“…some imprisoned people tell us that guards have refused to provide them with their prescribed medication, including for pain.  Although seemingly passive, withholding pain medication constitutes torture under the Criminal Code because it is the intentional infliction of “pain and suffering” through “omission.”  Catherine Latimer, Executive Director, John Howard Society of Canada, quoted from her “Canadian prisons need international oversight to prevent human rights violations,” published in the Globe and Mail, August 7, 2023, and Class Action News, Issue 31, Fall 2023.

This is but one example of a violation of the Mandela Rules, and how dual loyalties interfere with health care delivery in federal prisons.  As referenced on September 24 in “Prison health care – It’s not okay,” clinical decisions may only be taken by the responsible health care professionals and may not be over-ruled or ignored by non-medical staff.

Just so, when guards escort inmates to health care unit appointments, those escort guards might not allow inmate privacy with a health care provider.  If an inmate is on cuff status (put in handcuffs when out of their cell), guards might not remove those restraints for treatment or consultation.  Guards can become privy to an inmate’s health care information which is passed on to other guards for use as convenient.  Confidentiality of medical information is required, unless maintaining such confidentiality would result in a real and imminent threat to the patient or to others.  What is or is not a threat is a subjective assessment but is not within the authority of a prison guard in any case.

Health care personnel shall not have any role in the imposition of disciplinary sanctions or other restrictive measures.  Not to impugn the professionalism of prison nurses and doctors, there is all the same a mirky, grey indeterminate space between the medical and non-medical groups.  An inmate’s conditions on a range and in a clinic can be shaped, and are shaped, by consultations between the two parties.

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Kim Morin had no reference to damage to Brennan Guigue’s left knee in his prison health file at Port Cartier Institution in eastern Quebec when we spoke with her by phone on August 2, 2022.  She oversaw health care services in the prison at the time and the conversation was Correctional Service of Canada’s response to criticism of health care in that prison which began a few months earlier.

Brennan’s concerns had been ignored or brushed aside by the nurses and doctors since he arrived at Port Cartier at the beginning of the previous November.  We added our voice to his in a May 9, 2022, letter to Nadia Pelletier, who was then heading health care there before going on leave.  We copied the CSC’s assistant commissioner for health services in Ottawa, CSC’s regional health services director in Laval, and the correctional investigator and public safety minister, both in Ottawa.

On May 24, Manjeet Sethi, Acting Assistant Commissioner, Health Services, at CSC headquarters in Ottawa, answered our May 9 letter on behalf of Nadia Pelletier.  He ended with a typically baseless CSC position, “…I can assure you that Health Services are always available to Mr. Guigue, and that he is receiving care in accordance to his actual diagnoses and needs.”  “Factually incorrect,” we wrote back on June 24.   “Blatantly untrue” we noted when we copied the Sethi letter to Nadia Pelletier on July 2.  CSC NHQ in Ottawa then messaged Port Cartier via the Quebec regional office to snip this thorn.  Ergo the conversation with Kim Morin.

Kim Morin met with Brennan on July 15 for about an hour to discuss his concerns which at that time centred on his Opioid Use Disorder (OUD) Suboxone dosage and his relationship with Dr. Geneviève Coté who oversaw the program, and with his many requests for his mental health needs.  Our phone conversation followed on August 2, referencing those same two issues, but adding the status of a response to Brennan’s atrial fibrillation (AFib) and the treatment plan for his knee.

This was a refreshingly frank discussion, with Ms. Morin acknowledging she had no notation about AFib in Brennan’s file, even though he had been diagnosed at the same prison years before.  She had nothing about his knee on file although Brennan had been diagnosed with either a torn meniscus or damaged tendon two years before at Warkworth Institution, an MRI order was never executed, another doctor at Millhaven seconded the MRI order, again not executed.  I told Ms. Morin that Brennan had a video visit with the Port Cartier’s doctor two months earlier, brought up the problem with his knee, and the doctor’s response was, “Well, we’ll have to look into that.”

Ms. Morin conceded that inmates can be in for long waits.  For instance, the institution has 1 psychiatrist, who Brennan claims is in the prison once in every one or two months,1½ mental health nurses, 2 psychologist and 2 social workers to serve the rated 237 inmate population of Port Cartier.  An inmate who is not considered critical may never get on the list.  Health care resources overall are limited, but ‘understaffing’ is not in the CSC vocabulary.

So, what came of all this?  His Suboxone dosage was adjusted.

As a footnote, the correctional investigator’s office took an interest in that May 9 letter to Nadia Pelletier.  Derek Janhevich, the OCI director of operations for Ontario and Quebec wrote on May 20 that their senior investigator assigned to Port Cartier would be in the institution presently and would meet with Brennan.  They did meet in the second week of June, and Brennan reported, “I sat there talking to him for ten minutes. ‘I can’t help you,’ was his answer.  Useless.”  Why?  The correctional investigator’s team does have concerns about the care inmates receive but it can’t act.

