The coroner’s inquest into the March 4, 2011 overdose death of Robert Howard Clause, of Six Nations, commenced Monday, October 27th, 2014 in Brantford at the Superior Court of Justice, with Dr. Jack Stanborough presiding. A coroner’s inquest is mandatory when an inmate dies of unnatural causes while in the custody of a jail. The coroner’s inquest into the death of Robert Clause commenced just one day after another inmate, 27-year-old Kyle Dean Sandy, also from Six Nations, died suddenly while in custody at the Brantford Jail.
A key witness in the coroner’s inquest, Sgt. Mike Duchenau, the Operational Manager at the Brantford jail, testified that he completed rounds at 6:30am and saw Clause lying on the floor in his cell. His head was visible but his body was not because he had a blanket on. There were no signs of distress. The inmate appeared to be sleeping.
At 7:05am, Duchenau heard, “Shift ITC Unit 6,” which indicates to staff that it is an emergency. He immediately went to unit 6. Upon arrival, Duchenau was informed that there was no response from Clause. He ordered the lights to be turned on. He observed Clause still lying on his right cheek, but with the lights on, he saw a pool of clear fluid around Clause’s head, which had drained and spread approximately one foot from his head.
The officers secured the other two inmates, Jay Maracle and John Emburgh, in the community room and Duchenau directed the officers to start 2-man CPR on Clause. While en route to get the Automated External Defibrillator (AED), Duchenau had an ambulance called.
Duchenau testified the AED machine had not completed its diagnostics before paramedics got there around 7:30am. By 7:40am, the paramedics had pronounced Clause dead.
The Brantford Police arrived. When Clause was pronounced dead, the police, per protocol, declared the area a crime scene and an investigation commenced. Inmates Maracle and Emburgh were taken to A&D. Through the course of evidence given, it was stated that items were seized pertaining to the Clause matter, including a half book with crushed pills inside, folded paper, clear fluid in a toothpaste tube, a cap with an orange pill and a melted, congealed substance.
The inquiry focused on the issues of “dry celling” an inmate, which is the process of segregating inmates suspected of having contraband in their possession for 48-72 hours. Regular monitors by officers occur at least every 20 minutes but there is no video-supervising available in the Brantford Jail for this purpose.
Emburgh, one of the inmates in unit 6 at the time of Clause’s death, was being dry-celled. Emburgh was in custody for committing a robbery at Eagle Place Apothecary. It was believed that he had stolen 200 opiate pills from the pharmacy. A physician had informed the police that 100 pills had been recovered from Emburgh and that he believed that there were no more pills on his person. However, officer suspicions led to Emburgh being dry celled for 48 hours; he did not get dry celled for the maximum period of 72 hour period because the cell he was in was needed for another inmate.
Duchenau admitted that drugs in jails are a very serious issue. Officers must use the least intrusive method possible to conduct searches of the person. He described the 3 levels of searches of the person, including cursory observation, the pat down or frisk search and the strip search. X-rays are the best method of searching for suspected drugs available to the Brantford Jail staff, but inmates can refuse an x-ray. An inmate, even with loss of freedoms, still has basic human rights; therefore inmates must sign a “Consent of Medical Treatment” form in order for the institution staff to administer an x-ray.
During questioning, Sarah Dover, legal counsel for the Clause family, quoted evidence that Clause had requested an inhaler during night shift but could not get assistance. Duchenau had not been advised that Clause had had trouble breathing the night before.
When asked if he had ever been offered or taken training to identify signs of an overdose, Duchenau stated that he had not
Dover read a statement made to Detective Jeff Spencer by Operational Manager, Sergeant Keith Wright, who had been on duty the night Clause asked for an inhaler. Wright’s statement contained comments like we “didn’t shove it down his throat” and Clause’s “cell partners didn’t say anything.”
Dover inquired with Duchenau about the relationship between inmates and the officers and Duchenau stated that the inmates come to the jail “with needs and we should help them address their needs.” He thought that mentorship was a good way to teach staff how to handle inmates and he identified that this was an initiative the Ministry had introduced, although it is not mandatory.
The inquest continues this week.