Inquest hears how Gerald Burnouf fell through cracks in health care system before dying in jail

Jurors at a coroner's inquest in Saskatoon heard how Gerald Burnouf fell through cracks in the health care system in the days leading up to his death at the Saskatoon Correctional Centre.

The 49-year-old died at the jail on Oct. 8, 2016. The inquest at Court of Queen's Bench is scheduled to wrap up Thursday.

In his charge to the jury, coroner Neil Robertson reviewed the evidence from the 14 witnesses who testified.

Jurors heard how Burnouf had gone to St. Paul's Hospital and Royal University Hospital a combined eight times in the week leading up to his death. He was seen by nurses, doctors and a psychiatrist and was, at one point, diagnosed with "drug-induced paranoia."

Burnouf wanted help. He was agitated and suicidal, and wanted methadone to help with his addictions.

It appears no one knew that he had a prescription for methadone ready for pick-up at the Rexall Pharmacy on 20th Street West. The pharmacy is across the street from St. Paul's Hospital.

Autopsy does not reveal cause of death

Burnouf is from Ile-a-la-Crosse and had his original methadone prescription issued in Meadow Lake. He came to Saskatoon weeks before dying.

At various points, Burnouf was sedated at hospital, released, arrested by police, kept in detention cells overnight, taken to court and eventually taken to the local jail.

Provincial court workers alerted the jail that Burnouf was complaining about not feeling well when he was transferred to the jail. He told staff at the jail that he needed methadone, but they were unable to provide it because they did not know he had a valid prescription.

The placed him in a holding cell and kept him under observation. Jurors heard the staff's primary concern was that Burnouf not harm himself.

He was found unresponsive in his cell the day after arriving. He was pronounced dead later that day.

An autopsy did not reveal a clear cause of death.

The jail has since changed its policy on how staff in the medical unit monitor prisoners in holding cells.

The jurors are scheduled to draft their recommendations Thursday.