London Free Press
Oct 12, 2016 · 122 min read

By Randy Richmond, The London Free Press

A note to readers:

For the sake of the story’s flow and clarity, after first reference, the family and friends of Jamie High are noted by their first names. For example, Angie and Jamie High are quoted as Jamie and Angie.

But after their first references, court officials, lawyers, doctors and other professionals representing the institutions involved in the story are noted by their last names, in traditional newspaper style.

Chapter 1: From diamonds to stone


He’s trying to say something.

He’s taking the thoughts in his head and he’s dragging them into his mouth and working them around on his tongue to get them out in the right order, but they keep tumbling and mumbling out and no one can understand the words.

Listen. Slow down the sounds on the audio recording of the court hearing. Rewind and repeat.

Parse out his pleading words in the growing cacophony of correctional officers and lawyers and court officials talking through and around and over each other and him.

Try to make out his voice. Try to make sense of what is happening.

In the middle of a jumble of sounds, he slurs, “I’ll call you right back.”

This man, Jamie High, must think he’s on the phone, that notion a bit of flotsam surfacing from a good life now drowning.

He is not on the phone. He is a special room at Elgin-Middlesex Detention Centre in London that provides a video link to Courtroom 101 at the St. Thomas courthouse.

His appearance on the screen shocks Nicole Keating, duty counsel that morning, Dec. 23, 2014.

“I am very concerned, given Mr. High’s presentation. As you can see he’s in a wheelchair and in a white gown.”

Jamie says something, part whisper, part breath, part sigh.

“Mr. High, have you spoken to your lawyer?” Keating asks.

“No,” he says with a short exhalation of breath.

“No?” she asks.

Fragments of sounds return from Jamie’s mouth. The printed transcript of the court hearing describes the fragments as “indiscernible.”

One of the two correctional officers guarding Jamie weighs in.

“OK, just to let you know. He’s in a wheelchair right now because he’s apparently incoherent, unwilling to stand by himself and the only way that we’re able to transport him to present him to you was to place him in a wheelchair. He . . .”

“Is he getting medical attention?” Justice of the Peace Susan Whelan asks.

“ . . . doesn’t respond to any of our direction and, so I don’t know. . .” the officer continues.

“Is he getting medical attention?” Whelan asks again.

Jamie interjects, consonants and vowels that make up no words.

“Indiscernible,” notes the court transcript.

“He’s been seen by our health-care people, yeah,” the correction officer says.

Keating explains how Jamie High ended up in jail.

“Mr High was . . .” she starts to say.

He interjects, something unclear.

“There was a surety revocation in regard to his matter,” Keating continues, “and he was arrested at the psychiatric hospital over the weekend where he was a voluntary patient at that time.”

A tumble of words come from Jamie’s mouth.

Given the condition of the man on the video screen, the information alarms and confuses the justice of the peace Whelan.

“What I’m trying to understand is why his release wasn’t varied to allow him to stay at the hospital. Why, why . . . “ she says.

A page from the court transcript.

“No, no, stay in the chair,” the first officer tells Jamie.

“Stay seated,” the second says.

“I don’t wanna sit,” Jamie says.

“Does the Crown have any input into this?” Whelan asks.

“No,” Jamie says to the officers.

“Was there any discussions with Mr. Donald? (Jamie’s lawyer)?” Whelan asks.

“Don’t touch me like that,” Jamie says.

“I can’t answer that question,” Keating tells the justice of the peace.

“No you can’t,” Jamie says, then adds something indiscernible.

No one can tell Justice of the Peace Whelan how long Jamie was in hospital, why he was taken from the hospital, whether medical instructions came from the hospital to the jail, when he last saw his lawyer, what his lawyer wants to do about the matter, what the Crown wants to do about the matter and what kind of medical treatment he is getting in jail.

“I think there’s a serious situation going on here,” Justice of the Peace Whelan says.

“Obviously, there’s something amiss here.”

In 12 minutes of that court hearing in St. Thomas two days before Christmas 2014, Jamie High tries to speak 36 times.

Each time that he tries but cannot be understood, the court transcriptionist writes:

MR. HIGH: [Indiscernible].

Jamie’s word — indiscernible — appears on the transcript at random, sometimes in the middle of other people’s sentences, sometimes before and after he mutters a few understandable words.

Out of his 36 attempts to be heard, 26 are noted as indiscernible.

