Watchdog finds 'significant wrongdoing' with inmates' medical care at Alberta jail

An investigation by Alberta's Public Interest Commissioner has found that "significant lapses" in the standard of medical care for inmates at an Edmonton jail put patients' lives, health and safety in danger. 

A whistleblower's concerns that medical staff were failing to properly care for and monitor inmates prompted the investigation by commissioner Kevin Brezinski's independent office.

According to a report published Wednesday, the whistleblower identified seven patients who allegedly had severe medical outcomes because of inadequate care from health-care professionals. The health-care professionals — nurses and their supervisors — were employed by Alberta Health Services (AHS).

The whistleblower, who first brought concerns to the office in the summer of 2020, declined an interview with CBC News but shared a letter sent from the commissioner's office in April, which identified the jail as the Edmonton Remand Centre. 

As part of its investigation, Brezinski's office examined medical records, treatment history and retained an expert nurse consultant to review medical records.

"Based on the expert report of the nursing consultant, I found that for five of the individuals identified by the whistleblower, medical staff did not provide treatment that met the requisite standard of care," the commissioner's report says. 

The report cites problems with reassessing symptoms, managing pain concerns, reporting vital signs and documenting physical assessments.

In one case, it took two days for medical staff to begin treatment after observing an inmate's toe was black and swollen with fluid.

Based on the consultant's opinion, the commissioner also found medical staff did not properly implement protocols for two patients undergoing withdrawal.

The report calls the lapses in the standard of care as "serious and significant wrongdoing."

The investigation also found that in two cases, medical staff made decisions based on protocols that didn't exist, and in one case, medical staff denied care to a patient who had reported vomiting because the vomiting had not been witnessed. The latter practice did not conform with standards expected in other jails, the report said.

Brezinski said in the report that he did not view the wrongdoing as being the sole responsibility of specific individuals but that there were systemic lapses in medical care, stemming from a lack of clarity surrounding treatment standards for patients with abnormal trending vital signs. 

Brezinski made four recommendations to AHS for corrective measures, including examining the circumstances of the specific cases and referring matters to regulatory and disciplinary bodies if appropriate. 

'Horror stories' for decades

Tom Engel, a defence lawyer and president of the Canadian Prison Law Association, said he has been hearing "horror stories" for decades about bad medical care at the Edmonton Remand Centre.

"We're talking about human beings dying, human beings suffering," he said.

Engel said the issue is systemic and goes beyond the one jail.

"Part of the reason of issuing a public report is these recommendations are applicable to all correctional facilities within Alberta," Brezinski said in an interview with CBC News on Wednesday. 

Engel said he is pleased that the report, which he plans to use in court, offers an official acknowledgement of problems.

"Now I hope that the government will be forced to do something about it," he said.

AHS makes changes

The report says AHS indicated that it had implemented corrective measures to address all the recommendations. These included reviews of the incidents, discipline, coaching, training and performance reviews with involved medical staff. 

AHS also told the commissioner's office that new reviews and audits have led to workplace investigations resulting in coaching discussions, warning letters and suspensions. 

AHS has updated and implemented its vital signs monitoring guide, which is now mandatory, implemented facility-specific trending reports to identify gaps in care, changed how it responds to patient concerns, and digitized medical staff records.

"We express our deepest sympathies to the individuals impacted by historic care concerns within the Edmonton Remand Centre," AHS told CBC News in an emailed statement.

Heather Smith, president of the United Nurses of Alberta, said the outcome of the investigation offers reassurance for public employees and the public that whistleblowers' concerns will be taken seriously.

"We are encouraged that the process worked, allowing the identification of problems and the implementation of corrective measures by Alberta Health Services," Smith said in a statement.

Brezinski said in the report that AHS co-operated during the investigation and was already in the process of fixing problems when it began.

"I think the majority of the recommendations have already been accepted and implemented, which is a good thing," he told CBC.