An inquest conducted by Judge Heather Pullan into the 2016 death of 26-year-old Errol Greene in the Winnipeg Remand Centre has concluded that the facility’s medical unit is lacking oversight and requires a third-party review to ensure that medical operations are up to standard.
Greene died on May 1, 2016, after having two epileptic seizures and not being given his anti-seizure medication by staff at the Winnipeg Remand Centre. An inquest into his death was called December 6, 2016, following pressure from his family and community of supporters. Twenty-three days of hearings began in late 2017 and concluded in October 2018, with one lawyer representing Greene’s family and six government lawyers participating. Rochelle Pranteau, Errol’s spouse, along with her network of community supporters, were present in Court for nearly the entire inquest.
Judge Pullan released her inquest report on June 11, 2019, making several important findings, including that:
- Greene was clear about his diagnosis and his needs with staff. When admitted to the Winnipeg Remand Centre, he clearly described his epilepsy, his prescription for anti-seizure medication Valproic Acid and the frequency at which he took the medication, and his recent seizure history. By making that finding, the judge rejected the attempt by Manitoba corrections to write Errol off as unreliable.
(pg. 5, para. 2) - Errol was repeatedly restrained after having seizures. When the paramedics arrived and Errol didn’t have a pulse, the correctional officers initially refused to remove the restraints. The epilepsy expert who testified explained that the fact he was restrained could have contributed to his death. (pg. 16, para. 60)
As a result of finding multiple issues and significant challenges with the medical unit at the Winnipeg Remand Centre, Judge Pullan recommended “an independent, third party agency with no relationship with Manitoba corrections, with a mandate to recommend change in all operational and clinical areas, to perform a full and comprehensive review of the medical unit at the Winnipeg Remand Centre.” This was part of one of the recommendations proposed by Rochelle Pranteau.
This recommendation and the evidence supporting it (see pg. 160, para. 708) is crucial: it shows that the judge had serious concerns about multiple critical issues in health care delivery at the Remand Centre. These issues included: physician availability and accessibility; deficiencies in nurse training; nurse recruitment and retention; nurse staffing levels; quality of medical charts; nurse access to patient information; medical staff performance reviews; and bed usage in the medical unit.
Judge Pullan’s role was to determine the circumstances of Errol’s death and make recommendations to prevent similar deaths in the future. However, the inquest she conducted had no real power to hold individuals responsible, and Manitoba Corrections is not obligated to take action upon any of her recommendations. It has been difficult for Errol’s family to place faith in a process designed by the very system that failed him and ultimately cost him his life. Attempts to consider systemic racism as a factor in Errol’s death were repeatedly objected to and blocked from consideration—although it is hard to imagine that it played no part. Still, this process was the only way for Errol’s family to seek even this limited form of accountability and demand answers from the Winnipeg Remand Centre.
Judge Pullan made a total of 11 recommendations, all of which address the issues raised by Rochelle Pranteau at the Inquest—issues around training, ensuring that epilepsy experts are involved in policy-making and training, ensuring inmates can be properly identified, and ensuring better access to medical treatment.
The Judge strongly criticized Manitoba corrections for not having external accreditation for the medical unit at the Winnipeg Remand Centre. She explained:
“The medical unit at the Winnipeg Remand Centre is not accredited. It is not clear from the evidence why this is the case. If the focus on healthcare delivery in an institution is on quality and excellence, surely being held to an objective standard, assessed externally, is the best means by which excellence can be achieved and maintained.” (pg. 156, para. 687)
The Judge also criticized Manitoba’s claim that accreditation would be too expensive and labour-intensive. She explained:
“I appreciate that bringing the medical unit at the Winnipeg Remand Centre up to accreditation standard may be resource and labour intensive. That would only be the case should the current operations of the medical unit at the Winnipeg Remand Centre fall far short of standards required. If that is the case, it enhances the need for accreditation.” (pg. 157-58, para. 694, emphasis added)
Pranteau would like to receive an apology and recognition of their family’s deep loss. She hopes that Manitoba Corrections takes these recommendations seriously and that no one else needlessly suffers this way – “I never want another family to go through what we had to”. With the Inquest now concluded, Pranteau will be proceeding with a civil claim for damages against Manitoba Corrections on behalf of herself and her family.
