Download Report to the Minister of Justice and Solicitor

Report to the Minister of Justice
and Solicitor General
Public Fatality Inquiry
WHEREAS a Public Inquiry was held at the
in the
City
of
on the
Provincial Court of Alberta
Calgary
(City, Town or Village)
Fatality Inquiries Act
, in the Province of Alberta,
(Name of City, Town, Village)
8, 9, 10 and 12th
day of
June
,
2015
,
year
Before
The Honourable Deputy Chief Judge McLellan
into the death of
of
Calgary, AB
, a Provincial Court Judge,
Brian Joseph Lapensee
52
(Name in Full)
(Age)
and the following findings were made:
(Residence)
Date and Time of Death:
Place:
8:34 a.m., August 4, 2013
Calgary Remand Centre, Calgary, Alberta
Medical Cause of Death:
(“cause of death” means the medical cause of death according to the International Statistical Classification of
Diseases, Injuries and Causes of Death as last revised by the International Conference assembled for that purpose
and published by the World Health Organization – The Fatality Inquiries Act, Section 1(d)).
Chronic Alcoholism
Manner of Death:
(“manner of death” means the mode or method of death whether natural, homicidal, suicidal, accidental, unclassifiable
or undeterminable – The Fatality Inquiries Act, Section 1(h)).
Accidental
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Summary:
On August 3, 2013, Mr. Brian Joseph Lapensee was admitted to the Calgary Remand Centre. He
was assessed by health care personnel and an alcohol withdrawal regime was initiated. At
approximately 8:00 a.m. on August 4, 2013, Mr. Lapensee’s cellmate notified staff that something
was wrong with Mr. Lapensee. Nursing staff and correction officers immediately responded and
requested that Emergency Medical Services (“EMS”) and an ambulance be called. There was
delay in contacting EMS. The nursing staff and correction officers performed CPR until EMS
arrived who very shortly after pronounced Mr. Lapansee deceased.
Circumstances under which Death occurred:
Please see attached pages for the Circumstances.
Recommendations for the prevention of similar deaths:
Please see attached pages for the Recommendations.
DATED
at
October 21, 2015
Calgary
,
Alberta.
Original signed by
Deputy Chief Judge McLellan
A Judge of the Provincial Court of Alberta
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Circumstances under which Death occurred:
[1]
Brian Joseph Lapensee, 52 years (born March 28, 1961), died on August 4, 2014, while he
was an inmate at the Calgary Remand Centre (“CRC”). An inquiry was held at the Calgary Court
Centre pursuant to the provisions of the Fatality Inquiries Act. Witnesses at the Inquiry were:
Lloyd McFeeters, Lapensee’s cell mate; Jeremy Mannila, Registered Nurse (RN who did an
initial medical assessment of Lapensee); Sandra Strachan, RN; Alana Wade, RN; Kylie
McManus, RN; Dianna Paulson, RN; Melissa Berg, RN; Daniel Roos, Correctional Peace
Officer (CPO1) who had contact with Lapenesee on August 4, 2014; Bradley Cole, CPO2
who received a call from Lapensee’s cell mate and asked an officer to respond, Trevor
McGivern, CPO1 responded to the request to check Lapensee; Lane Maki, CPO2; Kathleen
Irwin, CPO 3 and supervisor of Central Control; Michael Sandford, CPO2 and first
responder who conducted CPR; Curtis May, CPO2 who contacted EMS; Dr. John
Gillespie; physician to CRC; Len Goueffic, Director, Administration and Operations; Dr.
Keith Courtney, Psychiatrist, Facility Medical Director, AHS; Tiffany Murray, Health
Services Manager; Dr. Bamidele Adeagbo, Medical Examiner.
[2]
[3]
Issues to be determined by the Court Fatality Inquiry:
•
Policies and practices of the Solicitor General regarding the monitoring of persons in
cells;
•
Policies and practices of Alberta Health Services regarding monitoring of persons in
cells and the alcohol withdrawal protocol; and
•
The reason for a delay in the call to EMS.
Counsel/Parties at the Court Fatality Inquiry:
• Jo-Ann Burgess, Alberta Justice – Inquiry Counsel
• Mylene D. Tiessen, Peacock Linder Halt & Mack – Counsel for the Alberta Solicitor
General/Calgary Remand Centre
• Blair R. Carbert, Stones Carbert Waite – Counsel for Alberta Health Services
[4]
The Assistant Deputy Minister, Alberta Correctional Services, convened a Board of Inquiry
to investigate the circumstances involving the death of Brian Joseph Lapensee at CRC. The Board
submitted a report with findings and recommendations that the Court was able to review prior to
the Court Fatality Inquiry. A transcript of interviews with individuals interviewed by the Board
was provided and helpful because of the time that had elapsed since his death. The Co-Chairs of
that Board of Inquiry were Len Goueffic, Deputy Director, Adult Centre Operations Branch at the
time of the Report and Tammy Cazal, Deputy Director Programs, Lethbridge Correctional Centre.
[5]
The provision of health care in provincial remand and correctional facilities is under the
sole authority of Alberta Health Services (“AHS”). All nurses referred to in this inquiry are AHS
employees.
[6]
The Board of Inquiry convened by the Assistant Deputy Minister, Alberta Correctional
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Services, recommended that:
[7]
a.
CRC review the status of all First Aid and CPR certificates and expedite training on
any elapsed certifications.
b.
