@ontario ce ot he Gnet Corner Coroner's Investigation Statement Page 1 of 2 ‘Statement #: Coroner: CIS Case 2016-1000-A 40637 - DR Grace, Archie 2014-13968 Porsonal Details of Deceased Name: High, Jamie Davia Gender: Male Date of Birth : O7/0cu1974 Age: 40,yrs Address: 6255 Pine GROVE ity: UNION Province: ON Postal Code: NOL-2L0 7 Detal Status: Final Inquest Required: Potential Death Pronounce: Investi 23/Deci2014 By what means: Natural Death Prosumé Environments Environment(t) Enviconment(2)_ PRIMARY Date: 23/Deci2014 Date 28/Dec!2014 Municipality: LONDON Municipality, — LONDON Institution: London HSC - Victoria Site Institution: Environment: Hospital E/R, VSA on arrival, ALS in E/R. Environment: Custody - Provincial Jel / Detention Center Death Factor: Nalurel Disease - Unspecified / Other Death Factor: Natural Disease - Unspecified / Other Adgress: 800 Commissioners RD E Room C214, P.0. Be Adress: 711 Exeter RD. Elgin Middlesex Detention Cen City LONDON Cy LONDON Involvements 981 Alcohol andior Drugs - history of abuse 804 Medical/Health Care Rx Issues - Coroner ei2 Psychiatic Treaiment - past / present Reports Expected Police Y Min. of Labour: N Laboratoy: = Other: N Fire Marshal: N Pathologist Hospital 22018 OR Tugaleva, Elena Medical cause of death: ‘Sudden death in a man with delirium and left ventricular hypertrophy Due to /as a consequence of: Contributing Factors: Depression, alcohol abuse Narrative This 40 year old man, who worked as a commercial real estate agent, was brought by a friend to St. Thomas Elgin Hospital ER, arriving there at 16:44 Dec. 20/14 in a state of severe depression. There were concerns that he was not sleeping or eating, and that he had ‘expressed suicidal thoughts of hanging himself. At that visit, he had expressed feelings of hopelessness, sadness, and suicidal thinking, He had allegedly been staying at a Notel, and wandering the streets without food or sleep. He was io await an assessment at the nospital the next moming by a psychiatrist who had treated him in the past. In the previous June, he had separated ftom his wife and was facing charges of domestic abuse, He had been out on bail and, at one point, was staying with a female fiend who had recently told him to leave because of suspected heavy alcohol intake. AS a result his bail ‘was revoked. While setting for the night at the hospital he nad apperenty contacted his exwife against a restraining order. The hospital staff were Informed and indicated to him that the police had been contacted by ner ang he was not to be getting in touch with her. Itis alleged that he then contacted her again in a threatening manner, uoset thal she had called the police. Police therefore arrived at the hospital ‘emoving him fom here io the Elgin Mdcesex Detenion Cente at 0:00 Dec. 21. Thee, he was pu ona sue watch, and checked every 10 minutes, aa. Printed: 20/Aug/2015(ontario cmasisecnicoum __ HoFENEH'S Investigation Statement Pasezot2 ‘Statement # Coroner: CIS Case #: 2015-1000-A, 40837 - DR Grace, Archie 2014-13968 'At 16:20 Dec. 21 he was seen at Health Care there complaining of feeling cold, and indicating he'd been off his regular medications (Paxil ‘and Clonazepam) for § days. His pharmacy (Welmart) was contacted and It appears his medications were then made available fo him. ‘At 02:50, he reported feeling unwell, allegedly stating that he was coming off steroids. He requested Tylenol. At 17:00, he was assessed at the Health Care requesting that he be transferred to hospital ‘Two nurses apparently examined him, and could find no abnormalities. His vital signs were checked, and found to be normal (BP: 130/80, HR: 92, RR: 16 temperature: 26.5, 02: 98 %). He was reported as being very anxicus, restless, and “sweaty ++", Their conclusion was that he was “witharawing from Paxil" which was now to be given at bedtime. ‘The checks through that night and early morning of Dec, 23 suggested a restless night of "pacing, at door, at sink, at bed, a tlle, talking to self, being naked” etc. At 08:25, he was noted to be lying naked cn the floor beside the tolet making a “grunty noise." A Health Care individual who was "in the ereat was approached and " believes that the lM (inmate) is coming off drugs & satisfied that lM can remain in call unti his next check’, Its not clear to me if he was actually examined at that point, or that any vital signs were taken. ‘At 08:40 he was removed from his cell and taken out for video court appearance. | was told that he needed to be taken there and back by wheelchair. After thet, he was pacing or at the door or at the sink. At 10:20, he was "leaning on bunk.” At 10:30, he was “ying on floor" and at 10:43 found vital signs absent. Two guards started CPR, and he was transferred by EMS to Victoria Hospital ER where, after unsuccessful resuscitative measures, he was pronounced dead at 11:20. An autopsy was performed by Dr. E. Tugaleva. | have kept his wife informed of developments. Family members are concemmed that ‘medical treatment was not pursued more urgently, both while he was in hospital (where they fee! he should have been kept so that his, ‘assesement could be completed), as well as when Ne appeared to be quite il at the detention centre. This was 2 man who had ‘apparently bean very fit and the fact that he required a wheelchair to get to his video court appearance, does suggest to me that he was demonstrating signs of being severely il at that point There was no trauma or injury found that could have caused death, There was evidence of hypertrophy of the left ventricle, possibly felated to steroid use, marked pulmonary congestion and edema and a fatty liver. Biochemical analysis of the vitreous fluid showed elevated urea and creatinine suggestive of either mild acute renal failure or dehydration. Toxicology examinations revealed no toxicologic cause of death. His betahydroxybutyrate was elevated suggesting possibly due to stress, starvation or diet ‘The cause of death was felt to be sudden death in a man with delirium and left ventricular hypertrophy. This was likely on the basis of ‘withdrawal from alcohol, Paxil, steroids or a combination thereof. The manner of death is natural Coroner's Signature: Date: Printed: 20/Aug/2015