Ronalda Wescoup died in hospital on June 4, 2019, just over an hour after being found unresponsive at Pine Grove Correctional Centre. (Submitted/Ron Bruce)

By Nigel Maxwell

Corrections

‘An inquiry won’t bring back anybody’: jury makes 12 recommendations to improve inmate safety at Pine Grove

Apr 5, 2022 | 5:36 PM

A registered nurse at the Pine Grove Correctional Centre broke down in tears when asked how she felt being told by a doctor he wanted a second test done by a different nurse.

Alicia York was on duty the night 40-year-old Ronalda Wescoup was found unresponsive in her medical cell. Part of Wescoup’s intake to the jail just over two hours prior was a medical assessment.

“I covered absolutely everything Miss Wescoup was willing to share with me,” York said, adding she provided the same level of care to Wescoup as she would have any member of her own family.

Testifying at this week’s Coroner’s Inquest, York explained that while she determined a high level of risk from alcohol withdrawal, the jail’s policy at that time dictated that a patient’s transport to hospital had to be ordered by a doctor. Based on the fact Wescoup’s vitals were not consistent with someone with such a high CIWA score (a test used to assess the level of risk from alcohol withdrawal), the doctor told York her numbers must not be accurate.

“I became a nurse because I care for people. I don’t hold bias,” she said. “I did feel disregarded.”

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According to the timeline of events, Wescoup was found unresponsive at 8:15 p.m. and no heart rate was found when staff performed life saving efforts (CPR and AED). Just over an hour later, Wescoup was pronounced deceased in hospital.

Earlier in her testimony, York explained when she first assessed Wescoup, Wescoup had indicated she was doing okay, and just had a bad hangover. Wescoup also requested being allowed to sleep in the medical cells as it was quieter and she wanted to sleep.

When asked by the Coroner’s Council what changes if any she would make, York, who has since been promoted to the nursing manager at the jail, said there needs to be better communication from the time the inmate is first arrested and in police cells to the time they are taken to Pine Grove.

“It’s a guessing game,” she explained, adding it’s difficult for staff to know what to do when inmates are just dropped off on the doorstep.

York also explained one big change that’s happened since Wescoup’s death relates to policy. As of June 2020, any inmate who tests 19 or higher on the CIWA scale now gets sent to hospital with no permission required by a doctor.

“We have not had another alcohol-related incident,” she said.

York also expressed an interest in having more medical training provided to correctional officers with respect to dealing with inmates who are suffering from alcohol withdrawal. When questioned about the possibility of having more nurses on duty, York said in a perfect world that would be great, but acknowledged issues related to staffing at both the jail and the hospital.

Lisa Venn was the nurse who performed the second assessment at 7:45 p.m., and said there was nothing at the time that would necessitate the need to call an ambulance, and no signs Wescoup was in imminent danger.

Despite a second high CIWA score, Wescoup’s vitals remained normal. Upon relaying the results to the doctor, Venn explained she was told to do another test at 10:30 p.m. At 8:15 p.m., Wescoup was found unresponsive with her body lying just off the bed.

“Hindsight is 20/20. We could have suggested someone sit with her,” Venn said. “Again at the time it didn’t seem like a necessary precaution.”

Jessie Buydens, council for the Elizabeth Fry Society, asked Venn about her interaction with Wescoup, to which Venn recalled Wescoup asking for some juice.

Earlier in the morning, Dr. Shaun Ladham, the province’s Chief Forensic Pathologist, testified he could not isolate a specific cause of death, but explained there were a number of indicators of chronic alcohol use, including both an enlarged heart and liver. He also explained there were no signs of pneumonia or other infections.

Dr. Ladham was also asked by the Coroner’s Council if Wescoup could have been saved had she been transported to hospital earlier.

“I cannot rule out had she been at hospital she would not have died at this time,” he said.

Over the course of two days, a total of eight witnesses testified at the Coroner’s Inquest. The jury, who was quite engaged throughout the proceedings asking questions, was ultimately tasked with drawing up a list of recommendations to help prevent similar deaths from happening in the future.

The recommendations

After three hours of deliberating, the jury returned with 12 recommendations, including ensuring the emergency intercom button is within arm’s reach of the inmate’s bed; hiring more nurses; a comprehensive database to share information between facilities (police, hospital, jail); a dedicated detox facility at Pine Grove; and comprehensive training for all staff at the jail with respect to how to use CIWA.

The jury also recommended having an addictions worker present during intake or medical exams; and ensuring there is better supports in place for when the inmates are released back into the community.

Response from family

Ron Bruce, Wescoup’s father, travelled from Portage La Prairie, Man. for the inquest. He told reporters he was happy with the jury’s recommendations.

“An inquiry won’t bring back anybody. It’s just that so nobody goes through this again,” he said. “Twelve recommendations sounds good to me. I figured they would come up with two or three but 12 is excellent in my books.”

Bruce explained he was most glad to see a suggestion for a detox facility, as well as a suggestion surrounding programming for both people in custody and for when they get released.

“Something should be done. They can’t just have an inquest just for the public eye,” he said.

Bruce revealed his daughter’s sister Marsha also struggled with addictions, and had passed away two years prior to her death. He also explained Ronalda also leaves behind four children who constantly still talk about their mother and how much they miss her.

When asked if he plans to do a follow up with the Ministry of Corrections, Bruce acknowledged he would.

“I will be following up or there will be another inquiry,” he said.

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nigel.maxwell@pattisonmedia.com

On Twitter: @nigelmaxwell