CRC and all centres generate a memorandum for all operation mangers outlining the
responsibility to oversee all emergency code logistics including the calling of EMS,
and to ensure clarity in that the AHS emergency bag cell phone is not intended for the
calling of 911.
With respect to AHS, the Board made the following recommendation:
a. The issue of accurate documentation of information on the part of a nurse be
addressed.
[8]
On August 2, 2013 at 6:14 p.m., Calgary Police Service (“CPS”) arrested Brian Joseph
Lapensee, 52 years. According to Complaint #13284210 and Arrest Processing Unit Booking
Form/Care Report (CPS C-20), he was drunk and uncooperative at the time of arrest. He did not
provide his name, but gave the name of another individual. He was taken to a CPS detachment.
[9]
Lapensee was found to be in breach of recognizance requiring him to remain in British
Columbia. He also had outstanding warrants for arrest for breach of peace bond, fail to comply and
two counts of fail to appear. There were additional warrants for arrest on outstanding fines in
relation to two counts of City of Calgary traffic bylaws and two counts of Gaming and Liquor Act
violations.
[10] At 9:49 p.m., Lapensee was examined by a medic at the CPS detachment. Observations on
the Arrest Care Report include:
•
‘On admission patient walked into medics room with officer(s) present. Pt is
cooperative. Has no obvious signs of discomfort and walks without assistance.
Assessment performed at time of first visit.’
•
‘History C/C: Pt. has no complaints, cooperates with questions, admits to ETOH
(alcohol) use, denies drug use prior to CSS arrival. Has 0 suicidal ideations. Pt. soiled
self enroute to CSS.’
•
‘PMHX: States cleared of Hep C via pegasus program’
•
‘O/E: Pt. conscious and alert, responds to questions normally and appropriately’
•
‘HEENT: Minor laceration to occipital region, 0 active bleeding, patient airway chest –
unremarkable, clear air entry throughout’
•
‘ABDO: soft non-tender’
•
‘Cooperates with questions, admits to alcohol-liquor’
•
‘Denies drug use prior to APS arrival’
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•
‘Has 0 suicidal ideations’
•
‘EXT: no trauma noted, good PMS CMX4, walks with a steady gait’
•
‘His pulse was noted as 111, blood pressure 131/97’
•
‘He was oriented as to person, place, time and event’
[11] On August 3, 2013, at 3:50 p.m., CRC admitted Lapensee from CPS. He was remanded into
custody on three counts of breach of recognizance and two counts of failure to appear in court. He
was scheduled to appear in Calgary Provincial Court and was serving default time on four
outstanding fines for municipal by-law and Gaming, and Liquor Act infractions at warrant. At the
time of admission, an Inmate Records Correctional Administration (“ORCA”) alert appeared on
screen in response to a suicidal record entry made on June 28, 1996.
[12] At 4:05 p.m., Lapensee was placed in a holding tank in the Admission and Discharge area
of CRC. A video recording shows two other individuals in the holding tank. The video shows
Lapensee moving around the area, sometimes lying down.
[13] At 7:08 p.m., AHS nurse Jeremy Mannila saw Lapensee in the Admission and Discharge
Health Care examination office at CRC.
[14] During his shift, Mannila was in charge of new CRC admissions. In this role, a nurse does a
brief medical assessment to identify, address and chart health concerns of new inmates, determines
whether there should be further referrals for medical or mental health issues and assesses the
inmate for appropriate unit assignment based on the assessment. The medical examination,
according to AHS protocol is to occur within 4 hours of admission to CRC. The time limit was met
in this case. Mannila also reviewed Arrest Processing Unit Booking Form/Care Report (CPS C-20)
during his assessment of Lapensee.
[15] According to Mannila, in his written statement of August 8, 2013, for the Board of Inquiry,
p. 4, Lapensee was “obviously hung over. Quite tremulous: shaky. Was complaining of nausea,
headache”. Mannila also said that Lapensee told him he was a “heavy alcohol user”, drinking “2 –
26 (oz. bottles) of vodka a day” and using “Ativan as a medication for when he was sober to get
him through to his next drink”. At the Court Fatality Inquiry, Manilla, in evidence before the
Court, said he knew Lapensee drank daily, drank “lots” and had seizures in the past.
[16] Mannila was questioned in court about the Arrest Processing Unit Booking Form/Care
Report (CPS C-20). When asked whether anything in the report stood out as being of concern,
Mannila said the pulse of “111” was ‘not super alarming”. He said Lapensee looked like he was
“physically unwell”. Mannila said Lapensee’s pulse and blood pressure of “131 and 97” were “still
normal limits.” Lapensee’s heart rate was 121 bpm when Mannila did his assessment (based on
memory).
[17] A Corrections Admission History form must be completed at the time of the interview and
electronic entries are made on the form pursuant to Adult Centre Operations Branch and AHS
policy. Mannila said that he made entries on this form and on the Multidisciplinary Notes at 7:08
p.m. He did not print the Corrections Admission History form or it was misplaced, as a copy was
not available. The computer system does not save this form and information on the form is lost if it
is not printed. Manilla said he entered remarks on the Multidisciplinary Notes from memory. Once
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he was aware the form was not available, he filled out another Corrections Admission History by
hand noting “Late Entry” and “Printer Malfunction” on that form. He entered Lapensee’s vital
signs from memory.
[18] Mannila explained that there was an Alcohol Withdrawal (“AW”) Regime at the time of
Lapensee’s admission to CRC pursuant to a physician standing order signed by Dr. Gillespie, a
contract physician for CRC for several years. The initiation of the regime was based on clinical
readings and observations that are scored during an assessment of the inmate. The score determines
the initiation of the regime including medication, dosage, frequency and duration of the regime.
