@ontario es Coroner's Investigation Statement Page 1 of2
‘Statement #: Coroner: CIS Case #:
2018-1000-8 40637 - DR Grace, Archie 2014-13966
Personal Details of Deceased
High, Jamie David Gender: Male Date of Birth: O7/0c\/1974 Age: 40yrs
Province: ON Postal Code: NOL-2L0
Investigation Detail
Status: Inquest Required: Potential Death Pronounced: 23/Dec/2014
By what means: Natural Death Presumed:
Environments
Environment(1) Environment(2) PRIMARY
Date: 2aiDeci2014 Date: 2aiDeci2014
Municipality: — LONDON Municipality: — LONDON
Insttution: London HSC - Victoria Site Institution
Environment: Hospital E/R, VSA on arrival, ALS in E/R Environment: Custody - Provincial Jail / Detention Center
Death Factor: Natural Disease - Unspecified / Other Death Factor: Natural Disease - Unspecified / Other
Address: 800 Commissioners RD E Room C214, P.0.Be Address: 711 Exeter RD_ Elgin Middlesex Detention Cen
City LONDON City LONDON
involvements
981 ‘Alcohol andior Drugs - history of abuse
804 MedicalMHesith Care Rx Issues - Coroner
oz Peychiatric Treatment - past / present
Reports Expected
Police: Y Min. of Labour: N
Laboratory: -Y Other: N
Fire Marshal: N.
Pathologist Hospital
2018 DR Tugaleva, Elena a - - -
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 2 friend to St. Thomas Elgin Hospital ER, arriving
‘here at 16:44 Dec. 20/14 in a state of severe depression. There were concerms 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 @ hotel, and wandering the streets without food or sleep. He was to await an assessment at the nospital
the next moming by a psychiatrist who had treated him in the past
inthe previous June, he had separated from his wife and was facing charges of domestic abuse, He had been out on bail and, at one
point, was staying with a fernale friend 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‘was revoked.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 had apparently contacted his ex-wife against a restraining order. The hospital staff were
informed and incicated to him that the police had been contacted by her and he was not to be getting in iouch with her. Itis alleged that
he then contacted her again in a threatening manner, upset that she had called the police, Police therefore arrived at the hospital
removing him from there to the Elgin Middlesex Detention Centre at 01:00 Dec. 21. There, he was put on a suicide watch, and checked
every 10 minutes.
QA. Printed: 20/Aug/2015@ontario Sees Coroner's Investigation Statement Paps2ct2
Statement # Coroner: Cis Case #:
2015-1000-A 40837 - DR Grace, Archie 2014-13066
‘At 15:20 Dec. 21 he was seen at Health Care there complaining of feeling cold, and indicating he'd been off his regular medications (Pax
land Clonazepam) for 5 days. His phermacy (Walmart) was contacted and It appears his medications were then made available to 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: $2. RR: 16
temperature: 36.5, 02: 98 %). He was reported as being very anxicus, restless, and "sweaty ++". Their conclusion was that he was
"withdrawing 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, at tole, talking
to self, being naked" etc. At 08:25, he was noted to be lying naked on the floor beside the tollet making a "grunty noise.” A Heaith Care
individual who was "in the area" was approached and" believes that the /M (inmate) is coming off drugs & satisfied that lM can remain
in coll until his next check", It is 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 irom his cell and taken out for @ video court appearance. | was told that he needed to be taken there and back
by wheelchair. After that, he was pacing or al the door or atthe sink, At 10:20. he was "leaning on bunk.” At 10:30, he was “Wying on
‘ioor" 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 11:30.
‘An autopsy was performed by Dr. E, Tugaleva. | have kept his wife informed of developments. Family members are concemed that
medical treatment was not pursued more urgently, both while he was in hospital (where they feel he should have been kept so that his,
‘assesement could be completed), as well as when he appeared to be quite il at the detention centre. This was a man who had
apparently been very fit and the fact that he required a wheelchair to get to is 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 ventric, possibly
related to steroid use, marked pulmonary congestion and edema and a fatty liver. Biochemical analysis of the vireous fuuld showed
clevated 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 @ combination thereof, The manner of death is natural
Coroner's Signature: Date:
aa. Printed: 20/Aug/2015