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Campbellton - A coroner's jury in Campbellton made nine recommendations last Wednesday as a result of an inquest held in the city arising out of the death of Leona Harquail, a homeless Aboriginal woman, who was found dead in a Campbellton apartment in January 2005 only a day after leaving the ADDU (alcohol and drug dependency unit) of the Restigouche Health Authority.

Enlarge Photo

Tim Jaques/Tribune

Coroner John Evans is shown speaking to Andy Wilson of the CBC after the inquest into the death of Leona Harquail. Evans said that the inquest showed there are "silos within the operation of the social safety net."

The jury heard evidence in Campbellton from April 21 to 30 with Coroner John Evans presiding.

The jury heard how Harquail, 43, and her seven siblings grew up in the foster care system and were subject to abuse and alcoholic caretakers. She eventually turned to abusing drugs and alcohol herself as well as suffering from mental instability that resulted from the violent upbringing.

Harquail had taken a number of pills the night before she was found dead. She was found the next morning by a man with whom she had been staying. Guy-Marc Levesque later testified at the inquest that he thought she was sleeping and went out for the day. When he came home later in the day and noticed she had not moved, he checked her, found her not breathing and called police, who knew Harquail from previous encounters.

Coroner's inquests are not ordered in all cases of death. However, the circumstances of Harquail's life and death caused her family to demand one. Many of them were on hand for the proceedings.

Responding RCMP officers were the first to testify laying out the weeks and days before Harquail's death.

On Wednesday, April 23, Harquail's sister took the witness box and through often emotional testimony, told the five members of the jury panel what she thought was the cause of her younger sister's death. Deborah Harquail attended the seven day inquest and was an active and articulate participant in discussing the issues surrounding her sister's death.

She said that after lifelong abuse her sister had turned to alcohol at a young age. Harquail had two daughters taken away from her because of that abuse but a son born in 1993 was not taken away after she had been forced into detox. She had stayed clean until her mental issues resurfaced when the boy was five.

"When she got sick again, she started drinking again and they eventually took him away," said Deborah Harquail. "She was a wonderful mother who treated him like gold but when she got sick his father took him to Ontario and didn't even give her his address."

She said her sister spent above seven years moving from one place to another, never staying in the same place long. Deborah moved back to Dalhousie in 2004 and spoke to her sister often on the phone.

"I saw her October and she seemed to be doing pretty good. That was the last time I saw her alive," said Deborah Harquail, crying openly.

She explained she had no car and limited funds and seeing her sister in Campbellton was difficult. She said the Christmas holidays were a turning point in her sister's life.

"I went to Fredericton for Christmas and when I got home, I got a message from Linda that Leona had started drinking again. I called the police and asked them to tell her to call me if they saw her."

An officer called Harquail Dec. 28 to tell her that her sister had been seen with some friends and seemed to be fine. Harquail said she was angry with the police that they didn't ask her sister to call.

"She was in a bad state. It was possible that she was a danger to herself or others and I wanted them to arrest her through the Mental Health Act. I think they (the RCMP) are responsible. I filed a complaint against them because of the way they handled this and covered it up."

She eventually found her sister on Dec. 31 at an apartment on Aberdeen St.. She was able to convince her to check into the "detox" on Stanley St. but had to leave to go back to Dalhousie to work. After her shift, she had gone to a house party and when she got home a message was on her phone that Leona had checked herself out of detox.

On Jan. 1 she checked into the hospital in St. Quentin, where doctors decided to keep her overnight for observation because of her high level of intoxication.

Things calmed down somewhat for a week or so until Leona was picked up Jan. 6 for having been drunk in the middle of Route 11 near Atholville, looking for a drive to St. Quentin. She had been released on a recognizance a week earlier that forbad her to drink, so she was arrested. She made a court appearance the next day and eventually checked into the detox again on Jan. 11 after having visited the St. Quentin hospital on Jan. 8

She spent about a week at the detox and checked herself out on Sunday, Jan. 16. She called Deborah later that day.