[19] In his statement to the Board of Inquiry, Mannila went through the Corrections Admission
History form and set out the following in terms of his assessment of the inmate (from memory and
his form filled out later when it was discovered the original was not on the file) and the
commencement of the AW Regime by him:
•
‘Inmate said he had no allergies’
•
‘He was a heavy alcohol user with straight vodka’
•
‘Stated he had Ativan when he was sober to get him through to his next drink’
•
‘He did have a history of seizures, so that’s a red flag for us, definitely for sure. And
just from working in the ER with alcoholic people before, I would know that he
definitely needs something to prevent the seizures’
•
‘He was not having any oral or visual hallucination so that was a good thing’
•
‘He was alert and oriented times three’
•
‘His pulse was a red flag...It was 121 here, but it was um...I guess...like, on the monitor,
ah ...stable.... People who have atrial fib...the numbers will jump around. And so that
would have been an indicator for me to, like, is something going on with his heart? By
this point it was perfectly stable’
•
‘His Blood Pressure didn’t jump around either. That was stable’
•
‘Breathing was OK’
•
‘He was able to walk in, he had no injuries reported’
•
‘Skin was looking fine’
•
‘He was diaphoretic (perspiration) and that’s nothing unusual with people who are
going through alcohol withdrawal’
•
‘He was talking, answering questions appropriately’
•
‘He said nothing wrong with eating/drinking, or elimination. Urinary or Stool’
•
‘He was hepatitis positive before...but he would have replied negative because he was
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cleared before that. Didn’t require further testing’
[20]
[21]
•
‘Stated he didn’t do any drugs or abuse any kind of prescription drugs. He only had the
Ativan, from what he told me’
•
‘He was quite ah... specific with his vodka and being a heavy user. He said daily’
•
‘His last drink was Friday, August 2, 2013 the day of arrest’
•
‘Lapensee also said ‘he has had seizures, tremors, confusion. But at this point he never
said he had hallucinations....’
Mannila made the following entry on the Multidisciplinary Notes at 7:14 p.m.:
•
‘Inmate seen in A&D, Corrections Admission History completed’
•
‘Inmate heavy ETOH user – vodka’
•
‘Been 24 hours since last drink’
•
Inmate complains of headache’
•
‘Alert and oriented x 3’
•
‘Visibly shaky’
•
‘Complains of diarrhea, upset stomach’
•
‘AW (alcohol withdrawal) = 9’
•
‘Inmate given Dioval in A&D to try and settle stomach’
•
‘Inmate then given stat dose Librium 100 mg, Gravol 50 mg, Motrin 200 mg’
•
Inmate dry heaved post meds; able to keep meds down’
At 8:40 p.m., Mannila made the following entry in the Multidiscipinary Notes:
•
‘Corrections Admissions History missing’
•
‘Inmate scored AW pulse = 3, respiration = 1, tremors = 3, diaphoretic = 2’
[22] At the Court Fatality Inquiry hearing, Mannila said he knew that Lapensee had been
without a drink for 24 hours, that the only thing out of the ordinary was the fact that Lapensee was
diaphoretic (perspiring), but he also said Lapensee had just had a shower and Mannila was not
certain if Lapensee was perspiring or still damp from his shower. He said that knew Lapensee was
a heavy drinker, that he had seizures before and took Ativan until his next drink.
[23] Mannila scored Lapensee as a “9” on the AW regime. That score, according to Mannila,
was based on a total of numeric values relating to the following categories: pulse, respiration,
tremors and diaphoretic: pulse = 3, respiration = 1, tremors = 3, diaphoretic 2. At the Court
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Fatality Inquiry, he described the score as ‘middle of the road’.
[24]
The ‘Doctors Examination/Orders’ form followed by Mannila states:
“If inmate scores 7 or higher, use Librium 100 mg po stat (orally immediately) then place
inmate in Health Care Unit and start Alcohol Withdrawal Regime.”
[25] As Lapensee had an AW score of 9, Mannila gave him a dose of 100 mg of Librium per the
physician’s standing order. Mannila stated that based on his experience, he also thought Lapensee
could be prone to seizures and Librium reduces the likelihood of brain seizures.
[26] He also gave Lapensee Dioval to settle his stomach, 50 mg of Gravol to reduce nausea and
200 mg of Motrin for headache.
[27] The physician’s standing AW order required that after receiving 100 mg of Librium (stat)
(immediately), Lapensee would receive 50 mg of Librium four times a day the first day, three times
a day the second day, two times a day the third day and once on the fourth day. After the fourth
day, the dosage of Librium may reduce from between 25 mg to 50 mg and would be given PRN (as
required) for 7 days. In addition, the regime provides Thiamine 50 mg, a B1 vitamin, twice a day
for 7 days, Zantac 150 mg twice a day for 7 days and Orafer, a multi vitamin, once a day for 7
days. Per the standing order, Lapensee was taken to a cell in the Health Care Unit (HCU).
[28] Mannila said that Lapensee, had he not died, would ordinarily have seen the CRC
physician, Dr. Gillespie, on Tuesday, August 6, 2013, as the Monday after his admission on August
3, 2013, was a statutory holiday.
