Coroner's inquest hears how prisoner died from drug toxicity while in custody

A coroner's inquest into the death of a Fredericton-area man two years ago heard today about the tense moments as sheriffs and paramedics tried to revive a prisoner who had gone into cardiac arrest while en route to the Saint John jail. 

It was ultimately determined he died from "drug toxicity" from a combination of methamphetamine and cocaine.

Regional coroner Sarah Barnett testified that a comprehensive Type 2 autopsy was performed on 59 year old Lonnie Carr, and that even though he had poor health - including cancer and heart problems - "that level of drugs was his cause of death."

Carr was arrested on April 3, 2023 following a call about a domestic assault in Tracy, near Fredericton. He was held overnight at the RCMP detachment in Oromocto, where police confiscated methamphetamine pills from his jacket during a body search. 

RCMP Staff Sergeant Dan Sharpe was one of the arresting officers. He testified that during a police interview the following morning, he monitored Carr closely as he took his cancer and heart medication, as it was prescribed on the bottles, and said that nothing in his demeanour changed during this time.

Sharpe and another arresting officer, RCMP Constable Patrick Jolin-Rodrigue, both testified that Carr was extremely cooperative and polite, and at no time in police custody did he appear to be under the influence of any drugs.

"The whole process was completely uneventful," Jolin-Rodrigue said. 

Carr was given a remand hearing by phone that morning, and then sheriffs arrived to transport him to the Saint John Correctional Centre. Sheriffs were briefed on Carr's health conditions and drug possession, and Carr was searched once again before leaving. 

But in the rural area between Fredericton and Saint John, Carr began shaking uncontrollably in the backseat, and went into cardiac arrest. Despite efforts from sheriffs, paramedics and physicians, Carr died five days later in hospital on April 9.

Paramedic response

Primary care paramedic Norma Hicks said she and her partner responded "lights and sirens" to the scene in Petersville Hill. It took 23 minutes to get there. 

She said the patient "didn't respond to voice, or pain stimulation" and was "awake but not alert." Sheriffs had already administered Narcan, in case he had ingested drugs, and had been keeping him conscious and monitoring his condition while they waited. 

Hicks said together with the sheriffs, they moved Carr into the ambulance where they performed a cardiogram which showed he was having a heart attack. 

"Then he went into cardiac arrest, meaning his heart stopped and he stopped breathing," she said. "That's when we started CPR."

She said she did everything in her scope of practice, including putting in an advanced airway "because he was no longer breathing," giving him more Narcan, and an IV with epinephrine to stimulate the heart to work harder and stronger, "trying to rule things out."

"There are many things that cause cardiac arrest," she said. "We run through a lot of what ifs, and I only have a few minutes to do this."

After the mandatory 20 minutes on scene, Hicks said they made the call to continue to the Dr. Everett Chalmers Hospital in Fredericton, with the sheriffs "still squeezing the bag, breathing for him." 

Hicks said they eventually got a pulse back, just before meeting up with the Advanced Care Paramedic on the highway, who then jumped in the ambulance and took over Carr's care for the last leg of the trip to hospital. 

Patient put on life support 

The jury watched a videotaped interview with Dr. Krishna Pulchan, a trauma control physician, who said Carr was completely unresponsive when he arrived. He said they gave him a breathing tube, put him on life support and the appropriate medications, and continued looking after him in the intensive care unit.

He said they performed a CT scan, which showed no evidence of a stroke, as well as an MRI, which showed extensive brain injury due to a lack of oxygen.

"For a prolonged period of cardiac arrest, despite the CPR, there is significant brain injury," he said. "We didn't see much of a neurological recovery."

He said the family understood that he was not going to recover enough to get better, and that if he wasn't going to get better, "it's really just torture."

Pulchan said Carr was moved to palliative care where he passed away quickly after being taken off of life support, as per the family's wishes.

Jury recommendations

The five person jury determined Carr died as a result of drug induced cardiac arrest, and that it was accidental, due to a drug overdose. 

The jury made seven recommendations aimed at preventing deaths under similar circumstances. Those recommendations were:

• Lower the threshold for strip searches (RCMP)

• Closer inspection of medications and personal items (RCMP)

• 20 minute wait on site should be at discretion of EMT (Ambulance NB)

• Have prior warning about moves with high risk medical transfers (Ambulance NB)

• Cameras in all vehicles monitoring passengers (Sheriff department)

• Check vehicles before and after transfers/moves (Sheriff department)

• No personal items given to prisoners (Sheriff department) 

Deputy chief coroner Emily Caissy said a coroner's inquest is mandatory when someone dies while in custody. It does not make any finding of legal responsibility. 

Carr's widow and supporters attended the two day inquest. None of them wanted to speak to reporters about the hearing or recommendations.