Expert says Burnouf inquest shows jail staff is trapped by lack of resources and the Sask. health system

A Saskatoon addiction expert who testified at the Gerald Burnouf inquest this week says the jurors' recommendations strike to the heart of the how the 49-year-old died in jail.

'We need to recognize that this is a health problem'

Jurors said jail staff were ill-equipped to deal with the medical issues Gerald Burnouf presented. (CBC)

Gerald Burnouf was already physically and mentally deteriorating when staff at the Saskatoon Correctional Centre admitted him in October 2016.

Staff suspected something was wrong with the 49-year-old from Ile-a-la-Crosse. He was agitated, suicidal and saying he needed methadone.

He died in his cell 24 hours later.

Jurors at a coroner's inquest this week at Court of Queen's Bench in Saskatoon heard how jail staff were ill-equipped to properly assess Burnouf.

He presented a complex medical puzzle. He simultaneously presented the "drug-induced psychosis" often linked to crystal methamphetamine use. But he was also withdrawing from methadone.

And when staff did try to access his medical records, they could not get to his files in the health care system.

"People can only provide the service that they're resourced to provide," said Dr. Peter Butt, associate professor of addiction medicine at the U of S.

Butt testified at the Burnouf inquest and knows the details of the case.

"If the facilities, if the resources aren't there, then they're trapped as well within this system."

'A desperate cry for help'

Jurors heard how, in the days leading up to his trip to the jail, Burnouf knew that he needed help. He went to local hospitals repeatedly, to no avail.

"Those eight visits over three days are a desperate cry for help," Butt said in an interview.

Dr. Peter Butt says the system bears much of the blame for Burnouf's death. (CBC)

"He repeatedly asked for methadone, he knew he was in withdrawal, he knew what the problem was, but people weren't able to respond — for systemic reasons, not out of malice, but for systemic reasons — in a way that would have helped to address this."

One of the unanswered questions from the inquest is why the health care system never connected the dots.

While Burnouf was at the emergency room at St. Paul's Hospital, he had a methadone prescription waiting to be filled and picked up at the Rexall Pharmacy right across the street.

Butt says what's particularly vexing is the care that Burnouf received in the community, versus what happened in jail.

In the days leading to his incarceration, he was seen by a psychiatrist, nurses and doctors. He spent one night at hospital sedated for his own safety. Police and courthouse staff were generally aware that Burnouf had medical issues that needed addressing.

That level of care ended at the jail gates. Butt says that is something that needs addressing.

"We need to ensure that they're getting access to treatment and that there's continuity going from community, into jail, and from jail back out into the community," he said.

"The more seamless this is, the fewer gaps there are that people will fall through. And these are individuals that will find those gaps."

'There are those gaps'

Provincial officials do not dispute the Burnouf jury's findings.

Corrections and Public Safety did its own internal review in 2016 after Burnouf died.

"It became clear that health information wasn't being provided back and forth, particularly from the community health offices to the correctional centre, and that's been a challenge for us for years," said spokesperson Drew Wilby.

"We're working on that and trying to address that with the Saskatchewan Health Authority now."

Drew Wilby outlined a pilot project meant to assess opioid withdrawl in prisoners. (CBC)
Wilby said that the province already has a pilot project underway at the Pinegrove Correctional Centre at Prince Albert and the White Birch Remand Centre in Regina.

The project aims to help staff assess how opiate withdrawal is affecting inmates. He called it, "a scoring assessment to determine where someone falls and what decision should be made out of that."

"It's for nurses, and then on a doctor's recommendation to make determinations whether certain treatments should be started, whether they should be taken to a hospital," Wilby said.

He said the project is at the women's facilities because the populations are more stable and inmates are not transferred between multiple jails, as often happens with male inmates.