A five person jury has made 12 recommendations following the suicide death of a Sarnia Jail inmate in February of 2018.
An inquest into Aaron Moffatt's death was held last week. The 32-year-old died on February 3 at Bluewater Health after being found hanging from a bed sheet in his cell on January 22.
Recommendations include requiring that all inmates on community Methadone Maintenance Treatment (MMT) receive methadone within 24 hours of incarceration. If the inmate does not receive methadone within 24 hours, they must be clinically reassessed for opioid withdrawal on an ongoing basis, and be provided pharmacologic options for treatment.
The jury said the Sarnia Jail’s on-contract primary care physician should be able to prescribe methadone, and say a needs assessment should be done to determine an optimal schedule for mental health nurses.
The jury also said the facility should consider a 24/7 on-call mental health care professional, to ensure continuity of mental health needs of the individual are adequately addressed and advocated for.
They also recommended the Ministry’s policies include regular assessments of jail cell infrastructure to identify and reduce potential anchor points.
Last week's inquest was mandatory under the Coroners Act.
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A full list of recommendations can be found below:
1) The Ministry of the Solicitor General’s Correctional Service’s (Ministry) policy on methadone maintenance treatment require that all inmates on community Methadone Maintenance Treatment (MMT) should receive continuity of care with every effort made to provide daily dispensing of methadone within 24 hours of incarceration, without any gaps in care, to avoid opioid withdrawal and ensuring physical and psychological distress that accompanies opioid withdrawal.
2) The Ministry policy on opioid withdrawal require that opioid withdrawal should be considered a significant contributing factor of patient distress, including distress that can contribute to suicidal ideation and suicidal behaviours and attempts.
3) The Ministry’s policy on withdrawal require that in the event the individual does not receive continuity of methadone within 24 hours, an inmate must be clinically reassessed for opioid withdrawal, on an ongoing basis, and provided pharmacologic options for the treatment of withdrawal symptoms. The pharmacologic management of opioid withdrawal should be monitored for adequate response.
4) The Ministry should consider auditing incarceration facilities that engage with an external service to provide OAT to ensure a formal written agreement detailing the expectations and responsibilities of both the institution and the service be executed, including scope of service, hours of service, on-call expectations, timelines for responding to calls and agreement to adhere to ministry OAT policies.
5) The Ministry’s policies should include regular assessments of jail cell infrastructure to identify and reduce potential anchor points.
6) The Ministry change its Interim Health Care Part A form so that the section on suicidality removes the word specify and replaces it with specify and explore and document detailed assessment in Health Care Part D. The Ministry will provide training to all its nurses on the expectations with respect to this change.
7) The Ministry amend the COWS form so that the suicide screening section include a tick box for health care professionals completing this form to document that they have completed the screening on this specific section.
8) The Sarnia Jail, in consultation with the primary care practitioners, develop a strategy to ensure timely access including treatment continuity to Opioid Agonist Treatment (OAT) including methadone. If an external service is engaged to provide OAT, a written agreement detailing the expectations and responsibilities of both the Sarnia Jail and the service be executed, including scope of service, hours of service, on-call expectations, timelines for responding to calls and agreement to adhere to ministry OAT policies.
9) Until an agreement with the Sarnia Jail and the OAT service provider is established which outlines a protocol addressing communication, the Sarnia Jail’s Health Care Unit is to create a written direction for health care professionals at the Sarnia Jail in respect of communications for the purposes of obtaining methadone prescription. The direction is to require health care professionals at the Sarnia Jail to accurately document in the Health Care Record D all attempts to contact the Sarnia Jail on-contract physician and/or the OAT provider and to follow up with the Sarnia Jail on- contract physician and/or OAT provider every 2 hours if a response is not received; and if there are any communication issues escalate to the Health Care Manager.
10) The Sarnia Jail’s on-contract primary care physician must be able to prescribe methadone to ensure treatment continuity.
11) The Sarnia Jail conduct a needs assessment to determine a schedule for mental health nurses that best addresses the needs of patients in the Sarnia Jail. The assessment may conclude a need for extended hours (into the evenings or weekends).
12) The Sarnia Jail should consider a 24/7 on-call mental health care professional to ensure continuity of mental health needs of the individual are adequately addressed and advocated for.