[29] Dr. Gillespie, contract physician with CRC, testified at the Court Inquiry. He talked about
Alcohol Withdrawal Syndrome noting that it varies in individual cases as factors such as the
amount of alcohol used and the length of time alcohol is consumed affect the person. He described
some of the symptoms including restlessness, tremors, shakiness, memory loss, sweating,
hallucinations, increased pulse rate, sometimes vomiting and occasionally diarrhea.
[30] Dr. Gillespie said that delirium tremens from alcohol withdrawal could lead to death. The
individual may become confused, not be aware of time and space, may sweat, have rapid breathing
and may progress to seizures and death. The alcohol withdrawal protocol is used to prevent
seizures and serious side effects from alcohol withdrawal. Chronic alcoholics may have
complicated brain damage (Wernicke’s encephalopathy or Korsakoff Syndrome).
[31] He said that symptoms of withdrawal occur from 12 to 24 hours after the last drink and the
symptoms intensify over time. The symptoms may vary tremendously. Causes of death could be
heart irregularities, liver failure, gastrointestinal bleeding, and seizures. Seizure medication is
sometimes offered where there is a history. Dr. Gillespie said that CRC deals with repeat offenders
who have alcohol withdrawal while in the facility and may sometimes know the history. He said
that alcohol withdrawal is a very common presentation at CRC. The treatment for alcohol
withdrawal includes benzodiazepine (the most common is Librium, but it could be Ativan or
Valium), vitamins, gravol, immodium and/or zantac. Many chronic alcoholics have gastritis from
drinking. Vitamins are provided as well as thiamine deficiency can lead to brain damage.
[32] Dr. Gillespie said that if there is a strong history of seizures, the drug Dilantin may be given
as well for a week or longer, but the use is controversial. That drug was not part of the standing
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order in effect at the time of Lapensee’s admission to CRC.
[33] Dr. Gillespie says a new protocol is being put in place that has a different scoring system
and includes some subjective components such as mental confusion.
[34] AHS has changed the Alcohol Withdrawal Management protocol that is now in use at CRC.
A working draft has been instituted as of October 25, 2013. Scoring with this protocol uses the
Clinical Institute Withdrawal Assessment-Alcohol Revised Scale (CIWA-Ar). Dr. Courtney, a
psychiatrist who testified at the Court Fatality Inquiry, said this protocol is becoming standard
around the world and the one most commonly used. It requires that a facility have health care
services on a 24-hour period and CRC meets this requirement.
[35] At approximately 7:28 p.m., Mannila completed the examination and at 7:28 p.m.,
Lapensee was taken back to a holding tank at Admission and Discharge. The video recording of the
holding tank shows that he sat and then lay down on the bench at about 7:30 p.m.
[36] At 8:19 p.m., Lapensee was taken to the Health Centre Unit (“HCU”) that has 13 cells and
can hold 26 inmates (2 persons per cell). At 8:23 p.m., Lapensee entered cell 206. The 9:00 p.m.
HCU formal count was 22 inmates. Lapensee’s cellmate was Lloyd Edwin McFeeters, age 48.
[37] Mannila had no further contact with Lapensee and gave the file over to Sandra Strachan, the
registered nurse on shift at the HCU until 11:00 p.m. She said Manilla gave her a verbal report,
that Lapensee had scored a 9 on the AW regime and been given Librium, 100 mg. She knew that
he would then receive 50 mg at the next medication round. She also said that she would do an
assessment at that time independent of the medication round. She was not aware of his seizure
history.
[38] At approximately 9:40 p.m., Strachan, accompanied by a HCU officer, conducted health
care rounds in the HCU. At 9:49 p.m., Strachan was at Lapensee’s cell, 206. The officer opened the
cell door and Strachan talked with Lapensee. She also did an assessment of Lapensee. She said he
was ambulatory, came to the door and was coherent. He told her he had diarrhea and she offered
him medication that he declined; she encouraged him to take plenty of fluids. She took his vital
signs including blood pressure, heart rate and respiration.
[39] Strachan gave him an AW score of 4, which is lower (in severity) than the previous score of
9 given by Mannila. In addition, she entered the following on the CRC Health Care Unit Flow
Chart (exhibit 4):
•
‘Time: 2130’
•
‘Activity: Awake / Ambulating’
•
‘Blood Pressure: 143/96’
•
‘Pulse: 118’
•
‘Respiration: 20’
•
‘Tremors: 1’
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[40]
[41]
•
‘Diaphoresis: 0’
•
‘Restlessness: 0’
•
‘Librium: 50 mg’
•
‘A/W Score: 4’
•
‘Librium: 50mg’
Nurse Strachan made the following entry in the Multidisciplinary Notes:
•
‘Inmate seen on HCU med rounds’
•
‘Complains of diarrhea but doesn’t want any meds as he is trying to hold it as long as
possible’
•
‘AW score 4’
•
‘Good eye contact’
•
‘Vitals taken and Librium 50 mg given’
•
‘Advised to increase fluids and alert nurse in a.m. if he wants medication for his
diarrhea’
•
‘Will continue to monitor’
The Medication Issue form was completed and indicated that Lapensee was to receive:
•
Thiamine 50 mg daily expiring August 10, 2013 at 8:00 a.m. and 10:00 p.m.
•
Zantac 150 mg daily expiring August 10, 2013 at 8:00 a.m. and 10:00 p.m.
•
Orafer daily expiring August 10, 2013 at 8:00 a.m.
[42] Strachan found that Lapensee fit the AW protocol and she gave him 50 mg of Librium and
Thiamine and Zantac. She said that he did not present with acute distress. She told him that if he
had any concerns, he should let the night nurse know.
