Windsor man who overdosed in jail was denied opioid meds because he wasn't eligible: nurse

CBC

a day ago

In the weeks leading up to his death, Joseph Gratton had asked medical staff at the local jail multiple times for drug tests and a medication that helps treat opioid addictions.
But the Windsor father of two would never access the prescription drug, and on an October night nearly six years ago, he overdosed on fentanyl in his cell at the South West Detention Centre.
A correctional officer found Gratton, 31 at the time, and his cell mate unconscious on the floor during a routine patrol. Despite several rounds of CPR and naloxone, Gratton was pronounced dead at the hospital just after midnight on Oct. 30, 2019.
A legally mandated coroner's inquest into the circumstances around his death began Monday. Inquest counsel Julian Roy revealed that a nurse had denied Gratton a prescription for suboxone, which helps people with opioid addictions fight cravings and tame withdrawal symptoms, eight days before his death.
On Tuesday, the jury heard directly from the nurse practitioner in question. Julie MacVoy, who no longer works at the facility, testified that she denied Gratton suboxone because he wasn't eligible for the drug, in part because he hadn't been formally diagnosed with an opioid use disorder.
MacVoy said she also didn't see any clear signs of withdrawal — though she acknowledged that those symptoms might not be present if he was still using illicit drugs.
She noted that he had a history of hoarding prescription medication as well, leading her to believe that he might misuse the suboxone — a drug that poses health risks if abused or prescribed to someone who doesn't need it. "He was known to do that," she said. A previous urine test had come back negative, too.
Gratton, the inquest heard Tuesday, had been transferred back to Windsor from a jail in Niagara on Sept. 29. Soon after, he asked to see the nurse practitioner and for a "piss cup" — a urine drug sample.
"The nurse sent my request a couple days ago," Gratton wrote on the Oct. 5 written request. "Whats the holdup."
Two days later, Gratton filled out another request for a urine test, saying he had heroin in his system, was going through withdrawal, and needed suboxone.
"Please and thanks. Soon as possible," he wrote. "Been asking for almost a week. Since I got shipped back."
A note on the bottom of the request from an unidentified nurse indicates that the urine test was ordered on Oct. 8, more than a week after Gratton returned.
MacVoy testified that urine tests typically can detect drugs in someone's system for three to five days after – and even up to seven days later in rarer cases. But by the time Gratton got tested, it had been roughly nine days.
In his medical chart, MacVoy wrote that Gratton "took contraband while in Niagara" but that the urine drug test came back negative. Still, she noted that the test was "performed late."
It's unclear why she didn't order another test. Even then, suboxone can still be used to curb addiction cravings in those who've been off opioids for a shorter amount of time, the inquest heard.
But MacVoy also didn't know then that Gratton was referring to opioids when he said contraband, she said. She testified she didn't remember their interaction, and as the only nurse practitioner in the building at the time, saw 20 to 30 patients per day. She wouldn't have seen the written requests, either.
But if he had told her what contraband he had been using, she would have marked it in his chart, she said.
She said inmates can be reluctant to admit to active illicit drug use in jail because of the investigation it would automatically prompt.
MacVoy said she believed "it wasn't very common for drugs to get into the jail" at the time — but that soon changed when the facility started "having some terrible outcomes."
In any case, it was also rare then for an inmate to start opioid addiction medication after they'd already spent time within the jail. "It was virtually unheard of to revisit that later in custody," she said.
"Generally it was frowned upon," she said, but couldn't specify why she felt that way. Those types of treatments typically started upon admission to the jail among those who had a history of drug abuse.
Things, however, were starting to change during her tenure, she said, which is in part why she considered Gratton's request for suboxone in the first place. She also believes in harm reduction and working with patients to make informed decisions.
Tuesday's witnesses also included a correctional officer who was assigned to Gratton's unit the night he overdosed. Randy Mascarin, now a staff sergeant, was present earlier in the night when another inmate was allowed to walk to Gratton's cell and pass something under the door — video of which was shown Tuesday.
Mascarin said the man was let out of his shared cell to give privacy to the other inmate while a sergeant entered to handle a misconduct case. He said it's normal for inmates to pass each other things — a pack of unwanted peanut butter could make another inmate's day — so he didn't think anything of it at the time.
He also shed light on why the key to open the cell was with him and not the officer actively patrolling the unit when Gratton was discovered at around 11 p.m.
Mascarin said he had been performing the patrols before that, and that handing them over to the other officer before he went on break was simply "lost in process."
He said that issue "really ate at" him "for a long time," but that he knows the facility has more safeguards in place now.
On Wednesday, the inquest is expected to hear from the other correctional officer assigned to the unit that night, as well as a senior official within the provincial corrections system on the types of changes that have been implemented at the jail and other facilities in Ontario since Gratton's death.
MacVoy, the jail's former nurse practioner, said they made some changes right away, though. "We didn't need an inquest," she said.
"I do think inquests need to be a bit more timely," she said, noting the six year gap.
Ultimately, she said she still feels her decision not to prescribe suboxone — now available in film and injection formats that are harder for inmates to divert — to Gratton was the right call at the time, because she lacked the evidence she needed.
She also offered her condolences to Gratton's family. "You don't go into medicine to watch people get hurt or die," she said, her voice shaking. "We also don't have a crystal ball."
Mascarin offered his condolences as well — specifically, to Gratton's mother, who is involved in the inquest. He said corrections officers might have a reputation for not caring about inmates, but that every person who responded that night wanted to save both Gratton and his cell mate's lives.
"Joseph was a decent guy to me," he said.