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MTC jury verdict and recommendations.

Chief Coroner Province Of Ontario


the jury serving on the inquest into the death of Elliott, Jeffrey Thomas
aged 20 years held at Midland Ontario
From the 13th of September to the 24th September 2004
By Dr. Peter Savage Coroner for Ontario
haveing been duly sworn, have inquired into and determined the following:

1. Name of Deceased Jeffrey Thomas Elliott
2. Date and time of death August 29, 2003
3. Place of Death Mount Sinai Hospital, City of Toronto, Province of Ontario
4. Cause of Death 1
(a) Acute Gastrointestinal Hemorrage Due to..
(b) Acute Hemorrhagic Gastropathy Due to..
(c) Septic Complications of Pentrating Hand Trama
5. By what means Accidental

Verdict was received on the 24th day of September 2004

We wish to make the following recommendations:

1. All hand wounds to be properly covered to avoid infection and checked daily until healing process is noted.

2. Food Hatches to be closed at all times except for meal and pill passes.

3. Medical Dept. at CNCC should review allotted hours for Physican coverage to facilitate optimum inmate care.

4. Upon inmate examination, attending Nurse/Physican should record findings immediately on note/memo pad to be transferred to appropriate Health Care Record in a timely fashion.

5. Medical facilities to establish protocol concerning essential medical records required upon transfer of patient.

6. M.A.R.S. to be checked daily by Nurse in Charge regarding date, time, and proper dosage of medication in Medical Unit.

7. Medical Staff to ensure proper hygiene of inmates when in Medical Unit.

8. Outside consulting Physician to be made aware of CNCC's medical capabilities regarding patient care.

9. As per Dr. Paul Binhammer's Recommendation:

a) "That Nursing Staff at CNCC review the signs and symptoms of soft tissue infection."
b) "That Physicians at CNCC review the management of hand infections."
c) "That CNCC review its' policies for accepting post-operative patients who have acute surgical emergencies. The management of these patients should be that they remain as patients at the treating hospital until it is clear there (sic) clinical situation has been stablized and does not require significant active treatment."
d) "That this report and its' discussion be distributed to the involved Physicians so that they may review issues of management of severe hand infections, the long term use of intravenous antibiotics as well as the need for appropriate documentation."

10. As pe Dr. Paul Binhammer's recommendation, that the case of Jeffrey Elliott be published in a widely distributed Medical Journal such as the CPSO Journal.

11. CNCC to educate Cleaning Staff on the necessity of proper sanitation procedures.

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