[43] At CRC, AHS nurses have a practice of providing pertinent information to the charge nurse
of the next shift on a digital voice recorder. Strachan used the recorder and said Lapensee was AW
with a score of ‘4’.
[44] Based on the protocol, Lapensee could have had another 50 mg of Librium before the
morning medicine round as 200 mgs was allowed in an 8-hour period.
[45] Dr. Gillespie at the Court Fatality Inquiry reviewed the use of the AW regime with
Lapensee. He said that the change in the AW score from 9 to 4 would mean the patient has
improved dramatically probably because of drug doses given earlier. He said that an AW score
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could go down and then up. As medication wears off, the score may change.
[46] Alana Wade, night nurse, wrote on the CRC Health Care Unit Flow Sheet that she
conducted a round at 4:00 a.m. and that Lapensee was asleep. The video recording does not show a
round near this time and according to Wade’s testimony during the interview with the Board of
Inquiry and at the Court Fatality Inquiry, Lapensee was awake. There was no information on the
CRC Health Care Unit Flow Sheet regarding a 4:59 a.m. round, nor any conversation with
Lapensee. When interviewed by the Board of Inquiry, Wade said she made an error in
documenting this information. Wade also stated that nurses are not supposed to, nor could, enter
cells in the HCU without the presence of an officer.
[47] What happened was that at approximately 4:57 a.m., Alana Wade conducted rounds at the
HCU with a flashlight without an officer being present. At approximately 4:59 a.m., she talked to
Lapensee for about 55 seconds through the closed cell door.
[48] Wade, at the Court Fatality Inquiry, said that Lapensee was awake and at the cell door. In
her statement to the Board of Inquiry, she said that he asked her when he might get medication (she
could not remember this at the Court Fatality Inquiry). She told Lapensee that the nurses would be
there at 7:00 a.m. She then asked him if he was all right. He said that he was fine and returned to
the area of his bed.
[49] Wade said that she knew Lapensee previously had a score of 4 on the AW regime and that
no “immediate or imminent concerns” had been passed on to her. When asked if she heard the
digital voice recorder left by Nurse Strachan, she stated that she had not. She was also not aware
that inmate Lapensee had initially received an AW score of 9 at admission, nor that he had been
administered 100 mg of Librium the prior evening.
[50] CPO1 Lane Maki worked night shift on the Assessment and Treatment Unit (“ATU”) that
includes the HCU on August 4, 2013, starting at 10:45 p.m. on August 3, 2013. He was responsible
for formal counts of inmates during the night. CPO1 Maki said he watches inmates through the cell
windows, looks to see if they are alive by looking for body movements, breathing and/or snoring or
if anything appears to be out of the ordinary. He did not see anything unusual with any of the
inmates on that evening, including Lapensee.
[51] At 10:51 p.m., a formal count was conducted for the start of the night shift. The common
area lights were turned off at 10:55 p.m. Formal counts were conducted at 11:57 p.m. and on
August 4, 2013, at 12:51 a.m., CPO1 Maki conducted formal counts at approximately 2:00 a.m.,
2:54 a.m., 3:00 a.m., 4:48 a.m. and 6:02 a.m.
[52] CPO2 Daniel Roos was working the day shift from 7:00 a.m. to 3:00 p.m. on August 3,
2013. At approximately 6:50 a.m., he did the HCU formal count for the start of dayshift.
[53] At approximately 7:07 a.m., Roos started the security inspection. Branch policy requires
security checks of the Centre twice daily, once by the day shift and once by the afternoon shift
within the first hour of the shift. The officer is required to enter cells and check windows, fixtures,
vents, locks, etc. and check for security problems. Roos was in cell 206 for approximately 9
seconds.
[54] Roos said that when he opened the cell door, Lapensee sat up on his bunk and asked when
he was getting medication. Roos told him that he would receive his medications when the nurses
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did rounds first thing in the morning. He said that Lapensee said “thank you” and Roos left the cell.
He said there was nothing to show Lapensee was in medical distress.
[55] CRC management and later the Board of Inquiry interviewed Lapensee’s cellmate, Lloyd
McFeeters. He also testified at the Court Fatality Inquiry hearing. McFeeters wrote a statement,
dated August 4, 2013:
“At approximately 05:00 a.m., my cellmate Brian asked the nurse when he could get some
medication. She told him he could get it at 7:00 a.m. that he had 2 more hours to wait till
medication time. At that time he went back to sleep and at shift change (7:00) a CRC staff
was doing a count as he just came on duty and Brian asked him for meds. He said the nurse
would be around at med times. Brian went back to his bed”.
[56] At the Court Fatality Inquiry, McFeeters said that Lapensee was ‘shaking pretty good’.
Lapensee told McFeeters he drank a lot and the nurses had given him medication. He said he was a
drinker and was having a hard time. McFeeters said he believes a nurse gave Lapensee medication
at 9:00 and they went to sleep. The only sign of a medical problem that McFeeters noticed in
Lapensee was shaking.
[57] McFeeters said the lights came on at 6:00 a.m.. McFeeters said that he sat up when
Lapensee pushed the buzzer and said he needed medication, that he was not feeling well. He heard
Lapensee ask for medication because he was not feeling well. During a round, Lapensee told the
corrections officer that he felt sick. The officer told him to “go back to f’n sleep, your medication
will be here at 8:00 a.m.” Lapensee lay back down and went to sleep.
