Jail guard never handed over vital letter, nurse tells inquest
The correctional officer in charge of escorting Shannon Sargent back to hospital the evening before she died in her cell at the Ottawa-Carleton Detention Centre (OCDC) never handed over a letter detailing concerns about Sargent's health, according to a retired nurse who dealt with him that day.
Nor did the guard, Paul MacPherson, ever indicate that Sargent was waiting in a van outside the ER of The Ottawa Hospital's Civic campus, Frank Byrnes testified Monday during a coroner's inquest into Sargent's death.
MacPherson, whose own testimony wrapped up Monday morning with a tearful message to Sargent's family, has insisted he did hand Byrnes the letter from OCDC nurse Diane Longmuir on July 19, 2016.
Sargent, 34, had undergone open heart surgery less than two weeks earlier, and was also suffering from what's been described as a "hospital bug," likely C. difficile.
It was Sargent's second visit to the Civic that day, but according to earlier testimony, the Ottawa police officers who had transported her to OCDC following an earlier hospital visit failed to deliver the discharge documents showing Sargent had been medically cleared to return to jail.
It remains unclear why, if all the jail required was that paperwork, Sargent, who was complaining of fatigue and chest pain, was required to return to the hospital unless the purpose of the trip was to have her undergo another medical assessment.
No letter, retired nurse testifies
Both MacPherson and another experienced correctional officer on escort duty that day, Erin Montgomery, have testified that they'd never in their careers transported an inmate to hospital merely to pick up documents.
According to earlier testimony, however, when they arrived at the hospital shortly after 6 p.m., MacPherson entered the ER alone to speak with staff at the triage desk while Sargent remained in the van with Montgomery and a third correctional officer, Mark Smith, who drove the van.
MacPherson has testified that he handed the letter from the jail nurse to Byrnes, who was just beginning an overnight shift as ER team leader. Byrnes, who worked as a nurse for more than 30 years, retired in 2019.
Byrnes testified Monday that normally, correctional officers would approach the triage desk with the patient, but in this case MacPherson entered the ER alone. Nor did Byrnes see Sargent when Montgomery brought her inside the ER to use the washroom.
Under questioning by inquest counsel Mike Boyce, Byrnes testified he was never handed a letter from OCDC.
"Did the correctional officer ever provide you with any paperwork that he had for you to review?" Boyce asked.
"No," Byrnes answered.
"Did the correctional officer ever communicate to you any health concerns that the institution's medical staff had about this patient?" Boyce pressed.
"No," Byrnes repeated, adding he would "never" refuse to triage a patient, even if that patient had been discharged earlier that same day.
'It would have changed everything'
Byrnes also testified that MacPherson never indicated during their five- to 10-minute interaction that Sargent was waiting outside in the hospital's parking lot.
"During your conversation with the [correctional officer], did you ever learn the whereabouts of the patient whose records you were dealing with?" Boyce asked.
"No, my understanding was she was at the correctional centre," Byrnes replied.
"At any point, did this correctional officer ever advise you that the patient was in fact on hospital grounds, like outside awaiting entry?"
"No."
"Did the correctional officer ever tell you that the patient was present and was there to be assessed by hospital staff?"
"No."
In later testimony, Byrnes said he would have acted differently had he known Sargent had been brought back to the hospital and was waiting outside.
"Then she would have spoken and said that she wanted to be seen again," Byrnes said. "It would have changed everything."
Byrnes provided MacPherson with photocopies of Sargent's original "record of treatment" and MacPherson returned to the van, telling his colleagues they were clear to return to OCDC.
"I said, 'So she has the medical clearance to go back?' He said, 'Yes she does,' and he said it all with confidence," Montgomery testified on Friday.
Barely an hour after leaving for the hospital, they returned to the jail.
'That's not who I am'
Shortly after midnight on July 20, MacPherson was doing his rounds in the special needs unit of the women's wing when he noticed Sargent was lying in a strange position. Surveillance video presented on Friday shows Montgomery peering through a hatch in Sargent's door before returning with colleagues and entering the cell, where they performed CPR until first responders arrived.
Sargent was pronounced dead at 1:20 a.m. on July 20, 2016.
MacPherson testified that he only became aware that some of his colleagues had challenged his version of events during interviews with investigators after Sargent's death.
On Monday, MacPherson's personal phone records were entered into evidence to show he had called his supervisor back at the jail to say he had the documents and was returning with Sargent and the other guards. He has acknowledged there is likely no physical evidence that he handed an envelope from the OCDC nurse to Byrnes.
Earlier, the inquest heard MacPherson appeared upset when he was informed shortly after arriving for his overnight shift that he was being sent to escort an inmate to hospital. On Friday, he acknowledged being "huffy" about the assignment because he thought he'd be at the hospital for hours and hadn't prepared any food, but said he quickly got over it.
"Would you go out of your way, Paul, to deny somebody who is in dire need of medical treatment in order to convenience your meal prep?" MacPherson's counsel Leo Russomanno asked him Monday.
"Absolutely not. Absolutely not. I would never, no," MacPherson replied, adding he resents any insinuation that he purposely withheld the OCDC nurse's letter in order to speed up the hospital trip.
"What my colleagues are saying about that stuff, that I did that, that insults me and it hurts me greatly. That's not who I am, I have integrity on this," he testified.
Emotional message to family
Offered a chance to address Sargent's family including her daughter Shauna, MacPherson quickly became emotional.
"On the few occasions that I worked with Shannon she was nothing but respectful to me. There was never any issues with her," he said through tears. "I understand the pain you, Shauna, and your family felt and are still feeling, as I lost my daughter to a car accident. She was 22 years old and her name was Shannon as well."
Following Byrnes's testimony on Monday the inquest heard from Mark Smith, the third correctional officer assigned to escort Sargent to hospital.
Smith, a correctional officer since 1994, testified that when he was assigned to the escort, he assumed they were taking Sargent, who was complaining about chest pain, to hospital for a medical assessment.
"My opinion is that yes ... we were taking her back to be seen by a medical professional," Smith testified. "Over the years, my experience would suggest that nurses don't send [inmates out into] the public unless it's necessary, and sergeants don't pull three officers off a floor in an institution without a legitimate reason."
Smith said about 10 minutes after entering the ER, MacPherson returned to the van and told them Sargent "didn't need to be brought into the hospital, that he was waiting for paperwork from the head nurse to clear her because she was there for the same complaints that she had earlier."
Smith also testified he did not witness MacPherson call ahead to inform his supervisor that they had obtained the required documents and were returning to the jail with Sargent.
Guard carried Sargent's photo
On Friday, correctional officer Erin Montgomery testified that after Sargent's death, she carried a photograph of the dead woman in her purse.
"I kept it with me as a reminder: Question everything, and to not give up until I get answers that are satisfying," Montgomery said.
The inquest, which is being conducted by video conference and will hear from approximately 25 witnesses over 10 days, is mandatory under the Coroners Act because Sargent died while in custody. The jury can make recommendations aimed at preventing future deaths under similar circumstances, but the process is not a punitive one.
Dr. Robert Reddoch is presiding over the inquest. Testimony is expected to end Friday.
