A nurse at the Regional Psychiatric Centre in Saskatoon took too long to call a Code Blue after finding an inmate unresponsive late one January night, three years ago.

That's one of the findings of a federal Corrections investigation report into the death of Kinew James, obtained by the CBC.

James is the 35-year-old aboriginal woman who died of an apparent heart attack on Jan. 20, 2013 while an inmate at the RPC, a federal prison.

She was found unresponsive in her cell and taken to hospital, where she was later pronounced dead. 

Inmates in neighbouring cells alleged staff ignored her calls for help.

Test not done after chest pains

The investigation report outlines a string of lapses and missteps that may have played a part in her death.

James suffered from several ailments, including obesity, type 2 diabetes, high cholesterol, and — while at RPC — recurring infections "which could have led to elevated blood glucose levels."

She experienced chest pains while at another federal prison, Grand Valley Institution in Kitchener, Ont. 

On Sept. 21, 2012 an electrocardiogram was ordered, and the results were abnormal, the report states. A week later a control electrocardiogram was ordered, but not done. 

James was then transferred to the RPC on Nov. 20, 2012. A month later, a doctor there noticed the ECG hadn't been done, and ordered one. However, that too was not done before James' fatal medical emergency on the night of Jan. 19, 2013.

Mistakes made with insulin

The investigation also found that on three of the four preceding days, James' insulin was "not administered as per the physician's order" six times — but these mistakes were not recorded in her medical file. Nor was there any record the insulin she was given was "independently double-checked", as the rules required.

The report says the night of Jan. 19 was a busy one on Churchill Unit, where James was held. One guard was constantly watching another inmate being kept in restraints in a remote end of the unit.

Starting at 9:35 p.m., James began calling staff to her cell, saying she felt sick. Earlier that evening she had been given insulin because her blood glucose was too high. A nurse identified in the report as Nurse B checked her blood glucose level, which was then 6.8 mmol/l. James left her cell and got an apple, which a guard then saw her eating as she sat on her bed.

About an hour later, James again told Nurse B she was not feeling well. Her blood glucose had gone up to 8.1. The nurse encouraged her to stay hydrated.

James in distress, crying

At 11:45 p.m., another inmate rang an alarm and told Nurse B that James was in distress and crying. Nurse B spoke to James through the cell door food slot. James kept moaning and crying, but did not say what was wrong.

The report says James then lied down on the bed, "closed her eyes and began to breathe deeply and to snore slightly." The nurse told her to rest, and said she would come back to check on her later.

Seven minutes later, James activated her call alarm again, said she wasn't feeling well, and that she thought she needed glucose.

A couple of minutes after that Nurse B found James lying on her stomach on her bed, breathing deeply and snoring heavily, "unresponsive to verbal commands." The nurse went to look for a guard to open James' cell door, but was told they would have to radio for another guard to do that.

Code Blue should have been called

"The Board [of Investigation] believed that a Medical Emergency should have been called when James was found to be unresponsive and that having to wait approximately five minutes for another Correctional Officer to arrive on Church Unit to open the cell door delayed the staff response to an emergency situation," the report stated.

At midnight a guard phoned another unit and asked another staff member to come so the nurse could get into James' cell and examine her. No one mentioned a medical emergency, so the staff member did not rush over.

After entering James' cell, Nurse B took James' blood glucose levels. She found James, meanwhile, to be "limp and non-responsive", and snoring heavily.

At this point, too, the Board of Investigation said Nurse B should have declared a medical emergency (Code Blue).

Not breathing, barely a pulse

Instead, the nurse and the guard put James in the recovery position on her bed, and the nurse went to get a vital signs machine. A couple of minutes later, James did not appear to be breathing, had no wrist pulse, and her neck pulse was "unsatisfactory", according to the report. The nurse went to get a defibrillator and oxygen machines, and asked a staff person to call another nurse — but did not declare a medical emergency.

When Nurse B came back and used the defibrillator, it signaled to start CPR. 

It was only at that point that a Code Blue was called.

Another nurse arrived and took over CPR compressions until paramedics got there. A few minutes later, an ambulance arrived.

The Board of Investigation also wrote that CPR should have been started while the nurse went to get the defibrillator.

In all, the Board calculated it took between 12 and 15 minutes from the time James was found limp and unresponsive for Nurse B to declare a Code Blue, "call 911, and initiate CPR as required in the Emergency Medical Directives."

After the ambulance got there, CPR continued while James was assessed by paramedics and moved to a stretcher. Rescue efforts continued as she was put in the ambulance. Just before 1 a.m., the ambulance took her to Royal University Hospital. A doctor there declared her dead about a half hour later.