[58] Roos denied saying anything like “go to f’n sleep”. He called it a polite conversation when
Lapensee asked when he would get medication.
[59]
According to the earlier written statement by McFeeters:
“...at shift change 7:00 a.m., a CRC staff was doing a count as he came on duty and Brian
asked him for meds. He said the nurse would be around at med time. Brian went back to his
bed.”
[60] Roos’ evidence at the Court Fatality Inquiry accords with McFeeter’s statements prior to
the Court Fatality Inquiry that do not include Roos or any CRC staff member uttering profanities.
[61] When asked about discrepancies in his testimony at the Court Fatality Inquiry and with his
previous statement, McFeeters said when he wrote his statement, he was “shaken up”. I accept the
information he gave prior to the Court Fatality Inquiry.
[62] McFeeters also said he noted an unusual or putrid smell that none of the other witnesses
who came into cell 206 after McFeeters made the call noticed.
[63] On the August 4, 2013, day shift, the Shift Manager was Robert McNiven and there were
five officers working at the Assessment Treatment Unit (“ATU”) that has four subunits and
includes the Health Care Unit (“HCU”) Assessment – Treatment Unit. The HCU has 13 cells to
hold 26 individuals for health care related problems. All ATU cells have cameras inside the cell,
but the HCU does not.
[64]
CPO2 Bradley Cole, working in the ATU control room, said that he received a call on the
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intercom system from McFeeters in cell 206 saying, “boss you might want to get a nurse down
here, I’m not quite sure if this guy is breathing”. Cole immediately called McGivern to check cell
206 and the video shows CPO1 Trevor McGivern walk from the HCU officer station area to cell
206 at approximately 8:06 a.m. McGivern said at the Court Fatality Inquiry that he went “right
away”.
[65] McGivern tried to wake Lapensee and called code 99 (the medical emergency code) at 8:07
a.m. He said he called out, shook Lapensee’s arm and described it as “squishy”.
[66] After calling the code, McGivern went back into the cell to tell McFeeters that he needed to
leave and be locked up somewhere else. Another inmate was also near cell 206 (in the common
area) and he was also removed from the area.
[67] Branch policy requires the employee discovering a medical emergency to immediately give
first aid and inform central control of the emergency code. Only a medical doctor or EMS can
make a diagnosis of death. At the Court Fatality Inquiry, McGivern said he did not immediately
provide first aid because he felt it was necessary to call the code and remove inmates from the
immediate area for security and to allow the nurses and emergency response team to enter. The
Health Care area, where the nurses were located, was in an area close to the HCU and their arrival
at cell 206 was within 33 seconds of the code call. Five AHS nurses, led by Melissa Berge, entered
cell 206 at approximately 8:07 a.m. The four additional nurses attending were Kylie McManus,
Megan Prediger, Dianna Paulsen and Amy Eng. McFeeters left the cell just as the nurses entered
the cell.
[68] The nurses said Lapensee was lying on his left side with his feet off the bed, his pillow had
saliva on it and he had froth on the left side of his mouth. He had no pulse.
[69] The nurses immediately commenced emergency procedures including a tube to hold
Lapensee’s tongue back and a non-rebreather. Paulsen started Cardiopulmonary Resuscitation
(CPR).
[70] The Emergency Response Team (“ERT”) comprised of nine CPOs arrived at the cell. On
his arrival at 8:08 a.m., CPO2 Michael Sandford, ERT member, was asked by the nurses to assist
with CPR. Some ERT members left the scene. The automated external defibrillator (“AED”) was
applied to Lapensee 5 times before EMS arrival and there was no shock. CPR resumed.
[71]
Melissa Berge was the charge nurse. This meant she was responsible for overseeing the
staff. According to Sandford, Berge immediately directed that an ambulance be called as Sandford
took over CPR from Paulsen. Sandford radioed central control to call an ambulance and resumed
CPR until EMS arrived.
[72] The code bag used at emergencies and present in cell 206 at this time contained a cell
phone. Berge stated at the Court Fatality Inquiry that the phone was new to the unit and used to
contact a doctor if orders were needed. It was not used for emergencies, that the procedure in
emergencies was always to call Central Control.
[73] The Code 99 form shows a call was made at 8:11 a.m. Response was at 8:12 a.m.: “Inmate
found in left side lying position, unresponsive, not breathing, no pulse. Froth in mouth. CPR
initiated. EMS called/requested by HCU staff”.
[74]
At approximately 8:08 a.m., Acting Deputy Director/Shift Manager Robert McNevin
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arrived at the cell.
[75] After several minutes had passed, some of the nurses and officers in Lapensee’s cell began
to inquire as to the status of the ambulance call. Sandford requested an estimated time of arrival
from Central Control and it was apparent an ambulance had not been dispatched.
[76] CPO3 Kathleen Irwin, supervisor in Central Control on August 3, 2013, acknowledged the
call requesting an ambulance. CPO2 Lane Maki, who was also working in Central Control,
responded by radio and instructed the officer at the scene to change radio channel to the Operation
Channel (channel 3) to get more information for the 911 call. There was no response. According to
Irwin, there was no response to further attempts to have the caller change channels. A request was
made for anybody from the code to respond, but there was no response.