It’s important to keep in mind that this cites health care issues of only one inmate, but that one inmate is representative of system-wide deficiencies for all prison populations.

Brennan Guigue’s left knee?  Well, he’s still waiting for help.

….WHEN YOU HAVE A TOOTHACHE IN PRISON?

“The lack of accountability CSC provides its physicians also allows for the negative stigma associated with criminal behaviour to infect those treating prisoners,” is from one of the media releases by Executive Director Catherine Latimer of the John Howard Society of Canada.

Prison inmates are no angels, and interactions with health care professionals can be difficult in some cases, but there is no place in the law or in our collective conscience for negative branding.  As omnipresent as it is throughout the penal system, the health care professionals treating incarcerated patients do well to recall our Supreme Court reminder that it is who we are, and not who they are, that governs our actions.  The few dissenters tarnish the reputation of their vocation, but any prison health care worker is under some pressure to compromise.

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You have a toothache, or otherwise need the attention of a dentist.  Only fear or uninsured expenses stand in the way of asking for help.  You can be in a dentist’s chair within hours if necessary.  That’s not so in our federal prisons.

“Miss, I have a toothache.”  Most inmates will see or pass by a nurse daily.  “Put in a requisition,” will be the response.  That’s the routine; use the institution’s internal mail system to ask for a dental appointment, and then wait.  Wait to be called to health care when your turn comes up.

How long is the wait?  That depends.  That depends on how a need is triaged, at times without the input of a dentist, and sometimes it depends on the health care unit’s subjective assessment of the needs of individual inmates.  Then too, because inmates don’t have advance notices of appointments, the call to a range to send an inmate to health care may not get to the patient, in which case the record will show that the inmate ‘refused’ to attend.  But, when an inmate doesn’t show up for an appointment, why doesn’t health care double-check with the guards on the range?  Why not?  There should be a concern for why the appointment was missed.

There is much anecdotal evidence of the impact of delayed dental care on inmates.  From two inmates in a Kingston institution a few years ago who were put in hospital on intravenous antibiotics to combat infections while waiting months for care, to a more recent case of an inmate in Quebec with a badly swollen jaw and cheek who could squeeze puss out of his tear duct be applying pressure under his eye.  These men must have been suffering through heavy pain with no recourse but to wait for help, not knowing when that help would arrive, and hopefully with the resources to pay for expensive prison black-market illicit drugs for relief.

Dentists are authorized to provide basic and essential care and from all accounts they are diligent in their service within the contractual limits and imposed time constraints.  Government bureaucracy and the proverbial red tape can prolong contract renewals for medical services, and the maximum number of dental clinic hours allowed in those contracts are often insufficient to meet patient needs.  In the case of the former, there are no dental appointments in institutions waiting new contacts, and with the latter, too few treatment hours leave some inmates on long waiting lists.

Looking at terms in some recent agreements, Collins Bay Institution in Kingson can accommodate up to 750 inmates, but a dentist is on site there a maximum of 12 hours a week.  Warkworth about two hours away allows 1 day a week, about 6 hours, for a population of up to 537.  Millhaven in Bath has contracted for a maximum of 364 hours a year, averaging 7 hours a week over a 52-week year.  In some prisons, dentists may book clinics (about 6 hours) according to need but only up to the contracted maximum number of hours.

While contracts prescribe a maximum number of hours, no dentist has spare openings for prison patients.  What’s more, internal institutional issues affecting inmate movement and incidents that lead to lockdowns will delay or cancel health care appointments.  Security trumps toothaches.

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Brennan Guigue’s inmate activism makes him a primary source of information, and this segment on prison access to dentists will end with one of his past oral health care experiences.

He was in Millhaven Institution at the beginning of 2019.  He’d been suffering with toothaches for a few months and was making futile requests for help.  He didn’t know then that CSC was still negotiating a new contract for dental services, and in the meantime, patients would have to wait.  Anxiety and discomfort exacerbated his distress as he watched what other inmates were going through.

We stepped in, expecting an intervention would be in vain.  Letters went to the institution, to the Assistant Commissioner for Health Services at CSC national headquarter in Ottawa, and to the Ontario regional headquarters in Kingston.  Eventually, a call from Ian Irving at the regional headquarters assured us that Brennan would be taken to a dentist.

By the first half of March, he had been transferred to Collins Bay temporarily due to operational issues.  He was taken from there to a Canadian Forces Base Kingson dentist on Monday, March 25, where x-rays were taken, as CSC had requested.  The dentist was concerned by the images, checked Brennan’s mouth, and felt he couldn’t let Brennan leave his office without help if he wanted it.

(“I can’t believe they left you in this condition.”)

Four teeth were extracted, including the 1-8 (upper right molar) which had a cavity and the beginning of an abscess, plus three others that were broken, pitted, blackened and rotting. The dentist gave him care instructions, a minimum supply of pain killers, and told him four other cavities needed attention but were not emergencies.

Brennan saw a dentist at Millhaven on Wednesday, May 8.

More prison health care, next…….