Barton Street jail had staffing shortage when inmate died: coroner’s inquest

The same year there was a hiring freeze at Hamilton-Wentworth Detention Centre in 2014, 38-year-old inmate Trevor Burke died in hospital.

These were details discussed during a coroner’s inquest Tuesday into eight inmate deaths that occurred at the Barton Street jail.

Hamilton-Wentworth Detention Centre Sergeant Michael DuCheneau testified that resources were stretched and managerial staff was diminished. When burn-out happens, he told the jury, you see performance levels drop.

James McIlveen, assistant to the deputy superintendent at the time, testified the lack of staff prompted the jail to reach out to Hamilton police to help fill guard duty at the hospital where Burke was receiving care for an infection on his leg.

Burke was to receive 24-hour surveillance. It’s a task that correctional officers receive training for, the inquest heard. DuCheneau explained it involves information about different restraints, a scenario-based approach to learning, as well as mentorship through senior officers.

The job of a community escort officer in hospital also involves documenting observations of an inmate, such as their activities, movement and general condition. It’s documented hourly in a logbook, according to McIlveen, so that the correctional officer coming in to provide relief is informed.

Sgt. Michael DuCheneau reviewed one log entry before the jury from when Burke was being watched, saying it lacked important details, such as the name or badge number of the nurse on shift.

The jury also heard from McIlveen that once per 12 hour shift a supervisor is supposed to visit the hospital and review the logs. After a review of documents pertaining to Burke, DuCheneau could only find one sign-off by a supervisor between the time Burke was admitted in early March and March 24, 2014, when he was found in distress.

In addressing questions from the jury, Ducheneau said, in his experience, there are a couple other practices in relation to guarding Burke that fell short.

The first pertains to the surveillance. Two correctional officers have testified they were watching Burke from outside the hospital room door. DuCheneau said he would have been at the foot of the patient’s bed while another officer watched from the hall, communicating any activity.

Burke was found with a syringe of hyrdromorphone on March 24, 2014, and later pills, the inquest has heard. An agreed statement of facts showed the only search to be documented was done after Burke was transferred to ICU.

Correctional Officer Craig Fournier testified to the challenges a strip search would present in that setting. DuCheneau, however, testified that he believes it could have and should have been done.

It’s not a policy or escort guard training issue, DuCheneau told the jury, but rather one of managerial motivation. Ensuring correctional staff maintain a “threshold of performance” was affected by staffing issues in 2014.

“We are coming out of the darkness now,” DuCheneau said in regard to the hiring freeze. Adding his recommendation for more managerial training could still be tough to accomplish because of the immediate needs of the operation.