Correctional staff gave emergency care while nurses stood, Hamilton jail inquest reveals

The second week of the Hamilton jail inquest reveals that medical staff are not always the one providing emergency care to inmates, even when they're present.

'I was desperate to save Mr. Acheson's life,' says correctional officer

The joint inquest into the deaths of eight men who overdosed in Hamilton-Wentworth Detention Centre between 2012-2016 started April 9. (Jeff Green/CBC)

Red vomit kept coming out of William Acheson's mouth.

It was making CPR difficult, said Sgt. Fred Duykers, who was trying to keep him alive while paramedics showed up.

"I was worried about him drowning in his own fluids," he said.

Duykers recalled his frantic medical efforts at the second week of the inquest into eight men who died from drug overdoses at the Hamilton-Wentworth Detention Centre between 2012 and 2016.

I was desperate to save Mr. Acheson's life.-  Fred Duykers, retired operational manager

Duykers asked for a nurse to pass him a suction device to remove the vomit — something he had never used before. Nor had the nurses attending the scene.

"I was desperate to save Mr. Acheson's life, and wouldn't have mattered it was Mr. Acheson or a member of my own family. I would've used it," he said.

When EMS arrived, paramedics continued CPR and suction, but they were unsuccessful in reviving Acheson. He was pronounced dead at 8:14 a.m., Sept. 12, 2012.

It was later determined Acheson had died from heroin poisoning.

A new inmate's arrival

Duykers is testifying as a retired operational manager at the jail, who had worked for 30 years at the facility at the time of Acheson's death.

According to the agreed statement of facts surrounding Acheson's death, there was a new inmate who was admitted into the jail the day before Acheson died. The statement says there is no record of that inmate, called M.B. (All inmates are being identified only by initials at the inquest) being searched upon being admitted into jail.

Throughout the day, M.B. was in and out of Cell 14 in Acheson's unit, a cell from which another inmate, K.D., was later sent to hospital for an overdose. When the ambulance was called for K.D., M.B. was put into Cell 18 with Acheson.

The next morning, Acheson died. M.B. was also sent to hospital for an overdose.

Morphine was detected in all three people's bodies.

The red vomit that was coming out of Acheson is likely "home brew," alcohol made by inmates fermenting bread and fruit scraps.

The floor plan shows what one unit looks like. Each cell is roughly eight feet by 10 feet and can house up to three inmates. (Flora Pan/CBC)

Search and monitoring

How effective are the cell searches in jail? How closely are the inmates monitored?

These two questions have come up more than once at the inquest since it started on April 9. It was revealed that no one is assigned to watch surveillance cameras at all times. The videos are only reviewed after something has happened.

During the day, two officers are responsible for watching as many as 72 inmates in a unit. At night, there is only one officer.

Cell searches become difficult when there are so many inmates, each with a lot of belongings.

"I've always believed in a dedicated search team," said Duykers. The team would have the "right of way to go up search any area they want and at any given time" and only report to the superintendent.

He said the team would also be more skilled in searching.

After a critical incident — such as one where an inmate is found unresponsive from an overdose — Duykers said he would try to search the inmates for contraband, but staffing is an issue.

"Unfortunately, in past years, we've never had that much manpower, that's something we've struggled with all the time," he said.

Neville said nurses are not allowed to use the nasal naloxone sprays. (Trevor Pritchard/CBC)

Emergency medical response on the inside

When Acheson was found unresponsive in his cell, Duykers was not the only person responding to the scene. There were medical staff there, but it was Duykers who ended up delivering air to Acheson with a bag valve mask and also using a suction device.

Mariea McNelis, a self-representing family member of one of the eight men, said she wondered why the medical staff did not take over from Duykers or helped him.

"I'm really concerned about somebody that is a nurse, that to me, that should have been their job," she said.

Duykers testified that the nurse who had helped him get the suction device had been standing at the cell door with another nurse.

Naloxone availability

Heidi Neville, a third nurse who was there, said she had left the cell to assess nearby inmates in the unit and was not there when Duykers used the suction device.

The device had come out of one of two "code white" kits used for emergency medical response, she said, but she had never been trained on how to use it. 

And while overdose deaths have became a lot more common in the recent years, Acheson was her first  experience with one. Given how much more frequently they're happening now, Neville said "narcan might be nice to have" in those kits.

However, nurses are not allowed to use nasal naloxone sprays as per Ministry of Community Safety and Correctional Services' policy.

Naloxone is an antidote to temporary reverse the effects of opioids. It's supposed to work in about five minutes to give time for a patient to be transferred to an emergency room.

Neville said once she was working in the admittance portion of the jail, and one person coming in had overdosed on opioids. She used a nasal spray to save him, but "had to write a report as to why [she] used the kit."

During her testimony, she also said there's no formal system in place for correctional officers to let nurses know where drugs have been found inside the prison, even though it would help give the staff a heads-up.

"There's not a good communication system," she said.

The inquest will continue on Friday with more testimonies from people in relation to Acheson's death.

About the Author

Flora Pan

Associate Producer & Reporter/Editor

Flora Pan is a multimedia journalist based in southern Ontario. She currently works out of Kitchener-Waterloo and Hamilton. You can reach her at flora.pan@cbc.ca or on Twitter @FloraTPan.