[77] At the Court Fatality Inquiry, Irwin said that she assumed Health Care had used the cell
phone they had to call for an ambulance. That was the procedure she said that she had been
informed was in place when she returned to work in this area, about two months previously. She
did not recall who told her about this procedure. She had been working in another area for a year
and half. She said she made a direction not to call 911. When the second call for an ambulance
came, she knew no one had called for an ambulance. At the Court Fatality Inquiry, she said that she
believed she then called 911 and answered questions. The investigation of the Board of Inquiry
shows that at approximately 8:21 a.m., she called 911 from a phone in Central Control. During this
call, the 911 dispatcher sent EMS to CRC and obtained some information from Irwin on the status
of the emergency.
[78] The 911 dispatcher asked Irwin to transfer the call to the scene. This was not possible and
the dispatcher then asked that CRC call from a phone close to the scene.
[79] At approximately the same time, another call was made from an HCU office to 911 by
CPO2 Curtis May. He was part of the ERT team and realized an ambulance may not have been
called. At approximately 8:24 a.m., Berge came to the health care office to help him provide
information.
[80] Branch policy requires that the health care manager and/or a member of the nursing staff
assume the responsibility for the overall coordination of medical emergency procedures and
recommend to the shift manager whether an ambulance is required.
[81]
Entries made by the nurses in the AHS Multidisciplinary Notes were as follows:
•
‘8:11 a.m.: Code 99 called in HCU’ (was actually earlier at 8:07 a.m.)
•
‘8:12 a.m. HCU nurses responded’ (again earlier)
•
‘Inmate found in left side-lying position legs hanging off the side of the bed’
•
‘Inmate appeared blue/grey/, mottled skin and unresponsive to verbal and painful
stimuli (sternal rub completed) and not breathing’
•
‘Pupils fixed’
•
‘Patient turned over to supine position’
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•
‘No pulses X4, No carotid’
•
‘Foaming noted to left side of mouth and pillow soaked with saliva’
•
‘CPR initiated with AmbuBag and entrained to oxygen at high flow’
•
‘OPA 90 mm in size inserted’
•
‘Charge RN called out for ambulance to be called’
•
‘IV access attempted unsuccessfully X2 on right arm’
•
‘20 G able to be inserted to left AC -normal saline bolus 250 cc then 500 cc hung via
gravity- roller clamp fully open’
•
‘8:20 a.m.: AED retrieved from HCU clinic room and applied to inmate’
•
‘No shock advised, CPR resumed’
•
‘Pupils still fixed’
•
‘AED re-analyzed approximately 5 times and “no shock” advised at any time’
•
‘CPR resumed between each analysis’
•
‘8:29 a.m.: EMS arrived on scene and applied their cardiac monitor to inmate
“Asystole” per EMS and inmate pronounced at 0830 hours’
•
‘8:32 a.m.: Charge RN phoned HCU manager and on call manager re: situation’
[82] The EMS report states that the ambulance was notified at 8:22 a.m., was enroute with
emergency lights/siren at 8:23 a.m., arrived at the centre at 8:27 a.m. and arrived at the patient at
8:30 a.m.
[83] The video recording shows EMS paramedics and firemen entering the HCU and cell 206 at
approximately 8:30 a.m., approximately 9 minutes after the 911 calls were made and 22 minutes
after Berge ordered an ambulance be called.
[84]
The EMS report indicated the following:
•
‘Chief Complaint: Death – Obvious’
•
‘Comments: “52 year old male found lying supine in cell, pulseless and apneic.
Correction officers and nursing staff performing CPR, ventilating using OPA and
BVM, AED in place, and IV access to left AC. AED removed and cardiac monitor
placed on pt. Pt. confirmed asystolic. Staff states they have been doing CPR with OPA
and BVM ventilations for at least 20 minutes with no shock advised on AED.’
•
‘Confirmed asystolic. Discontinuing CPR’
•
‘Pt was seen approx. 1 hour prior awake and sitting upright. Staff states pt. came in last
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night and stated to cell mate he is a heavy drinker, 2 bottles/day and Hep C positive’
•
‘Staff has no other info regarding medical hx, or medications’
[85] The EMS report stated ‘Response outcome: Dead at Scene and ‘death diagnosed at 8:34:09
a.m.’.
[86] The body of Lapensee remained in the cell. ERT member, May, remained outside of the
cell door and at 10:20 a.m., the Office of the Medical Examiner removed the body from the HCU.
[87] Dr. Bamidele Adeagbo, Medical Examiner, testified at the Court Fatality Inquiry and
confirmed his findings. He noted in the autopsy that Lapensee had a history of chronic alcoholism,
homelessness, drug seeking behaviour, multiple previous incarcerations while intoxicated and a
hepatitis C viral infection. The autopsy, confirmed by Dr. Adeagbo at the Court Fatality Inquiry,
showed liver cirrhosis, hesitation marks, which indicated previous self-harm, and large and heavy
heart. The cause of death is “following the review of the circumstances, historical information,
autopsy and toxicological findings, Brian Joseph Leo Lapensee died as a result of chronic
alcoholism. The precise mechanism of his death may not be determined; however, it may include,
but is not limited to, seizure disorder or cardiac arrhythmia”.
[88] As stated above, Len Goueffic was the Chair of the Board of Inquiry convened by Dr.
Curtis Clarke, Assistant Deputy Minister, Alberta Correctional Services to investigate the
circumstances surrounding Lapensee’s death The Board was also to submit a report with findings
and recommendations. At the time of Lapensee’s death, Goueffic was Director, Adult Centre
Operations Branch. A Board of Inquiry is mandated under the provisions of the Corrections Act of
Alberta.