"I could barely understand what she was saying," said Deborah Harquail. "She told me the doctor had prescribed all kinds of medication and when she said Percocet, I told her not to take them, they are too dangerous."

She said she tried to get her sister to go to the hospital or to call an ambulance, but she never did. It was the last time she spoke to her sister. Police officers came to her door two days later to tell her that Leona had been found dead on Jan. 18.

"I blamed myself for a long time," said Deborah Harquail. "But later on I got more and more angry because all of my requests for help for her were ignored."

Const. Jeff Foster testified that the RCMP is limited in what it can do. He said that if someone calls to say someone is a danger, an investigation is done and the appropriate action is taken. If they are drunk then normally they are kept in custody until they sober up. If they show suicidal signs they are taken to the hospital but those with other issues are referred to mental health personnel.

One patient, one record

Many other health professionals, governmental agencies and other friends and family of Harquail also testified.

John Estey, the Director Quality Management and Executive Support for the Department of Health outlined a new procedure called "One patient, one record." He said that all visits to all governmental agencies for all patients would be tracked via computer. That would allow a doctor in Saint John to see that a patient had, for example, visited the Restigouche Hospital Centre the day before.

Evans asked Estey that if an intoxicated patient presented himself to the Emergency Room at the Campbellton Regional Hospital that the attending doctor would be able to see that there might be underlying issues that could be seen with this new system, such as chronic alcoholism. Evans said that the "doctors would be better informed about the patient and his history" and that "yes this would be one of the advantages of this new system."

But, he said, the new system would not likely be available to police.

It's hoped this new program, launched by the federal government in 2001 would be on line by the end of 2009.

Anne Thibeault, chief of medical records at the CR, said that currently when patients are admitted their history would only be available should the doctor request it. She agreed the "One patient, one record" would be of great benefit because doctor could pull the entire medical history of a patient via computer rather than many paper charts that might be on record.

Traditional Elder Donald Caplin, formerly of Listuguj and now living in Maria, said that he had met Harquail on at least two occasions.

"We did a sweat [ceremony] on her a couple of times and she seemed to be doing pretty good. We tried to help her...she was a beautiful human being."

Caplin explained that a sweat, done in a sweat lodge (saplings covered with canvass to make it completely dark inside), are traditional ceremonies used for people with any of a number of different afflictions or problems. He said that while sweats are only done in certain places, other traditional Aboriginal ceremonies can be performed almost anywhere, including hospitals.

The last witness to testify was Michael Levesque, the manager of the Regional Addiction Services since 2003. He had been at the inquest from the first day. He said that detox is a common word used to describe the ADDU when detoxification is just one of the many services provided at the ADDU.

He outlined a typical scenario where people spend seven days in the ADDU drying out and that's just the first step in the long recovery, depending on which drug was being battled. He said there are some clients still using the ADDU's services more than two years after originally checking in. He said that about half the people who come to the ADDU have concurrent disorders (CD), such as alcoholism and some form of mental problem, such as bi-polar disorder.

Levesque said that Harquail had been to the ADDU on many occasions and that she suffered from CD. He said her addiction to alcohol was severe and that society's view on addictions is generally that of "you put yourself in that position, you get yourself out."

He said that there are three components to addictions, the person (coping skills, sense of worth, value system, etc.); the situation (family environment, childhood) and the type of drug that is being abused. He said opiate abuse, which has been ruled Harquail's cause of death combined with positional asphyxia, is the most difficult habit to break.

"Addictions often give people the opposite of what regularly occurs in their life. But the problem is, it's artificial and wears off" meaning people continually to abuse drugs to forget or deal with everyday challenges.

He also agreed the "One patient, one record" would be beneficial to the ADDU. Levesque said that since Harquail's death, a service agreement has been set up between mental health and the ADDU to co-track a client's progress. If a client checks into the ADDU, mental health is advised and vice versa. As well, should an Aboriginal person check in, then contact would be made to the First Nation from which the client came to speak with counsellors there.

