deemed accidental: inquest

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A provincial judge is proposing changes and improvements to how staff in Manitoba jails receive complaints and concerns from inmates, medical record-keeping and the hours nursing staff work at Headingley Correctional Centre.

Judge Robert Heinrichs’s inquest report and findings regarding the accidental death of Donald Ray Moose, 32, were released today.

Moose, a diabetic with heart disease, died in Grace General Hospital on Oct. 2, 2009. He was rushed there from the HCC after staff saw he was disoriented, having difficulty breathing and not responsive to glucose to address his diabetes, the province said.

He had two heart attacks and couldn't be revived.

A forensic pathologist ultimately found Moose's cause of death was coronary artery disease, with elevated levels of the drugs Amitripyline and Nortriptyline as a contributing cause.

In his 88-page report, Heinrichs pieces together the series of events leading up to Moose's hospitalization, death and autopsy.

He found no fault with jail staff, or jail and emergency medical workers.

"What emerges is a picture of an institution which took good care of its inmates, a busy medical staff that provided quality care for the inmates, and emergency personnel who did what they could with all of their professional ability and experience, during Donald's medical crisis," wrote Heinrichs.

The judge did, however, find problems and gaps in communication between HCC staff and inmates and issues with medical records and how they are recorded.

In response, Heinrichs recommends the province take swift action on the following fronts:

— Formalizing a reporting system so that complaints and concerns voiced by inmates are heard by jail staff.

"The evidence this Inquest has heard showed that the correctional officers are sensitive to the needs of the inmates and appear to care about them. This may be particularly so in a unit such as ATC, where they have to request to work and then receive extra training to work there; however, even at ATC there was a general mistrust of the staff by the inmates. A number of them felt they weren't being heard; that there was no point in telling them that they were concerned for Donald's health. If the staff had been told about the inmates concerns for Donald's health when they first saw something, it is possible that Donald might have had a better treatment outcome," Heinrichs said.

— That all provincial jails strive to improve their medical record keeping, including expanding to electronic documentation as much as possible. This should include an ability to share jail health records with hospital emergency rooms.

"It is important that all inmate medical file records have a patient summary, or "Problem Sheet" completed and kept up to date so that when an urgent matter or emergency arises with respect to any inmate, there is a brief and relevant summary available for quick access. As well, the Problem Sheet, or similar pages on an electronic file, should be checked and updated at the time of an inmate’s release from custody so that it presents an accurate reflection of the inmate’s medical issues at that time. This page should be readily accessible to them if he or she ever returns to custody. Accurate, clear and concise medical documentation which facilitates communication and assists with continuity of care for each individual inmate is what is to be strived for. This should be equally true of all nurses, doctors, psych nurses, and psychiatrists working within or for the corrections system," said Heinrichs.

— HCC should expand nurse staffing to 11 p.m. — and possibly to round-the-clock — as soon as possible. Currently, a nurse is on duty until 7:45 p.m. The inquest heard recruitment issues have held back expanding duty hours despite funding being in place.

"This Inquest was advised that the funding was in place but that there had been recruitment issues. Based on the evidence given at this inquest, this should remain a priority for HCC. In addition, HCC should continually review all overnight medical situations with a view to reassessing the merit of 24 hour staffing. This should include evaluating every medical situation that arises during a time when there is no nursing staff on duty and assessing what difference a nurse might have made if he or she had been available for that situation," Heinrichs said.

— Manitoba Corrections should develop a public health information program geared to educating inmates about heart disease, the leading cause of death in Canada.

History

Updated on Wednesday, May 21, 2014 at 2:56 PM CDT: A forensic pathologist ultimately found Moose's cause of death was coronary artery disease, with elevated levels of the drugs Amitripyline and Nortriptyline as a contributing cause.

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