Inquest hears woman who died at Pine Grove was experiencing opioid withdrawal

The autopsy was performed on June 27, 2022 and Musgrove noted there was gastric fluid in the chest cavity, which was believed to have been caused by a recent rupture of the esophagus. This was likely caused by forced vomiting (Boerhaave syndrome).

Pine Grove Correctional Centre. (File photo/ paNOW Staff)

Coroner Aaron Fox is presiding over this week’s inquest and prior to Musgrove’s testimony, read a number of background facts to the six-person jury.

Kakakaway was initially arrested in Regina on June 20 and admitted to police she had consumed fentanyl. In the following days she displayed signs of opioid withdrawal.

On the morning of June 24, she was first observed at 5 a.m. using the toilet and then an hour later she was lying on the floor. She was encouraged by staff to move to the bed and at 8 a.m. she was observed sitting on the lower bunk, her chest was not moving and there was vomit on her shoulder.

Forensic toxicologist Dr. Jennifer Billinsky testified to finding a trace amount of ethanol, and low amounts of methamphetamine, fentanyl, benzodiazepine (sedative to assist with seizures) and methadone.

At the end of the inquest, the jury may make recommendations to prevent similar deaths from happening in the future. When asked what advice she would offer the jury, Billinsky suggested asking Corrections whether more can be done to monitor an inmate’s health status or medical issues.

“I would approach it that way,” she said.

Billinsky was unable to answer how long the drugs were in Kakakaway’s system, and reiterated drug users build up different levels of tolerance and so what be a fatal dose to one person, would have a lesser impact on someone else.

She also stated Kakakaway’s last methadone treatment was in June, and none was administered while she was in custody.

Advanced care paramedic Elliot Haines testified that upon arriving on the “active” scene, there were lots of correctional officers present and Kakakaway was lying on the ground outside the cell.

He also stated CPR was in progress and there was lots of Naloxone boxes, signalling an assumption by staff the incident was drug-related.

“I believe they were doing everything they could,” he said.

Haines also stated that when he and his partner took over the scene, they performed advanced cardiac life support, which is same as what’s administered in a hospital trauma bed. Roughy 30 minutes later, Kakakaway was pronounced deceased.

A LUKAS (Lund University Cardiopulmonary Assist System) machine aids in the performance of CPR and unlike a human does not get tired. Haines stated there was no machine present at the scene.

“The LUKAS machine may have been beneficial,” he said, but added with so many people performing CPR that too can be effective.

Inquests are mandated by law when a person dies in custody unless the coroner is satisfied the death was entirely due to natural causes and was not preventable.

While five days have been scheduled for this week’s inquest, it’s expected to wrap up after only two days.

Among the other witnesses expected to testify are medical staff, and Kakakaway’s former cellmate.

There were no members of Kakakaway’s family present on Monday but they are expected to attend on Tuesday when the inquest resumes. A person who knew Kakakaway and contacted paNOW, stated since her passing, her twin sister and mother have also passed.

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nigel.maxwell@pattisonmedia.com

On X: @nigelmaxwell

by Nigel Maxwell

Inquest hears woman who died at Pine Grove was experiencing opioid withdrawal

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