Jail staff neglected policies days before Clayton Cromwell's death
Documents detail how correctional officers failed to do proper searches and monitor medication
Staff at Nova Scotia's largest jail knew in the days before Clayton Cromwell's overdose death that illicit drugs were floating around the facility, but failed to properly search inmates and cells and did not adequately monitor inmates receiving methadone.
This is according to internal documents obtained by CBC News through freedom-of-information laws that show staff at the Central Nova Scotia Correctional Facility, also known as the Burnside jail, did not follow their own policies and procedures leading up to the inmate's 2014 death.
Devin Maxwell, lawyer for the Cromwell family, says the newly disclosed information paints a powerful picture of how the 23-year-old's death could have been prevented.
"We know that there is a contraband issue there at the jail, and so that's a problem that might have been addressed if they were doing cell searches at the level — quantity and quality — that they're meant to," said Maxwell.
"Perhaps that would have turned up the drugs that eventually led to Clayton's passing."
Cromwell died lying on a mattress on the floor of his jail cell on April 7, 2014. He had a fatal mixture of methadone and benzodiazepine, according to autopsy findings reported by the Canadian Press. Cromwell was not in the methadone program, which administers liquid doses to help inmates curb their opioid addiction.
Testimony of drugs
A corrections investigation report dated July 22, 2014, details how Cromwell appeared groggy on video footage the night before his death.
His bunkmate said Cromwell had been gurgling in his sleep between 11:30 p.m. and 2 a.m. and that he rolled him over on his side. At breakfast time, the inmate called for help when he noticed Cromwell wasn't moving.
The same report discloses that Cromwell's wing was on lockdown since the previous day, and correctional officers were aware inmates had been "all pilled up."
One offender describes how drugs were circulating days before Cromwell died.
"I had seen like, uh, I think they're called tramadol or, so it's basically methadone pills … they're little pills that had been floatin' around, somebody from the street brought 'em in," the inmate said in the report.
Tramadol is an opioid painkiller.
Cromwell's mother, Elizabeth, is suing the province. She alleges the jail failed to set up sufficient safeguards to prevent the flow of potentially dangerous drugs.
The Department of Justice declined comment, citing the ongoing lawsuit.
Access to methadone
Justice and health officials have previously told CBC they believed Cromwell had taken methadone that was "cheeked" by another inmate. That's when someone either conceals methadone during intake or throws it up and sells the filtered liquid.
The Nova Scotia Health Authority said as a result, it changed the jail's methadone policy to hold inmates for 30 minutes after they received methadone, rather than 20 minutes.
An internal memo dated Sept. 9, 2014, shows the 30-minute time limit was in fact the requirement before Cromwell's death, and staff did not adhere to the policy the day before he died — not even close.
"Offenders were held between 3 and 18 minutes in a secure vestibule not the required 30 minutes after taking methadone," the memo states.
In the same memo, Sean Kelly, director of correctional services, focuses on inadequate searches within the Central Nova Correctional Facility.
"A review of search records conducted for a one month period prior to the death in custody shows the quality of searches does not meet acceptable performance standards with respect to being thorough, systematic, and appropriately documented," Kelly writes.
He ordered the superintendent to "undertake a review of area and person searches conducted at the facility" and to "strengthen practices."
Minutes from a manager's meeting held nine months after Cromwell's death discussed how the guards were searching inmates without witnesses.
Senior management also raised concerns about the jail's intercom system and why correctional officers disabled the communication tool for inmates.
Extensive interviews with offenders and staff in the corrections report describe how intercoms in cells did not work on the morning of Cromwell's death. One staff member described the intercoms as a "nuisance."
Inmates explained how they yelled to the person inside the barrier-free cell — a cell designed for people with physical disabilities — but that button also didn't work.
As a result, inmates resorted to waving their arms through food slots and yelling to get the attention of correctional officers.
In his memo, Kelly says "there was no documentation to explain why the intercom was disabled."
In addition, he said supervisory approval wasn't sought, offenders weren't told the intercoms were disabled and the buttons didn't work for "a period beyond 24 hours."
Kelly asked for barrier-free cells in living areas to be included in the regular audit of intercoms. There was no directive for other cells to have intercoms turned back on.
President Jason MacLean of the Nova Scotia Government & General Employees Union (NSGEU), which represents correctional officers at provincial jails, said it makes sense to have intercoms in barrier-free cells, but otherwise agrees they are an unnecessary annoyance.
A former jail guard, MacLean also points out that correctional officers do not have the authority to disable intercoms.
"This has been an issue ever since Central Nova Correctional Facility opened up, and actually it's been such a nuisance and hindrance of getting work done in the other facilities that intercoms weren't part of the plan," he said.
"So if you look at Northeast Nova, there are no intercoms. Why? Because intercoms were being abused."
MacLean said chronic understaffing at the Burnside jail, paired with the presence of street drugs, creates an unsafe environment for correctional officers. However, he adds the recent addition of body scanners has made a difference finding contraband.
"That's been a huge help. There's been a lot of packages found and everything else. It makes it a safer place," said MacLean.
'Veil of secrecy'
Even though some progress has been made since Cromwell's death four years ago, Maxwell can't understand why the province continues to limit information. He says that has been the biggest frustration for Cromwell's family.
"The province's approach to Clayton's death and conditions in the jail in general has been a difficult thing," Maxwell said.
"You know their efforts to keep a veil of secrecy over as much of this as possible, whether it's with us, whether it's with the media, whether it's with the general public has been a frustrating thing to watch for them."
The Canadian Press fought for access to internal reports relating to Cromwell's death and were denied. A review prompted Nova Scotia's privacy commissioner to speak out against the province, which then led to the release of redacted documents.
"Beth's main goal in this is to achieve change. She wants the system to change. She doesn't want anyone else to go through what she and her family has gone through," said Maxwell.