Inquest opens with prayer and song
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Updated: June 30, 2009 3:59 PM
Bruce Winfield
Gazette staff
PORT HARDY - A prayer and song for reconciliation began a week-long coroner's inquest into the Mar. 14, 2008 death of 48-year-old Debra Marie Coon.
"Ms. Coon was in medical distress while in the custody of Port Hardy RCMP," said coroner Jeff Dolan in a press release. "Emergency medical services transported her to the Port Hardy hospital. Later that day, she was transported to Victoria General Hospital, where despite medical treatment, she died."
Ms. Coon was the second prisoner to die after being in Port Hardy cells that month and the third that year. She was originally jailed for causing a disturbance at the hospital, said a report at the time, and reportedly hit her head in the cells.
Dolan and a jury were due to "publicly hear evidence from witnesses in order to determine the facts surrounding the death," said the release. After that, "the jury will have the opportunity to make recommendations aimed at preventing deaths under similar circumstances in the future."
One of the first of 21 witnesses on the list was forensic pathologist Dr. Litwin, who said Ms. Coon died from sub-dermal hematoma, which is bleeding around the brain that's generally caused by blunt force, the five-member jury was told.
A video from the RCMP cell played while Dixie Travis, the day matron, testified. Ms. Coon seemed fine to everyone until the morning of Mar. 15, 2008, when she fell four times in an hour, said Travis. "The last time she hit her head really badly and could not get up," said Travis.
Officers involved in the case were called and they immediately took Ms. Coon to Port Hardy hospital, Travis said.
Dr. Granger Avery said he had been Ms. Coon's family doctor, first in Kingcome Inlet and then in Port McNeill "She was a very pleasant lady, easy to get along with, but her life was punctuated with addictions, alcohol and perhaps drugs."
When he was asked for suggestions on what the coroner's jury might recommend, Avery suggested a local treatment centre for alcohol.
"Addiction, particularly alcohol, is the biggest medical problem in the North Island ... that needs to be recognized and accepted by everyone," he said. "We need a multi-level treatment centre in the North Island, that would provide variable care, depending on the patient's needs."
RCMP Staff Sgt. Chris Stewart, who testified later that day, agreed with Avery.
"We had three inquests and alcohol played a part in every death," said Stewart. "We have 1,000 prisoners per year and 50 per cent of them are related to alcohol. This is a social issue that we have to come to grips with and a sobering centre would be beneficial."
The inquest is scheduled to wrap up on July 3.
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