Pubdate: Wed, 26 Jan 2011 Source: Province, The (CN BC) Copyright: 2011 Postmedia Network Inc. Contact: http://www2.canada.com/theprovince/letters.html Website: http://www.theprovince.com/ Details: http://www.mapinc.org/media/476 Page: A4 Author: Sam Cooper 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. - --- MAP posted-by: Keith Brilhart