Serious medical condition killed man injured in PAPS cell: pathologist

The head wound that Norfield got by hitting his head several time while incarcerated did not lead to a fracture or hemorrhaging, Musgrave said. That was re-inforced by an MRI taken after Norfield was first admitted to the ER on Dec. 2.

INQUEST DAY 2: Guard thought Norfield “was a mess” but he had already been seen at the hospital twice the day before

Musgrove noted that Norfield had signs of a fatty liver, which is common in people who are overweight and early signs of a thickening heart along with neutrophils. None of those factors led to his death.

Blood tests taken at the hospital show a blood alcohol level below the legal driving limit.

How much Norfield’s history of alcohol consumption impacted what happened in the days leading up to his death five days after being detained by PAPS on a COVID hold has been a central theme for the four days of the inquest.

INQUEST DAY 3: Sergeant was trying to reduce COVID exposure and thought Norfield was not having a genuine seizure.

After being taken from cells to the Victoria Hospital the morning of Dec. 2, Norfield was seen by Dr. Ferdie Smit and diagnosed with rhabdomyolysis and admitted.

He then came under the care of Dr. Comfort Alara, the final witness to testify in the inquest.

She said that Norfield was stable that day and was admitted later in the afternoon so she did not see him in person until the following morning.

Alara had given instructions that nursing staff start an alcohol withdrawal treatment protocol along with treating his rhabdomyolosis. Alcohol withdrawal can be fatal.

“He was awake, he was talking, he seemed like he was restless,” she said.

The next day, Dec. 4, things changed. His levels of creatine kinase (CK), an enzyme that normally measures between 22 and 198 units per litre had gone from 11,000 two days before to 73,000.

He was agitated, hallucinating and trying to leave his room, which was forbidden at the time because it was during the pandemic and he had COVID. Norfield had also pulled out both his IV and his catheter.

“We were maxing the medication for his alcohol withdrawal and we gave him other meds to settle him down and it didn’t work” Alara explained. “We couldn’t do anything. He was all over.”

They did manage to calm him down eventually, a crucial need as being agitated increases CK levels.

He had no other alarming symptoms of increased blood pressure or lowered blood oxygen levels at the time.

The morning of Dec. 5, the day he died, Norfield was sedated, clamer and staying on his bed. He complained of some pain but did not show signs of distress.

But tests show some lowering of his kidney function so out of an abundance of caution, Alara called an internist to examine him.

When she left the hospital at 6 pm, Alara said he was stable and was being seen by the internist. His CK levels had dropped and she thought he was recovering.

By 8:30, that had changed and nursing staff called to say his vital signs were dropping. He was being seen by the internist and another doctor.

“I was getting ready to come back to the hospital and they said he coded,” Alara said.

When asked, she said that knowing what had happened while Norfield was in the PAPS cell would not have changed how she treated him.

The protocol to deal with rhabdomyolysis is to flush the patient’s system with fluids to get rid of any toxins and to have a catheter in to monitor for kidney function.

Had she known about his seizures, she acknowledged she might have consulted the internist a bit sooner.

Jordan Norfield is shown with his mother in this submitted photo. She told his doctor he had a history of seizures. (submitted/Sandy Pitzel)

“The more the muscles are injured, the more the rhabdo is going to get worse,” she stated.

While Norfield had a history of seizures well before being in PAPS care, and a video evidence of the PAPS cell showed him having several, nursing staff saw no signs of them while he was in the hospital.

Addressing concerns over the approximately 18 to 22 litres Norfield drank while he was in the cell, Alara said she did not know that information but saw no evidence of water overload when she examined him.

After several hours of deliberation, the jury returned with a finding of accidental death.

They also made three recommendations to the Prince Albert Police Service regarding cell block management.

The first recommendation was that a minimum of four random audits be conducted annually to make sure that the cell area is being run according to the service’s policies.

Second, all officers and security personnel assigned to the cell block should be required to review the policies annually.

The final recommendation was that the Sergeant in charge of the cell block be given the ability to have limited playback of video surveillance in the cells.

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susan.mcneil@pattisonmedia.com

by Susan McNeil

Serious medical condition killed man injured in PAPS cell: pathologist

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