The transcriptionist did not have the luxury of slowing down the audio recording of that hearing and replaying the segments in an attempt to understand what he was saying.

The London Free Press began a long journey trying to figure out what happened to Jamie High by obtaining the audio recording of the transcript and listening repeatedly to the chaos of the court hearing and the words he spoke.

See the entire interactive map:

That journey led us to court, hospital and jail records, the investigation by the Ontario coroner’s office, interviews with family and friends, manuals guiding Ontario’s police, court and hospitals, and research on bail, jails, courts, police and mental-health care in the province.

We can finally tell you what we have learned about what happened to Jamie High.

We can tell you what we learned about the problems in the province’s justice and health-care systems that aided in his silencing.

Why him? Why his story?

Largely because of who he was.

If a man like Jamie High can end up alone and naked and incoherent and dead in a jail cell in Ontario, so can any of us.

“His perfect life,” friend Dylan Eldred says, “became a perfect nightmare.”

What happened to Jamie High seems perfectly described by that one word: Indiscernible.

Etched into a diamond-shaped stone above the entrance of the handsome home where Jamie used to live are other words: “Some days are diamonds.”

That they were.

He grew up in a boy’s paradise, in a modest home and loving family, surrounded by fields and woods just outside a small town that sits on the banks of a wandering river.

The week he was born, the most troubling news in the local paper was a front-page story about the dangers to children of a big ditch, but getting bigger play was a story about a parade.

The population of Dunnville was about 5,000 then and is about 5,000 now.

The town stretches along the Grand River where it widens into marshland and deltas a few kilometres before entering Lake Erie.

The river gives the town a sleepy Huck Finn symbol — the mudcat. So named for thriving in the muddy Mississippi River, a catfish logo adorns the town’s minor hockey jerseys, greets visitors on one entrance to town in the form of a 15-metre-long statue and is celebrated in the annual summer festival.

Jamie fished and played baseball and hockey. There was always a hockey game going on; a league game in town, shinny on his backyard pond, ball hockey in his basement.

He flourished in the warmth of a mother, father, brother and a sister so close to him the only way they will agree to meet a reporter is together, and the only way they will answer most questions is as one, by email.

“We, as a family, were in love with him,” the family writes. “We loved everything about him. He had the ability to light up any room he entered . . . he had the unique ability to capture everyone with a simple glance, smile, or joke.”

His younger sister Jessica adored him.

“As a child, he tucked me in at night and told me bedtime stories, even if he had a handful of friends waiting to hang out with him,” she writes. “All we did was laugh.”

Every Christmas Eve the children slept together, even when they got older. When Jamie got married, his wife was told she had to pile into the one room on Christmas Eve too.

“Whenever anyone had some kind of celebration, everybody would get together,” says Shannon Gould, one of Jamie’s high-school sweethearts.

“Everybody was always hugging and kissing when people came in. They would always say, ‘Love you’ — sisters, aunts, cousins, everybody.”

By high school, Jamie was an athletic, outgoing and handsome teenager with a big grin and a sequence of cool cars.

“Everyone knew Jamie,” Shannon says. “He was a catch. He was charming. He was good looking. Everything was fun. He did and said all the right things.”

If he was a catch for the girls, a girl named Angie in the year below was a catch for the boys.

Angie and Jamie High in their high school graduation pictures (supplied photo)

She was a member of the ski club, soccer team, cheerleading squad, social committee, fashion show and in her final year named prom queen. Naturally, she and Jamie dated briefly in high school.

“Everybody knew Jamie,” Angie High says. “He always had a big personality, very popular, laughing and joking.”

After high school, Angie went to the University of Windsor and earned a BA and a BComm, with a semester of study in Holland and began a career in sales.

Jamie worked for the family business, taking a few college courses, then decided to try real estate and moving to London.

The two ended up back in Dunnville one weekend in 1999 for the annual Mudcat Festival. A cousin of Angie’s planned it so the two spent the day together on Jamie’s jet boat.

“That was it,” Angie says with a laugh. “Small-town love. Everyone knows who you are and where you’re from and that was the thing that worked for Jamie and I. I didn’t have to explain Dunnville and where I was from to him, because so was he. I knew his history and he knew my history.”

When they were married in 2003, the wedding had to be held at Jamie’s parents’ house in the country because there wasn’t a hall big enough in town for the 300 guests. The marriage brought together big families that already knew each other in so many small-town ways no one on the outside could ever keep track.

