STAFF ERRORS LED TO INMATE'S DEATH

Nurse Wasn't Authorized To Give Methadone To Man WHO Faked ID

A nurse who should not have been administering methadone supplied the
dose that killed a 32-yearold inmate at a Maple Ridge prison, he
Province has learned.

Details of the unidentified man's death in October 2010 are revealed
in a confidential review by B.C. Corrections, which was released to
The Province under freedom of information law.

As a result of stunning staff errors in the death at Fraser Regional
Correctional Centre, B.C. Corrections has completed a review of its
methadone program and is making changes.

"Our response in this case was lacking," Marnie Mayhew of B.C.
Corrections said in an interview. "The best thing we can do is look
at the mistakes and take action to ensure they do not happen again."

The man, believed to be a heroin addict, was not registered to
receive methadone and his prison profile contained a medical alert
"never to be housed with a [methadone] program inmate," the review says.

But the alert was "not adhered to" -- and shortly before his death he
was transferred into a cell with an inmate on the methadone program.

Methadone is a synthetic drug given to addicts to wean them off heroin.

The nurse who was tasked with administer ing methadone to inmates on
Oct. 19 was only on her second orientation shift at the jail. The
review says she should only have been shadowing a regular nurse on
the methadone rounds. Apparently, she was given the job because
another nurse called in sick.

The review suggests the 32-yearold man tricked the nurse and got his
cellmate's dose of methadone by presenting a fake photo identification card.

"People who are addicted are desperate and desperate people do
desperate things," Mayhew said.

The review does not pinpoint when the man died, but evidence shows he
lay against his cell wall for about seven hours until he was
pronounced dead, around 7 p.m.

Staff passed the man by without doing required safety checks, and
made a false log entry indicating that he had declined a routine
medical checkup. When emergency care was finally given by prison
staff, the care was flawed.

Mayhew said, for privacy reasons, she can't say if any staff were
suspended or terminated.

"B. C. Corrections has followed up with our medical contractor to
ensure when a new staff member is being oriented, there is
appropriate supervision in place," Mayhew said.

An especially troubling review finding shows prison staff suspected
the wrong inmate had been given methadone, but they did not report
concerns to supervisors or attempt to confirm their suspicions.

Mayhew said the report "speaks for itself" and she would not comment
on specific findings.

Dean Purdy -- chair of corrections and sheriff services at the B.C.
Government and Service Employees Union -- said he has not been
informed about the review findings and he is not aware of any staff
discipline coming out of the inmate death investigation.

He said overcrowding and rampant drug use at the jail make it
increasingly difficult to monitor inmates.

Purdy estimated there is a ratio of 40 inmates to one staff member at
Fraser Regional and based on staff reports, it may have the worst
illicit drug use among B.C. jails.

There are currently 228 inmates on the methadone maintenance program
out of an average population of about 2,740 in the province's nine prisons.

*SIDEBAR*

Chain of events on Oct. 19 that led to an inmate's death

- - 7:08 a.m. A nurse on her second shift and only supposed to be
"shadowing" a regular nurse improperly administers methadone
treatment to inmates.

- - 7:29 a.m. The nurse and staff helpers perform an identity check on
a 32-yearold male as required, before he ingests a methadone dose.
But the man, who is not on the methadone program, presents a fake
picture identification card, believed to belong to his cellmate who
is on the program. He is given a dose of methadone that turns out to be lethal.

- - 7:31 a.m. The man is seen via closed circuit TV appearing
hyperactive, pacing around the room, talking and laughing. During the
methadone distribution process, his unit remains unlocked, which is
contrary to policy.

- - From 8:18 a.m. to 9:26 a.m. The man is supposed to be locked in his
cell after the methadone dose but, instead, is allowed to enter the
yard with other inmates.

- - Unit staff discuss suspicions that the wrong inmate has received
methadone treatment, but they don't investigate or report concerns to
supervisors.

- - 11:06 a.m.

Lunch trays arrive. The man is seen on his top bunk facing the wall.
Staff don't recall if he ate.

- - Dinner arrives at 4:15 p.m. and the man does not eat it, according
to his cellmate.

- - 12:23 p.m.

The man and his cellmate are asked to attend medical checkups. The
man doesn't respond, "and the staff reported snoring-like sounds."

- - Health care arrives at 6:43 p.m., finding the man "cold, pale and
cyanotic, with no pulse or breathing." There is a delay in starting CPR.

- - 6:36 p.m. An officer unsuccessfully attempts to rouse the man.

- - 6:53 to 7:08 p.m. CPR is administered. He is given a number of
doses of Narcan [an antidote to opiate drug overdoses]. Paramedics
arrive and find no sign of life. The man is pronounced dead at 7:08.