@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 As a result his bail ‘was revoked.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