“Everyone is intertwined,” Angie says. “When I married Jamie, I married his family and we’re all very tight, very close.”

The couple got to work as soon as they moved in together. They bought a house on Ridout Street in London and began renovating.

“We would stay up all hours of the night, working on the house, get up, both go to work, come back home, renovate,” Angie says. “In your 20s, it doesn’t matter, you don’t get tired.”

Jamie earned his real estate licence and Angie moved up in sales jobs and the two bought and sold several houses. They did well.

They bought a sleek, 12-metre cabin cruiser, which they kept in Dunnville, and a RV for trips with family and friends. They bought a cottage in Port Stanley near the beach.

They bought a home in Union, just south of St. Thomas, through a power of sale. The house offers a pleasant but hardly ostentatious brick front — with the diamond shape stone above the entrance — to a cul-de-sac, but grows much larger as it extends and widens back to an indoor pool and nearly 2,000 metres of space among the trees. Only when they were ready, in their 30s, did they have children.

“There were lots of things to do, lots of things to get ready,” Angie says.

In 2007, a son was born, and on Christmas Day no less, and the two happy parents joked in a St. Thomas newspaper story about the event.

Jamie threw himself into fatherhood the way he threw himself into everything. He coached his son’s tyke hockey team and at the end of the year made each player an individual certificate praising their accomplishments.

“He’s so close with our little guy,” Angie says. “A fun-loving dad, building snow sculptures in the backyard. He did that all the time. They would play cars, sit in the living room and play. They would listen to music. He was a good dad.”

Jamie moved into commercial real estate and its multi-million deals. He began taking his health seriously and worked out at the gym. Circles of friends — hockey buddies, business partners, workout partners, Dunnville pals — orbited around him. A daughter was born in 2011.

All the days were diamonds.

Except that is not what the words on the beautiful home with the beautiful life say.

The words say, “Some days are diamonds.”

The sentence demands a reply. If some days are diamonds, what are the others?

In the country song by the same name, the second line follows naturally from the first.

“Some days are diamonds.

Some days are stone.”

“I can’t even explain the magnitude of it,” Angie says of their life together. “We had that high that our friends envied. That love, connection with our whole surrounding families. This larger, bigger-than-life love. We had it all. We had everything.”

She holds one hand up high in the air, then drops it low.

“It was shocking. It just went from way up here to way down there.”

All the way to Dec. 23, 2014, Jamie naked under a heavy gown and in wheelchair in a jail, appearing on screen in a courtroom.

Elgin County courthouse (Morris Lamont/The London Free Press)

Jamie struggles to get up. He struggles to be heard.

“Can I?” he mumbles as the justice of the peace, lawyers and correctional officers discuss what to do with him.

“I’m taking it off?” he asks in the voice of a child seeking permission.

“No you can’t take that off. Relax, relax, relax,” the first correctional officer says.

“Just stay calm. Just stay calm,” the second officer says.

“I just take it off,” Jamie mutters.

“You know about the rule,” the second officer says. “We’ll get you back. We’ll get you back to the cell.”

“Shut up,” Jamie says.

Listen to him try to be understood for 12 minutes and the words — “Shut up” — come as a relief.

Finally, he tells everyone to be quiet.

No one listens.

The court hearing goes on until 9 a.m., and after a break, begins again at 9:44 a.m.

Jamie does not appear on the video screen.

“Mr. High, James High is refusing to come out of segregation to go to video,” a correctional manager from Elgin-Middlesex Detention Centre tells the justice of the peace. “He’s acting aggressively right now. . . . We’ve made every attempt to get him to come out of his cell and he’s refusing to come out, ma’am.”

Soon after, Jamie is observed in his cell “pacing at the door or at the sink,” according to the logs from the jail.

At 10:20 a.m, Jamie is “leaning on bunk.”

At 10:30 a.m., Jamie is “lying on floor.”

At 10:43 a.m, correctional officers find him lifeless on that stone cold floor.

They start CPR, and soon after, Jamie is taken to London Health Sciences Centre.

At 11:30 a.m., Jamie High is pronounced dead at the hospital.

Read the initial London Free Press story about an inmate found dead at EMDC here:

The next day in court, the charges that brought him to court are withdrawn.

“Mr. High passed away in custody yesterday so the charges are moot,” the Crown counsel says.

Only there is a typographical error in the transcript, which is otherwise exceptional in capturing in astounding accuracy the chaos of Jamie High’s court appearances.

