In support of prisoners and prison justice activism in Canada
Lawsuit Launched over Medical Neglect in Prisoner Death

Epileptic prisoner received no medical care until two hours after guard noticed he was ill
September 7, 2005
Montreal Gazette

Prison guard Jocelyn Poirier was making his rounds about 2:30 a.m. when he looked through a small window and saw Roger Guimond lying on his cell floor, breathing heavily, foam trickling from his mouth.

It was Oct. 18, 2002, and Guimond had had an epileptic seizure at the Port Cartier Institute, a maximum security prison in Quebec's North Shore region. Guimond, 40, died later that day, his suffering recorded on a disturbing videotape his family released to the media yesterday. The footage was played at a press conference held in Montreal.

Guimond's family has filed a $275,000 lawsuit against the Solicitor-General of Canada and the doctor responsible for providing health care at the prison.

Poirier finished his rounds and returned to Guimond's cell 15 minutes later to make sure the prisoner wasn't "faking it." After confirming Guimond was in severe distress, Poirier called his supervisor at 2:45 a.m.

But despite the presence of several guards, and a nurse who was called to the scene, Guimond received no medical attention until 4:30 a.m., two hours after Poirier first noticed he was ill.

By the time ambulance technicians began treating him at 4:30 a.m., Guimond was in respiratory arrest. He was later brought to a hospital, where he died.

A distressed Guimond, gasping for breath, convulsing and suffering respiratory arrest, can be seen on the 45-minute videotape. During much of the tape, a handcuffed Guimond is lying on the floor, struggling to breathe, as nurse Pierre Banville and several prison guards stand by without providing medical care.

The scenes, filmed by a prison guard, caused Guimond's father, Gaston, 71, to flee yesterday's news conference in tears.

"The nurse gave him no oxygen, no Valium and no Dilantin (an anti-convulsant). He did nothing, he didn't even sit him up," said Jean-Pierre Menard, a lawyer for Guimond's family, who launched the lawsuit Friday.

When Banville arrived at Guimond's cell just after 3 a.m., the prison guards told him they couldn't open the cell door until they had retrieved their "riot gear." About 30 minutes later, five guards clad in helmets, orange jumpsuits, and holding riot shields, returned to the cell. Guards are required to use the equipment whenever they enter the cell of a prisoner considered violent.

At the time of his seizure, Guimond was serving a two-year sentence for an aggravated assault that occurred when he tried to steal a car. He was considered dangerous because he had threatened prison staff.

When the nurse and guards finally entered the cell at 3:47 a.m., a guard handcuffed Guimond while another placed a riot shield over his body.

After Guimond failed to respond to the nurse's questions, the guards told the nurse they wanted to move Guimond to the infirmary, where oxygen and medication were available. But instead of using a stretcher, which is standard practice, three guards picked up and carried the heavyset prisoner, whose breathing was getting louder and more laboured.

At the infirmary, they finally removed the handcuffs, wrapped him in a sheet and left him alone in a cell for 20 minutes, until ambulance technicians arrived. During that 20-minute period, Guimond went into respiratory arrest and stopped breathing. As a guard continued to film the critically ill prisoner, Banville stood outside the cell and said: "There isn't much more I can do for him." Another guard peered through the window and said: "I don't think he is breathing."

It wasn't until ambulance technicians arrived at the prison at 4:30 a.m., two hours after the prison guard first noticed Guimond was sick, that Banville dispensed any medical care.

Guimond's father, who watched the videotape for the first time Sunday, said he was shocked at the lack of care.

"They did nothing," he said.

Coroner Bernard Lefrancois's report into Guimond's death concluded: "It is possible his life could have been saved if the intervention time had been shorter."

Lefrancois said Guimond might not have taken his medication that night, prompting the epileptic attack. He encouraged officials to reduce the time it takes for guards to enter cells in emergency situations.

Corrections Canada officials would not comment on the case because of the lawsuit with Guimond's family.

An internal investigation by Corrections Canada, however, concluded that the prison guards acted properly, apart from not using the stretcher. It said the nursing care was "not professional, humane or adequate."

In a subsequent independent investigation into the death, a neurologist who reviewed the case said it was very difficult to say whether Guimond would have survived if he had been treated promptly.

After a disciplinary hearing this summer, the Quebec Order of Nurses suspended Banville for one year for failing to provide proper care, said Sylvie Truchon, who handles complaints for the order.

Banville was also ordered to take a nursing course that would help him "provide proper care to patients who have convulsions, loss of consciousness and breathing difficulties."

Banville's lawyer told the disciplinary committee that his client no longer wants to be a nurse.

During the hearing, which Banville did not attend, his lawyer couldn't explain why his client failed to provide Guimond with proper care. He did say his client was tired because he had worked a double shift.

Guimond's family and prisoners' rights advocates said yesterday they want the Quebec College of Physicians and the Quebec Order of Nurses to jointly investigate health care services in prisons across the province.

"What happened here is completely unacceptable," said Jean-Claude Bernheim, a prisoners' rights spokesperson. Bernheim said he receives numerous phone calls from inmates complaining of poor medical care in Quebec prisons, but had never seen a case as serious as Guimond's.

"They had no respect for this man," he said. "I was shocked when I saw the video."

What happened the night Roger Guimond died in convulsions

This is a timeline that shows how guards and a nurse responded to prisoner Roger Guimond, who had a epileptic attack in his cell in October 2002 at Port Cartier prison. Guimond died later in a hospital.

2:30 a.m. Prison guard Jocelyn Poirier notices that Guimond is lying on his cell floor, breathing heavily, with foam coming from his mouth.

2:45 a.m. Poirier returns to the cell to make sure Guimond is still sick. He notifies his supervisor, who calls nurse Pierre Banville at home.

3:07 a.m. Banville arrives and calls Guimond's name while standing outside the cell.

3:15 a.m. Banville tells guards he wants to enter the cell.

3:47 a.m. Five guards dressed in riot gear return to the cell, open the door and carry Guimond to another cell.

4 a.m. Banville calls the doctor, who tells him to call an ambulance.

4:10 a.m. Guimond has convulsions while alone in the cell, as the nurse looks on.

4:27 a.m. Guimond goes into respiratory arrest.

4:30 a.m. Ambulance technicians arrive and try to revive Guimond.

4:48 a.m. Guimond is transported to a hospital, where he dies later that day.