OCC Inquest - High 2016

Office of the Chief Coroner

Verdict of Coroner’s Jury

Office of the Chief Coroner

The Coroners Act – Province of Ontario


Surname: High
Given name(s): Jamie
Aged: 40


Held at: 6675 Burtwistle Lane, London
From: November 7
To: November 11, 2016
By: Dr. Elizabeth Urbantke, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jamie High
Date and time of death: December 23, 2014, at 11:30 a.m.
Place of death: London Health Sciences Center, Victoria Campus, 800 Commissioners Road East, London, Ontario
Cause of death: Sudden death in a man with delirium resulting from alcohol withdrawal, complicated by left ventricular hypertrophy.
By what means: Natural

(original signed by Foreman and Jurors)


This verdict was received on the 11th of November, 2016
Coroner’s name: Dr. Elizabeth Urbantke
(original signed by Coroner)


We, the jury, wish to make the following recommendations:


Inquest into the death of:

Jamie High


Jury Recommendations

To the St. Thomas Elgin General Hospital, St. Thomas Police Service and the Elgin Middlesex Detention Centre:

  1. The St. Thomas Elgin General Hospital, St. Thomas Police Service and the Elgin Middlesex Detention Centre shall collaborate to develop a plan for the safe transfer of a patient, if at all, and to determine the appropriate information that can be shared including but not limited to information about medications.
    A meeting shall take place with representatives of the St. Thomas Elgin General Hospital, the St. Thomas Police Service and the Elgin Middlesex Detention Centre to discuss how to put this recommendation into effect.
    At this meeting, topics to be discussed should also include barriers and opportunities to develop an appropriate permanent method (ie. electronic or written) to ensure effective and timely communication of critical information between institutions.
    Consideration should be given to extending an invitation to other local police authorities and health care facilities to attend this meeting.

To the Elgin Middlesex Detention Centre:

  1. Elgin Middlesex Detention Centre should implement ongoing and meaningful training for correctional officers and non-medical staff with respect to the supervision of inmates with medical and mental health issues including but not limited to Alcohol and Drug withdrawal and the urgent and/or emergent presentations requiring medical attention.
  2. Education and support should be provided to correctional officers and non-medical staff at Elgin Middlesex Detention Centre with respect to communication and an appropriate permanent method of documenting any communication with nursing staff regarding medical issues, including mental health issues, for inmates.
  3. Elgin Middlesex Detention Centre should ensure that there is ongoing and meaningful training for nursing staff with respect to the management of the health and welfare of inmates.  Education and support should be provided to nursing staff at the Elgin Middlesex Detention Centre with respect to communicating and an appropriate permanent method of documenting any communication with correctional officers regarding medical issues, including mental health issues, for inmates.
  4. Elgin Middlesex Detention Centre should review and develop best practices for all staff regarding the recording and review of information related to inmates receiving medical care and treatment.
  5. Elgin Middlesex Detention Centre should review and develop best practices for all staff regarding an understanding of continuity of care.
  6. Elgin Middlesex Detention Centre should review and develop best practices for all staff regarding the types of information that should be required to be communicated to the health care unit regarding an inmate.
  7. Elgin Middlesex Detention Centre shall review and develop best practices for continuity and exchange of information between non-medical and medical staff for inmates requiring ongoing care and treatment.
  8. Elgin Middlesex Detention Centre shall develop ongoing and meaningful training for all staff regarding the recognition of occupational stress, management of occupational stress and supports available to employees, with consideration given to areas identified as having elevated operational stress.
  9. Elgin Middlesex Detention Centre shall install security monitors for each individual segregation cell, to be monitored 24 hours a day.

To the Ministry of Community Safety and Correctional Services:

  1. The Ministry of Community Safety and Correctional Services shall review the health care staffing at the Elgin Middlesex Detention Centre to work towards ensuring the mental health nurse and nursing staff complement is sufficient to meet the needs of the inmate population at the Elgin Middlesex Detention Centre.
  2. The Ministry of Community Safety and Correctional Services shall review the correctional officer staffing at the Elgin Middlesex Detention Centre to work towards ensuring the staffing complement is sufficient to meet the needs of the inmate population at the Elgin Middlesex Detention Centre.
  3. The Ministry of Community Safety and Correctional Services shall hire a nurse practitioner with mental health and/or drug and alcohol addiction scope of practice.  Their role will be to provide health care to the inmates of the Elgin Middlesex Detention Centre in support of the most responsible physician and the psychiatrist, as well as ensuring ongoing and meaningful training of all staff with respect to inmate health care.