Mom wants inquest after son turned away from Brandon hospital for addiction help

A Manitoba mother is pleading with the province's chief medical examiner to hold an inquest into her son's death, arguing the systems that failed him need to be exposed.

Ryan Eamer, 46, died in February 2021, the day after he went to the Brandon emergency department in an unsuccessful attempt to access detox services.

His mother, Brenda Eamer, has called for an inquest, but Dr. John Younes, the chief medical examiner, called her last week to say he had decided against one.

"I was shocked," she told CBC News. "We need to have some measures put in place now that will address all the failings that happened to Ryan."

The night she and Ryan went to the Brandon hospital, a nurse initially said he was too intoxicated to be admitted to a detox bed, Brenda says. They were told to go home and come back when he was sober.

However, she insisted her son should be seen by a doctor that day, and left the hospital after checking him in. At some point while waiting, he fell. Police were called to take him into custody, and he was never assessed by a doctor, two reviews into his death found.

He spent over four hours in police custody before he was returned to the hospital. His mother then took him home, where she found him dead the next day.

Last week, following his phone call, Brenda got a letter from Younes, further outlining his reasons for deciding against an inquest.

He pointed to the recently announced inquest into the death of Lee Earnshaw, a 42-year-old Winnipeg man who died in 2021 of a drug overdose after making repeated attempts to get help through a provincial rapid access to addictions medicine (RAAM) clinic.

Younes wrote that both men had similar "challenges with the system" and it would be "redundant" to call an inquest into Eamer's death, despite documented "shortcomings" in his care at hospital.

Younes told Brenda he will monitor the changes that the Prairie Mountain Health authority promised to make in the wake of her son's death — and said he will take action if they don't happen in the next six months. 

But Brenda Eamer says an inquest would highlight the need for more addictions services, like a sobering centre, and show the gaps in his care. 

"The circumstances under which Ryan died were much different from Lee Earnshaw," she said.

"I'm asking for an inquest so that … [Younes] can address the discriminatory practices and behaviour of the staff at the hospital that day."

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Letter sent to medical examiner

She sent a letter to Younes on Tuesday, outlining her concerns and asking him to reconsider his decision.

When contacted by CBC, Younes said he will respond to Eamer's letter but has no further comment to make to the media.

Last week, he told CBC News Ryan Eamer's death could have been prevented if there was better access to addictions services in the province.

Public inquests are called by the chief medical examiner and presided over by a provincial court judge, who considers the circumstances of a death and can make recommendations to prevent similar deaths from occurring.

Some deaths, such as those in police custody, automatically trigger an inquest.

The medical examiner can also choose to call an inquest if they think it may give a judge the opportunity to recommend changes to prevent a similar death, according to Manitoba's Fatality Inquiries Act.

Prior to changes to the act under the Progressive Conservatives in 2017, a government minister could order an inquest.

The Opposition NDP says if elected in 2023, they will reverse those changes, and have pledged to call an inquest into Eamer's death.

NDP mental health critic Bernadette Smith said while there are similarities between Earnshaw's and Eamer's deaths, they both deserve an inquest.

"These are two different people, two different families," she said. An inquest could "make sure that changes happen so that no other family … [has] to experience what they're going through."

A spokesperson for Justice Minister Kelvin Goertzen said the government is not considering any legislative changes that would allow the minister to call an inquest.

Fall at home likely cause of death: examiner

Dr. Younes's initial autopsy report did not conclusively say when Ryan's fall happened, only noting a possible fall at the emergency room the night before his death.

But in his letter to Brenda Eamer, he outlined more specific information about her son's death, after taking a more in-depth review of the entire investigation file. 

That was in response to her questions to him about the cause of Ryan's death, he told CBC News.

When police returned him to the hospital the night before his death, he was "apparently sober," Younes wrote in the letter.

Brenda previously told CBC News the experience of being in police custody and being turned away from detox services soured him on staying at the hospital.

He asked his mom to take him home to sleep, and suggested they would try for detox again in the morning. 

Younes says that when Ryan went home, he began to heavily drink and fell — a fall that was likely the cause of death.

For Brenda, what matters is that he never got the medical help he needed.

"Where Ryan died does not change all that happened to him the day before," she said.

"What would have changed is if at the time that he asked for help, they would have let him see a doctor."