The charges, the transcript says, are “mute.”

Somehow the error seems appropriate, given how Jamie High has fallen so suddenly silent.

Chapter 2: A fractured life

A snap of fingers.


Some days, something goes K! in my head, Jamie High tells his wife.

He snaps his fingers when he says it.

Like that, Jamie tells Angie.

He tries to elaborate.

I don’t know what it is. It’s like k-k-k-k.

Like the sound of something cracking; ice, glass, the image in a mirror.

He breaks down crying. I don’t know what’s wrong with me, he says.

He felt that way once before, he says. He can remember the day, but doesn’t tell his wife until now.

He doesn’t tell anyone else ever.

How can he? How can Jamie admit there is something wrong?

“His life was perfect,” says Scott Jarvis, Jamie’s business partner.

Women say he is every woman’s dream. Men say they want to be like him.

It’s his smile and determination and the easy way he is liked and likes. It’s his looks and his physique.

Jacked, that’s what men say about Jamie High in admiration and astonishment.

“He could have been on the cover of a magazine,” Scott says.

When he is 30, married just a year, Jamie reads in a health magazine that a man will age the most between the ages of 30 and 40. These are the years a man must begin to look after his heart.

“I remember him reading it,” Angie says. “If he’s going to do something, he’ll be the best at it,”

So Jamie, already athletic, starts working out in a home gym, but after a few years that isn’t enough.

He joins a gym in St. Thomas and starts lifting.

Jacked: not just muscles, but big muscles — the upper body especially — and well defined muscles.

“He always denied using steroids to me,” Scott says.

But he wonders. At 5’ 10” and 185 lbs, Jamie can bench press a lot, 460 lbs four times in a row, and sometimes at the office Scott notices Jamie gets packages of liquid containers from the U.S.

At first, Jamie only takes “test boosters,” oral supplements that help increase testosterone levels for greater muscle mass and strength.

Anabolic steroids, synthetic variations of testosterone, are much more powerful.

“He’s talking to these guys in the gym. They’re big; they’re strong, they’ve been working out for a long time and they’re all doing steroids on a regular basis,” a friend says.

Jamie hates needles. But he starts taking steroids through a transdermal patch and by the summer of 2014 is injecting steroids. He has to hide it from his family and friends. A crack forms in the reflection of himself.

The long list of known side effects of continued steroid abuse include paranoia, extreme jealousy, mood swings, extreme irritability and delusions.

“All of a sudden you feel artificially like a superman,” says Brody McVittie, a personal trainer and writer about gym life. “You are invincible. Alcohol can’t touch you. You are outside of yourself.”

The gym life can be like the bar scene, he says. Good looking men and women working out, dressed in tight clothes, laughing, flirting, endorphins pumping.

“All of a sudden that girl over there who’s looking at you. . . .”

Jamie starts to have fun with a group at the gym, some members and some staff.

“We were there all the time,” his friend and workout partner Dylan Eldred says. “Everyone had the same common goal, to be in shape, to have a good time.”

They socialize, sometimes at house parties or a special event put on by the club. At one gathering, an attractive fitness trainer named Julie Ferguson puts her name and number in Jamie’s cellphone, Dylan says. Julie remembers it differently, that Jamie put his number in her phone. Whoever did, that simple line of text is the start of another fracture.

There’s a photo of Jamie High his friends call “classic Jamie.”

Friends call this photo ‘Classic Jamie,’ as he enjoys the camaraderie in the dressing room after a Friday afternoon hockey game (supplied photo).

He’s sitting on the bench of a dressing room, hockey jersey off but skates still on, a beer beside him, like it is beside the other players.

He has his cellphone in one hand ready to chat with someone on the phone or send off a quick text, and a big smile on his face as he looks toward someone, about to make a joke or reacting to someone who’s just made a joke about him.

The photograph is after a game in the Friday Afternoon Classic Bruins vs. Flyers league, a two-team, invitation-only competition where the players have to handle the puck on the ice and the chirping after.

“Most guys do the game, have a beer or two, tell a few stories, and get home in good time. Jamie lived for Friday afternoon hockey,” league organizer and friend Steve McVittie says.

Jamie wears the Bruins’ jersey with the captain’s C on it, number 9 and the name of Hall of Famer Johnny Bucyk on the back.

“It was like everything came, it seemed like it came so easily to him, like whether hockey, or work or people liking him,” Dylan says.