[89] Goueffic set out what the Board did to investigate the death and to make findings and
recommendations. They gathered staff reports, shift reports, interviewed managers, supervisors,
AHS nurses and those involved in the incident. CCTV was collected and saved. They collected and
reviewed policies and procedures, standard operating procedures and supporting documentation,
incident report, staff reports, the medical and legal files, the EMS response report and shift
manager reports, and the Medical Examiner’s Report that included toxicology and histology
findings. They looked to see if there had been non-compliance with policies and procedures and
evaluated any non-compliance. For example, the first officer into Lapensee’s cell did not
administer first aid per the standard operating procedure. The Board considered the fact that the
officer was concerned about safety as other inmates were in the area and the fact that the nurses
arrived 33 seconds later.
[90] The Board of Inquiry found that there was confusion as to who was responsible for calling
an ambulance.
[91] I agree with the Board of Inquiry that confusion arose at CRC as to who was responsible for
the calling of an ambulance. I also agree with the Board of Inquiry that the delay caused by the
confusion was not a contributing factor in the death of Lapensee, as the first nurses who arrived on
the scene noted no pulse. CPR was performed until EMS arrived and shortly after made the
pronouncement of death.
[92] The Board of Inquiry recommends that “as an education point, operational staff are advised
of the importance of calling 911 at the soonest possible opportunity, whether able to convey
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detailed information or not, and to allow the 911 dispatcher to direct the next action. It is important
that a policy be in place that does not result in confusion. All staff should be aware of and trained
in the correct procedure”. Exhibit 4 is a Joint Communication Memorandum dated August 21, 2014
subsequent to the death. The subject is “Contacting Emergency Medical Services (EMS) in
Centre”.
[93] Board policy requires that staff members appointed to an emergency response team hold
current certification in first aid, automated external defibrillator (AED) use and CPR. The Board of
Inquiry recommends that CRC immediately review the status of all First Aid/CPR records and
expedite recertification. This is, of course, a good recommendation.
[94] Tiffany Murray, Health Services Manager, was on leave in 2013 and away during the time
of the death of Lapensee. At the Court Fatality Inquiry, she said she reviewed the incident when
she returned from leave. The cell phone in the code bag had been provided at around the time of
this incident, as there was a movement away from standing orders to direct physician orders. She
said that nurses need to be able to call a physician and there is not always a phone available in all
areas. She could not confirm the intent was to replace the practice of calling Central Control, that
the phone was not intended to use to call 911.
[95] She was also asked about the fact that the first corrections officer in cell 206 did not
immediately start first aid or CPR. She noted there is 24-hour nursing care at CRC, that the nurses
arrived in 33 seconds and in a code 99, it is important to have confirmation the site is safe.
[96] She was also asked questions about the fact that the form filled out by Mannila was not
saved on the computer. She said the computer does not have an option to save. The expectation is
that there will be a paper copy and the nursing staff is under a professional obligation to ensure the
paper work is complete and delivered to the correct file and person.
[97] With respect to AHS, the following recommendation was made by the Board: that the issue
of accurate documentation of information by a nurse be addressed. I would expand that to include
that the issue of accurate documentation includes ensuring the Corrections Admission History is
printed and placed on the correct file.
[98] I cannot find, however, that issues in documentation contributed to the death of Brian
Lapensee. He was assessed by Manilla and put on the AW protocol in place at the time, assessed
again by Strachan at the second medication round. There were routine checks by Correctional
Officers. Lapensee talked to Wade during the night and later Roos during the security check.
While Lapensee may have inquired as to when he would receive medication, he did not appear, to
those who dealt with him, to be in medical distress.
Recommendations for the prevention of similar deaths:
[99] The cause of Brian Lapensee’s death is chronic alcoholism, the precise mechanism of death
is unknown. Following his death, there was an intensive review of the incident and previous events,
policies and practices at CRC and AHS to ensure the death of Mr. Lapensee was fully investigated.
Recommendations were made concerning the delivery of care including health care to inmates.
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[100] The Alcohol Withdrawal Regime used at CRC has changed since the death of Lapensee.
The change in procedure did not arise as a direct result of this death, but in recognition of the need
to deal with individuals who will suffer from the effects of alcoholism and alcohol withdrawal at
CRC.
[101] The delay in contacting EMS, although not causing or contributing to the death, was
immediately recognized and steps were taken to ensure a consistent policy was developed and
made known to all appropriate personnel.
[102] CRC and AHS have reviewed the circumstances of Mr. Lapensee’s death in detail. After
hearing and reviewing all of the documents and evidence in this Court Fatality Inquiry, I do not
make any recommendations for the prevention of similar deaths.
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Appendix A:
[103] The following items were marked as Exhibits during the Court Fatality Inquiry:
•
Exhibit #1 – Binder containing the medical examiner’s records and CPS records
•
Exhibit #2 – Exhibit 2 – Binder containing CRC records
•
Exhibit #3 – AHS “CIWA-Clinical Institute Withdrawal Assessment” form
•
Exhibit #4 – AHS “Joint Communication Memorandum” dated August 21, 2014
•
Exhibit #5 – 1-Page “CIWA-AR Algorithm” depicting various arrows and boxes
•
Exhibit #6 – 2-Page AHS Memorandum dated June 10, 2013, “Subject: Protocol Pilot”
•
Exhibit #7 – White DVD titled “Fatality Inquiry re: Brian Lapansee-CCTV Format5828” in a clear plastic case
•
Exhibit #8 – 4-Page Curriculum Vitae for “Bamidele Adeagbo, MD, Office of Chief
Medical Examiner, Calgary, Canada”
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