A coroner’s inquest has revealed that the Hamilton-Wentworth detention centre only had one “code white” kit at the time 40-year-old inmate Louis Unelli died.
It’s the kit that contains blood pressure equipment, gauze, a stethoscope, and more recently, the opioid overdose-reversing drug Narcan (or naloxone).
Registered nurse Andrea Brewster testified, that she believes the Hamilton-Wentworth Detention Centre has a “good system” when it comes to responding to medical emergencies, such as an overdose, with defibrillators and oxygen readily available.
However, on March 17, 2012, the day Unelli died, she told the jury, there was only one code-white kit available. When she was alerted to the code-white situation involving Unelli, she said she had to wait for the kit. At that time, the jury heard from multiple witnesses that CPR was already being administered, 911 called and an AED (Automated external defibrillator) eventually brought in, that advised no shock be given.
Counsel to the coroner, Karen Shea, asked Brewster if the possibility of overdose crossed her mind.
“Usually does,” she responded.
When asked about what would further assist or augment a nurse’s response to an overdose in that environment, she pointed back to the accessibility of code-white kits.
Next, Shea asked Brewster if she would have used Narcan on Unelli, if it was available in the code-white kit.
“Sure,” said Brewster.
Forensic pathologist Dr. John Fernandes testified on Monday, that Unelli’s death was an accident, caused by toxicity from a mix of oxycodone, hydromorphone and lorazepam.