These notes are prepared from the coroner’s report. The regie de l’assurance maladie reports that Justin Scott did not consult a doctor in 2005,2006 nor 2007 before the events that led to his death on 28 November 2007. Justin Scott lives with his mother and had temporarily suspended his job as a telephone pollster to concentrate on his other job as a DJ. He smoked pot every day.
On the night of 18 to 20 November 2007, he is very agitated and transported by ambulance to Santa Cabrini hospital. The doctor concludes it is a case of hyperventilation and follows up with an appointment as an outpatient on the 24th. He leaves the hospital at 7 AM. He doesn’t work on the 20th to the 23rd. On the evening of the 23rd, he has an altercation with his mother, the police intervenes and he is transported by ambulance to Maisonneuve-Rosemont hospital. At midnight, he is transferred to a police station, the centre operational Est and a family member happens to cross his path as he is leaving the hospital. The policeman on the scene assures her that he will be better at the police station.
Police investigators prepare charges of inflicting wounds. They conclude the report with this paragraph: “According to family members who have a background in psychiatry, he is about to be diagnosed with schizophrenia. The mother is scared of Justin Scott but she doesn’t want to accuse him. A psychiatric evaluation is needed because the suspect is a danger to the public.”
At 9:15, on the 24th of November, he is transferred from centre operationnel Est to centre operationnel Nord for a videoconferenced court appesrance which takes place at 14:15 and lasts 2 minutes. The lawyers present do not ask for a psychiatric assessment. Justin Scottt asks why he is accused and his bail hearing is set for the 26th. At 5 PM a bus transfers him to the etablissement de detention Riviere des prairies (EDRDP). He is admitted to the clinic, which has 32 beds including 4 isolation cells designed to accept suicide risks or people who are violent or contagious. This evening (we are the 24th) he is reported as coucou and unpredictable. He hits the walls and tries to hang himself. He is tied up. On the 25th he is praying at 4 PM and a doctor prescribes 5mg Haldol and 2 mg ativan by telephone. The medication is administered at 8 PM. On the 26, he is taken to the Palais de Justice de Montreal. He is calm but disorganized. He is sent back to EDRDP around 7:30 PM. That evening, the judge asks for a psychiatric evaluation of his ability to appear in court and of his criminal responsibility. This expertise is to be provided by Institut Pinel, accompanied by guards. The night of the 26th to the 27th is agitated.
On the morning of the 27th, Justrin Scott is seen by the consulting psychiatrist three times. He concludes that an urgent transfer to Pinel is required. The transfer is planned for 1 PM, then reported to the 28th.
On the 28th, at 2 AM, Justin Scott floods his cell and shouts a lot. Correctional agents restrain Justin Scott and then notice he is unconscious. The death is
confirmed at Santa Cabrini hospital at 3:33 AM. The chaplain notifies the family who had not heard of Justin Scott since the chance entounter on the night of 23 to 24 except for a short call by the police on the 24th to say he was in a police cell. The autopsy reveals a broken incisor.
The coroner concludes that legal psychiatry is not given adequate resources. The need for more resources and better coordination was a conclusion of the March 2001 report of Brian Bedard’s death which occurred on 27 April 2000. The number of experts’ reports required by Pinel grew from 600 per year to 1000 for year 2007-08 so one third of those reports are prepared at EPRDP. Pinel is planning a reduction of its services because of an expected decrease of available psychiatrists.
Here is a list of deaths in a provincial jail:
Janiak Zbigniew, 2001-02-21, transfer, psychiatry
Fitzroy Clarke, 2001-04-04, no meds for his epilepsy
Marc-Antony Christie, 2001-10-19 lack of communication
Yan Rossignol, 2003-02-08 poor communication, psychiatry
Sylvain Guindon, 2004-01-08 no agreement between Bordeaux jail and Sacre Coeur hospital.
Steeve Saint Germain, 2004-01-08 was uder methadone treatment
Yves Chenier, 2005-02-09 problem with communication of notes
Eric Archambault, 2005-06-13 goes through 3 jails
Alain Picard, 2005-12-06 disorganized care
Sylvain Lemelin, 2006-01-03 Baie Comeau
Roger Lalonde, 2006-12-12 death in a federal prison after bad care at EDRDP
Paul-Joseph Pinette, 2007-12-02 Baie Comeau
Hermes Lennis, 2007-01-25 manque de coordination entre lEDRDP et le Palais de Justice de Montreal
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