THUNDER BAY — Mental health workers at the Thunder Bay District Jail in 2017 say a lack of information sharing resulted in the full extent of Moses Beaver’s mental health crisis not being realized, putting him at risk.
“I think my point of view, critical information was not made available from the beginning, even probably from before he was arrested,” said Dr. Peter Schubert, the psychiatrist at the Thunder Bay District Jail in January 2017.
“One thing is there should be a good exchange of information when an individual is transferred from one custody to another custody, so from police to a correctional facility.”
Schubert was one of several mental health professionals testifying during week two of the coroner’s inquest examining the circumstances surrounding the death of Beaver on Feb. 13, 2017 at the Thunder Bay Regional Health Sciences Centre after being transferred from the jail.
Beaver first attended the nursing station in his home community of Nibinamik First Nation on Jan. 14, 2017 while experiencing a mental health crisis. Attempts were made to medivac him to a larger centre to receive an assessment and treatment, but weather and a lack of available aircraft caused delays.
On Jan. 18, 2017, Beaver was arrested by the Nishnawbe Aski Police Service and eventually transported to the Thunder Bay District Jail.
According to Schubert’s testimony, the jail was under-serviced in terms of mental health care in 2017, a problem that persists today.
“If we take the number of 200 inmates at any one time, the majority of them have significant addiction issues and a subset will have significant mental health and addiction health issues and another subset will have addiction issues,” he said.
“We had at one point another psychiatrist earlier on who was also helping out. The jail as far as I’m aware were aware of this issue. We were trying to recruit more physicians. It is a desperate situation to recruit psychiatrists to work in this setting. This is a current issue right now.”
Beaver would not undergo an assessment by Schubert until Feb. 8, 2017, three weeks after first arriving at the jail.
Schubert said it is not uncommon for inmates to be triaged, where individuals get bumped down the list for other individuals who may have more acuity.
“It could have been Mr. Beaver was doing well for a few weeks, so the level of urgency may have gone down in terms of triaging,” he said.
Beaver was initially placed under a suicide watch at the jail because of a possible attempt at self-harm while in custody before being transferred to the jail.
Schubert testified that he was not made aware that Dr. Megan Bollinger, the Sioux Lookout First Nation Health Authority physician serving Nibinamik First Nation, contacted the jail to provide information relating to Beaver, including a diagnosis of bi-polar disorder.
When asked if he would have contacted Bollinger if he was aware of this information, Schubert said he has no doubt, as it would been beneficial to know about a past diagnosis before Beaver’s assessment.
During the Feb. 8 assessment, Schubert testified that Beaver described himself as an alcoholic and experienced many family losses and trauma, leading Schubert to come to the view that he was suffering from depression.
Beaver also denied a history of any previous bi-polar disorder symptoms.
“In my opinion, the best situation is someone who is doing fine on anti-depressants and is off alcohol and getting proper housing and food and slowly improving, which he endorsed as well,” Schubert said.
The report following the assessment stated Beaver was at low risk for suicidal ideation and ordered he continue taking anti-depressants and be taken off enhanced suicide watch.
Schubert testified that if he had known Beaver had a history of bi-polar disorder, he would have developed a different care plan.
“I would have reassessed Mr. Beaver,” he said. “I would have talked with Mr. Beaver about the situation and that we can’t prescribed Zoloft for bi-polar disorder because of risk of mania and use a different medication.”
In the following days, Beaver’s behaviour became more erratic and he was noted disturbing other inmates, acting bizarrely, and refusing to see a mental health nurse.
Schubert testified that reading that report is upsetting because he was not made aware of the changes in Beaver’s behaviour.
“There’s some change here that isn’t right,” he said. “He is obviously becoming mentally unwell for some reason and we need to have a closer look. I don’t think this is safe.”
Jason Cooper, a mental health nurse at the jail in 2017, was also called to testify.
Cooper completed the jail screening assessment tool on Beaver, during which he denied having any suicidal or self-harm ideation.
Cooper testified that had he had access to proper documentation of Beaver’s previous diagnosis of bi-polar disorder, he would also have followed up with Bollinger.
“It would have brought in some other questions surrounding bi-polar or additional diagnosis with Mr. Beaver,” he said. “Also, I could have properly identified the other previous diagnosis to the psychiatrist and the medical physician.”
According to Cooper, this incident speaks to the District Jail’s use of “archaic paper” charting, making it easier to miss pertinent information.
Cooper further testified that, after Beaver began exhibiting more erratic behaviour on Feb. 11, had he known he was behaving similarly while in the nursing station in Nibinamik First Nation, he would have tried to reconnect with him on the cell block.
“That was an important piece we were missing. On the day of, I really wish I would have made another face-to-face contact with Mr. Beaver to at least assess safety and if there was a need for the re-initiating at least enhanced supervision or even suicide watch to ensure his safety,” Cooper said.
Julian Roy, counsel for the coroner, asked Cooper if not having knowledge of Beaver’s previous behaviour in Nibinamik First Nation led him to believe his actions were attributable to normal behaviours inside a correctional institution, to which Cooper agreed.
“It wouldn’t have raised concerns about safety, fair?” Roy asked.
“Fair.”
When asked about any recommendations to prevent a similar incident, Cooper said electronic charting could help flag important information relating to an individual’s mental health.
A correctional officer at the Thunder Bay District Jail began testimony on Wednesday and will continue on Thursday.
