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EDMONTON — Two inmates at the Edmonton Remand Centre died and three others were hospitalized after receiving poor medical care at the institution, the province's public interest commissioner has found.

"These significant lapses in the standard of care demonstrated a substantial and significant danger to the life, health and safety of patients," said the investigation report from Kevin Brezinski. 

"This was serious and significant wrongdoing."

Alberta Correctional Health Services said it has implemented reforms in light of the report, released Wednesday.

Brezinski said the investigation began after a whistleblower filed a complaint with his office in the summer of 2022. That person drew Brezinski's attention to the treatment of seven inmates.

Some events had occurred several years before the complaint and some were current. A nursing consultant hired by Brezinski's office investigated five cases.

Although the report doesn't attribute the deaths or hospitalizations specifically to treatment the inmates received, it finds a long list of problems.

The consultant found staff didn't assess symptoms of pain, shortness of breath, poor vital signs, high temperature or high blood pressure. Vital signs weren't documented and patients weren't examined.

"In one specific incident, it took two days for medical staff to begin treatment after noting a patient's toe was black and swollen with fluid," the report says.

Brezinski said patients with addictions weren't afforded proper treatment.

"There didn't seem to be an appropriate protocol in place to manage drug withdrawal," he said. 

"Addictions and people that are in custody sometimes go hand-in-hand and you would think that medical professionals would have adequate training to assess these issues. I would expect more."

Medical staff used what they called "pain protocols" that turned out not to exist. In one case, a patient was refused treatment for vomiting because staff didn't witness it, a violation of Alberta Health standards. 

Although the consultant didn't investigate the remaining two cases, the report said Alberta Correctional Health Services acknowledged similar problems with their treatment. 

In a statement, the health agency said it has already implemented many of Brezinski's recommendations. 

They include requirements to monitor and record vital signs, new protocols to manage substance withdrawal, pain management and wound care. Twice-yearly audits are to ensure treatment quality. 

A consultant has been hired to continue to ensure policies and practices remain current. 

"It is imperative that all individuals in our corrections system are provided with the same consistent, high-quality care as every Albertan," said spokeswoman Kristi Bland. 

Brezinski said those changes need to be made throughout the system, not just in Edmonton. 

"I would assume at other correctional facilities similar behaviours would probably be taking place," he said.

The agency did not say if any staff may face disciplinary action, despite Brezinski's recommendation for Alberta Health Services to review the actions of individual staffers. 

Otherwise, Brezinski praised the health agency's response. Protocols are now mandatory and audits are getting results.

"They are actually getting ahead of things," Brezinski said. "When they do do these audits and identify concerns, they're getting to it a lot quicker."

But he reserved his greatest praise for the whistleblower who raised the concerns. 

"This is a great case where you have a whistleblower who is courageous enough to come forward."

The public interest commissioner is an independent officer of the Alberta legislature to whom public-sector employees can bring concerns about government officials. Brezinski also serves as Alberta Ombudsman, to whom the public can report concerns. 

Brezinski said it was the first time his office has investigated complaints into Alberta's correctional system.

This report by The Canadian Press was first published on Oct. 25, 2023. 

Bob Weber, The Canadian Press