Windsor man overdosed in jail after being denied addiction meds, coroner's inquest hears

A Windsor father of two died from a fentanyl overdose at a local jail just days after being denied a prescription for a drug that treats opioid addiction, a coroner's inquest heard Monday. 

Joseph Gratton, who was 31 at the time of his death, had asked a nurse for suboxone eight days before jail staff found him unresponsive in his cell on the night of Oct. 29, 2019. 

Gratton was being held at the South West Detention Centre, a provincial jail on the city's outskirts, while awaiting court proceedings on robbery and assault charges. 

It's so far unclear why Gratton wasn't prescribed the medication. The nurse involved in the decision is set to appear as a witness Tuesday.

But on the first day of the coroner's inquest, the jury and other participants heard new details about the circumstances surrounding his death nearly six years ago at a jail that's been repeatedly criticized for overcrowding and understaffing. 

The inquest heard that there were several factors that might have delayed the medical response to the incident, including missing keys to quickly open the cell door where Gratton and his cell mate, Blake Carter, were found unconscious on the floor just after 11 p.m. 

The correctional officer who first made the discovery also had a "history of conflict" with Gratton that prompted a police investigation, inquest counsel Julian Roy said. She was working overtime that night, and normally wasn't assigned to his area.

Coroner's inquests, which look at the circumstances around a death, are mandatory under law when someone dies in custody from non-natural causes. It's not a trial, but a jury is responsible for establishing basic details about the death, and can also craft recommendations to prevent future ones. 

Roy extended his condolences to Gratton's mother — who is involved in the process — before delving into an overview of the case Monday morning. 

"You trusted he was safe in a difficult time in his life," he said. 

"I hope you will get some answers about what happened."

Gratton had "a fatal level of fentanyl" in his blood, according to a postmortem exam report shown at the inquest. He also had a plastic baggy in his rectum. Separate testing showed it contained fentanyl. 

Gratton had two other drugs in his system — trazodone, often used as a sleeping pill, and vortioxetine, an antidepressant — that he had been prescribed, the coroner found. 

Peter Spourdalakis, an acting sergeant at the time of the incident, told the inquest Monday that Gratton and Carter were lodged in an area known as A2, a behavioural management unit with stricter rules.  

Gratton "had had some behavioural challenges" at the detention centre, Spourdalakis said by video, but he hadn't had any bad interactions with him. 

Carter, however, had been caught with illegal drugs before, Spourdalakis said, and he'd recently returned from what's known as a "dry cell" — a single-person cell with barely anything in it where offenders are subject to bowel movement inspections and scans for potential contraband.  

Spourdalakis, as the night shift supervisor, was in the unit checking that all the cell doors were locked just before 7 p.m., he said. Gratton and Carter stopped him and asked for cleaning supplies, Spourdalakis said, which he took to be gamesmanship, since cleaning time was over. Gratton seemed to be in good spirits and joking around, he said. 

But not long after that, someone was allowed to leave their cell and pass something under Gratton and Carter's door, Roy said. A video of that moment will be shown later in the inquest, he said. 

At around 8 p.m., Carter was "unwell" when a nurse came around for medication rounds, Roy said. He had recently thrown up, but "no focused assessment" of him was done. 

It wasn't until roughly three hours later that one of the correctional officers assigned to the unit for the night noticed something was wrong in cell four, where Gratton and Carter were housed.

That correctional officer — who will appear as a witness later in the inquest — had previously alleged Gratton had threatened her, leading to the police investigation, the results of which are unknown. 

That officer had told Spourdalakis earlier that night that she had concerns about being posted to Gratton's unit, which was not her usual assignment. He said "it's not best practice" to have an officer stationed in a unit where there's a potential conflict with an offender, but that the staffing situation doesn't always allow for flexibility. He also didn't have the authority then to re-assign officers, he said. 

At around 11 p.m., according to video shown at the inquest, that officer stopped at cell four's door during a regular patrol. She lightly kicked the door a handful of times, then kept walking to check the remaining cells, after which she appeared to make a call on the radio.

She then walked back to Gratton and Carter's cell, knocking the bottom with her foot again. At that point, Spourdalakis quickly walked up. 

He said she had called for available staff to come to the unit, which was "certainly an anomaly" at that time of night, when inmates are locked in their cells to sleep. But she hadn't called for a medical emergency, which would have summoned medical staff, too. 

When he got to the unit to figure out what was going on, the correctional officer pointed to cell four and the two men on the ground, saying she wasn't sure if they were joking around or something was going on. 

Spourdalakis said he looked into the cell door's window and saw them lying on their stomachs, with their arms wrapped around each other.  

He then loudly banged and kicked the door and yelled at the men, knowing that if they were joking, they'd immediately get up, as causing unrest at that hour would likely result in serious consequences.

"There was no response," he said. 

Spourdalakis then called a medical emergency over the radio and asked the correctional officer to open the door. He knew minutes and even seconds mattered in that scenario, he said. 

"I don't have the keys," she replied, according to him. The other officer assigned to the unit had them and was on break, he said. 

That officer, along with several others, arrived in the moments that followed, according to a roughly three-minute video shown.

Spourdalakis said once he got into the cell, he rolled Gratton over and saw he had fluid coming from his mouth. He detected a very faint pulse, he said, and a nurse, who had since arrived on scene, directed someone to call 911. 

Another officer gave Gratton the first of three naloxone doses he would receive, Spourdalakis said, but Gratton was turning grey and no longer had a pulse. So they started several rounds of CPR and defibrillation, and a nurse gave Gratton oxygen until paramedics arrived at around 11:19 p.m.

"Absolutely, I was trying my best," Spourdalakis said. Carter, meanwhile, had regained consciousness after a shock to the chest, but was confused.

Both men were transported to the hospital, and Gratton was pronounced dead just after midnight. Carter survived that night, but has also since died, Roy said, explaining why he wasn't at the inquest.  

The incident had upset both staff and at least one inmate, who was physically distraught, Spourdalakis said. "He had mentioned, 'That's my friend'," Spourdalakis said. 

Since then, the jail has seen a number of changes, in part as a result of Gratton's death, said Spourdalakis, who now serves as a staff sergeant in charge of security for the entire facility. 

The detention centre now has a dedicated K9 unit that does more frequent searches, he said, including random ones, as well as better scanners and intelligence-sharing relationships with local police. 

There are more sets of keys for each unit, and what was then the behavioural management unit is now reserved for offender intake, where staff can more closely monitor for contraband and other issues before inmates are integrated into the jail. 

The volume of contraband making its way inside the jail has "subsided substantially," he said, but the facility remains overcrowded and has been for several years now. 

The centre's official capacity is 340 offenders, he said. "But we're significantly above that count today."

The inquest is expected to last through Friday.