Evans asked how many people are out there who might be in a similar position in which Harquail had found herself. Levesque said that there would be many many people who would fall into the category, estimating about half of ADDU clients face similar challenges.

"The success rate on helping people with addictions is much lower if people leave to go back to a similar environment," said Levesque.

He then took out his own list of recommendations, which he presented to the inquest.

Levesque said that 1. it would be better policy for treatment centres to go over previous records of clients when they check in; 2. contacting clients after they leave; 3. ensure they have a place to stay; 4. a drop in centre where former ADDU clients can speak to professionals; 5. make family part of the treatment process; 6. call clients to remind them of appointments; 7. add specific treatment programs for Aboriginal clients and 8. train doctors or police officers for intervention when dealing with intoxicated people, rather than simply housing them until they sober up. He said it's a well known fact that people with addictions tend to have more frequent dealings with police or need medical attention. Doctors should be trained to see signs of habitual drug abuse or a "weekend binge".

Evans asked Levesque about involuntary committal to treatment centres if people are a danger to themselves or others. Levesque said that as it stands now, it would be a breach of the Charter of Rights to hold them against their will, except through the Mental Health Act or when police keep someone in cells until the sober up.

"They have to want to be helped."

Summation and recommendations

After Levesque's testimony, the inquest was adjourned until the next day, April 30, when Evans took about 90 minutes to instruct the jury. He told them they had to determine the cause and manner of Harquail's death.

He then went over the events that led up to the day Harquail was found dead in a Dufferin St. apartment.

"Your job is to determine if there is something that could have been done to prevent Leona Harquail's death," he said. With that, the hearing was adjourned.

The jury returned four-and-a-half hours later with nine recommendations and took about 10 minutes to read those to Evans and the rest of those gathered in the courtroom.

The jury said the cause of death was an accidental overdose combined with positional asphyxia. Evans had noted that the source of codeine in Harquail's system came from drugs for which she had no prescription.

The recommendations made were:

1. The government should proceed with the "One patient, one record" program plus the PMP (prescription medication program) program.

2. Follow up after discharge from a treatment centre. The jury said that "people should not be returned to a poor environment and there should be some control on the social assistance to enable this person to have a permanent address."

3. Police should inform family and the "detox" if an habitual user is picked up. The person should then be taken to the hospital and not simply allowed to sober up in cells.

4. Police should be advised of available services, such as Family Social Services. If the detainee is Aboriginal, the First Nations Social Services should be advised.

5. Members of the RCMP should be posted to the city for more than three years.

6. The provincial government should launch an educational program to not abuse the Medicare system.

7. Prescriptions of opiates should be for a maximum of 14 days.

8. The entire native support system should be involved in the treating Aboriginals.

9. Authorities picking up habitual users should take the person for psychiatric treatment.

Leona Harquail's sister, Colleen Peterson, told the jury afterwards in an emotional address that she hoped something good would come out of the recommendations.

"I am so pleased with this outcome that I feel in my heart that we lost a sister but I feel like you saved the next one, whether a sister or a brother."

Coroner pleased

Coroner Evans, speaking to the media afterwards, said that he was pleased with the recommendations.

"First of all, I'm quite pleased with the recommendations that the jury has come up with. I think that the overall process is beneficial. It is beneficial for a whole variety of reasons, not the least of which is how it focuses in on the death of an individual in the community whose tragic loss is one we really do care about. The reality is that there are many more Leona Harquails in New Brunswick. Quite frankly, we tend to think ‘out of sight, out of mind', as a society. We don't see this before us all the time, and I think it is important that the community —indeed the whole province — to acknowledge that we have many people in this province who are living like Leona Harquail was living," he said.

"It behooves us as a society to look after one another, and if out of this tragedy come a positive result that maybe in the future there will be a different approach…towards members of the community who are addicted to alcohol or drugs then that will have been a positive outcome...The recommendations of the jury in this case are very much looking forward to encouraging the province, particularly the Department of Health, in regard to significant initiatives they have underway regarding the prescription monitoring program and the ‘one patient, one record' program … there are silos within the operation of the social safety net."