Barton Street jail inquest highlights gaps in ‘code white’ training

An inquest exploring the circumstances surrounding the deaths of eight inmates in four years at the Barton Street jail is being held at the Hamilton Plaza hotel. Global News File

Testimony at a coroner’s inquest has revealed an emergency response device was used during a “code white” event at the Barton Street jail, without training.

Current health-care services manager Angela DiMarco has already told the inquest that medical records and “code white” kits, are only to be used by medical staff, such as a nurse or physician. Correctional officers can administer CPR, and current policy allows sergeants to use the overdose-reversing drug naloxone.

On Sept. 12, 2012, operational manager Fred Duykers said he requested a suction device because he was worried that 42-year-old William Acheson was “drowning in his own fluids.”

He was responding to a “code white” involving Acheson, who had been found on the floor of his cell. He described him as pale, eyes partially open.

READ MORE: Contraband search protocols examined at Barton Street jail inquest

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He knew a defibrillator was needed, he said. After some difficulty adhering pads for the AED, further CPR was given, no shock advised.

Resuscitative efforts were further hindered, according to Duykers, by a red-tinged, fermented-smelling fluid in Acheson’s mouth.

Heidi Neville, one of the responding nurses, told the inquest a suction device was found in a “code white” kit. It was handheld, she said. Adding, she had never used it before or received training on it.

It was handed off.

READ MORE: Barton Street jail inquest reveals scarcity of ‘code white’ kits

Duykers, told the jury he had never seen the device before that moment but that he was desperately trying to sweep the contents of Acheson’s mouth out by hand.

“Wouldn’t matter if it was a member of my own family or Acheson,” he stated. “I would have used it.”

Duykers said he popped off a red cap, specifically recalling the yellow tip of the suction device. After two pumps, he said it was clogged with fruit and he tossed it aside.

An agreed statement of facts shows a bright red cap was found in Acheson’s larynx during a post-mortem exam that determined Acheson was asystole (a condition in which the heart ceases to beat) and therefore beyond resuscitation when efforts to revive him were underway. Heroin poisoning was established as the cause of death.

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Overdose the day before

Video surveillance is not actively monitored in the jail, the inquest heard on Thursday, but rather footage reviewed when necessary.

On Sept. 11, 2012, the day before Acheson’s death, surveillance of his unit shows a flurry of activity between certain cells, including that of a new inmate, referred to as M.B..

The agreed statement of facts shows his cellmate was sent to hospital that day with a drug overdose linked to morphine.

M.B. and another inmate were then moved to Acheson’s cell, number 18.

When the “code white” was called for Acheson, corrections officer Brooke Storm, said she was going to move them to number 17, when she noticed a familiar fruity alcohol smell coming from a bag of home brew. An item also documented through surveillance.

When asked about the possibility of real-time monitoring in order improve response time to a potential incident, Duykers said there are only one to two surveillance screens, and that it would require more staff to successfully implement.

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