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Inquest jury recommends for new jail to be built; rules inmate's death to be caused by alcohol withdrawal

THUNDER BAY - For the second time this year, a coroner’s inquest jury is urging the provincial government to replace the nearly century-old district jail.
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(tbnewswatch file photograph)

THUNDER BAY - For the second time this year, a coroner’s inquest jury is urging the provincial government to replace the nearly century-old district jail.

Building a replacement to the Thunder Bay District Jail was one of nine recommendations the jury made in the inquest into the death of 29-year-old Christopher Coaster, who was found dead in a jail cell nearly eight years ago.

The inquest, which began earlier this week, concluded late Friday afternoon after three days.

The jury determined Coaster’s death to be of natural means with delirium tremens caused by alcohol withdrawal as the cause of death. As well, they accepted all eight recommendations proposed by the parties with standing and added one of their own.

Those recommendations include implementing an electronic medical record system, working with the Centre for Addictions and Mental Health to explore revisions to the present alcohol withdrawal screening tool to require automatic hospital transfers in severe cases, review duties of jail staff to identify gaps in health care needs and to ensure jail staffing levels.

The inquest heard evidence that Coaster had been arrested for breaching his conditional release by consuming alcohol. He was remanded into custody at the district jail pending his next court appearance.

While in the jail he was put in a segregated cell, enclosed from the inside with Plexiglas, in the northeast corner of the second floor of the building after being deemed a suicide risk and behaving erratically.

On the morning of Aug. 3, 2008 Coaster had been observed banging the walls of the cell while yelling and psychotically laughing. Correctional officers who testified described him as being disoriented and they believed him to be hallucinating.

The cell lacked air conditioning with one officer describing the hot conditions as “disgusting” and Coaster did not consume much food or liquid. While officers stationed outside the cell had a small fan, there was nothing for the inmates.

At about 10:30 a.m. he appeared to begin to calm down and relax. He laid down in his cell and staff believed he was sleeping.

They tried to rouse him two hours later and found him dead in the cell.

Earlier this year the jury in the coroner’s inquest of Ronald Fagan and Jacy Pierre, two inmates who died in the jail a month apart in 2007, also called on the Ministry of Community Safety and Correctional Services to build a new jail.

The recommendations:

To the Ministry of Community Safety and Correctional Services

  1. The Ministry shall build a new facility to replace the THunder Bay Jail. The design and construction should address:
  • Fostering the health of inmates
  • Eliminating overcrowding of inmates
  • Adpoting the best design to provide in-house medical care to inmates from intake assessment to appropriate continuing monitoring and provision of medical care to inmates within the jail.
  • Having enough medical observation beds and medical segregation cells to meet the needs of the present and anticipated population of the jail.
  1. The Ministry implement an electronic medical crecord system to:
  • Facilitate continuity of care through improved communications among professionals and enable safe clinical decision making
  • Improve the ability to monitor health status, including substance use disorders and outcomes over time
  • Enhance appropriate utilization of services, including health-related programs
  • Collect data for future resource program planning, research or education
  • Conduct quality of care reviews
  • Develop an alert and notification ssystem to ensure compliance with provincial standards of care (e.g. CIWA-Ar scoring thresholds)
  1. Explore with CAMH the revision to the present CIWA-Ar screening tool to include language that:
  • Scores between 10-20 require consultation with a physician directly or through the Ontario Telehealth Network
  • Scores of 20 or greater require automatic inmate transfer to the hospital
  1. Ensure that the training for health care staff includes both the provincial orientation manual and case studies such as the one involving Mr. Coaster to personalize the illustrate the importance of adhering to provincial standards. Regular and timely review of all coroner inquest recommendations that relate to deaths in correctional facilities as a source of continuing education

To the Thunder Bay Jail

  1. Review the duties of nurses, correctional officers and operational managers to identify gaps in the health care needs of inmates and address any that may exist. For example, the use of medical observation forms by correctional officers to assist in health care decision making and regular debriefing between medical staff and correction officers.
  2. Management of the Thunder Bay Jail should review both the health care and correctional officer staffing levels to ensure compliance with provincial standards. For example, the ability of nurses to administer the CIWA-Ar assessment tool and conduct reassessments every one or two hours or as required. Management shall request addtional staff from the Ministry if and as required.
  3. That all staff receive additional and ongoing training on alcohol withdrawal and delirium tremens (DTs) conditions in the inmate populations.
  • In the particular the medical (nursing and contract physician) staff be trained on the proper utilization of alcohol withdrawal assessment tools (CIWA-Ar and the management of alcohol withdrawal policy and procedures)
  • All non-medical staff receive awareness training on signs and symptoms of alcohol withdrawal and DTs.
  1. Explore addtional options for the management of dehydration in inmates experiencing symptoms of alcohol withdrawal.
  2. Until an adequate infirmary is made available all inmates being assessed with the CIWA-Ar form with scores between 10-20 require a one-to-one correctional officer watch.


Matt Vis

About the Author: Matt Vis

Born and raised in Thunder Bay, Matt is honoured to tell the stories of his hometown.
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