“But he worked hard. He didn’t start out being super-successful. He had to build that.

“The guy was kind of my idol, to be honest,” Dylan says. “Everyone loved him. We never went anywhere, a hockey tournament, out, that he didn’t know people and people didn’t love him. It was almost like going out with a celebrity, but he wasn’t cocky.”

Nine times out of ten, Jamie High doesn’t finish his second beer after hockey, Dylan says.

When they go to a bar, Jamie never gets drunk.

“It’s hard for me to resolve his drinking when he spends six days a week at the gym.”

One day at work, Scott Jarvis hears someone say Jamie smells of alcohol early in the day.

Scott fires back: “Pick another problem, because you can’t be drinking and do weights like he did. He was ripped.”

Jamie and he began working together in commercial real estate about 2006, Scott says.

“You couldn’t count the number of deals we did in the $1.5 million to $15 million range, condo conversions, multi-residential buildings. Jamie was very successful at what he did.”

Angie High smiles even now when she talks about her husband’s way with people.

“You knew he was in a room. He was bigger than life. People would open to him. Jamie had a way. If something was bothering you, you’d tell him and he listened. Jamie was a guy everyone felt comfortable with.”

In about 2012, Jamie gets involved with Fincore Canada, a development company with large dreams.

Fincore has plans to build a $300-million wellness centre, with medical, commercial and residential components, on the north bank of the Thames River on Wellington and South streets in London.

Jamie High helps Fincore gather the property and promote the plan to residents.

But the project is controversial from the start.

Neighbours complain about the scale of the project in a largely residential area. The company plans to build on land it doesn’t yet own, including property held by the Upper Thames River Conservation Authority, which doesn’t rubber-stamp development along any river.

Two years later, the proposal has died.

In 2012 Fincore also opens up a $10 million, 55-bed retirement residence in Lucan, just north of London.

A year later, it’s taken over by one of the financial partners.

Jamie has an interest in that deal but it turns out badly for him, Angie says.

That’s all she will say about the details.

“That threw him. That really destroyed him a little bit,” Angie says.

By 2013, his family notices Jamie is struggling.

“He changed from being the most extroverted, outgoing man to a shy and distant man,” his parents and brother and sister write in an email.

“He became lost. We, as a family, would call him out on how much he was changing and how evident his struggle had become. We offered getting him help and begged him to get the help he needed. He denied he needed help and reassured us that he was just going through a difficult time, that he would be OK.”

Jamie can handle it. He can keep his balance. It’s just like hockey on his boyhood pond. He can skate over any small cracks.

At home, though, Angie notices Jamie is drinking more, from weekends only to during the week.

“I knew something wasn’t right. He pushed himself to the limit with work, with the gym, with everything. He knew he was in turmoil and he would break down. How do you just snap? Was it the stress of life, all the other things?”

A man who tries so hard to be so good at everything cannot give himself a break.

“I think his pride was so hurt on so many levels,” Angie says.

In June 2014, the cracks in the marriage split open. The family fractures. Jamie leaves Angie and their home in Union, and moves in with Julie in St. Thomas.

Julie Ferguson and Jamie High moved in together in the summer of 2014.

She and Jamie share many good times, Julie recalls. Playing with their children, hers from a previous marriage, watching football and movies together, doing a bit of travelling.

They were in love and planned on getting married, Julie says.

“You know when you know,” she says.

Jamie makes her dinner every night. They stay up late and watch Netflix. They go to London Knights games on Friday, run together, train together, cross the finish line in an extreme race together.

They text each other all the time, a play-by-play of their days. Check out this song. What are you doing? How are you? Did you read this?

But the fissures in Jamie’s life keep deepening. In August, he asks his family doctor for a referral and on Sept. 16, 2014, is assessed at the mental health outpatient clinic at St. Thomas Elgin General Hospital.

Jamie complains about anxiety, depression, drinking daily, manic-like periods, trouble falling and staying asleep, and trouble focusing, according to the notes from that assessment. He talks about his marriage breakdown and his lack of interest and motivation in life.

Jamie rates his self-esteem at a five out of 10.

The assessment notes that he considers his childhood “great” and his family “close.”

He denies any thoughts of suicide, and lists as factors deterring suicide “own thoughts, family, children.”

He has, at this point, no legal problems. He’s described, as usual, as “well-groomed, well dressed, appeared relaxed.”

This is a real picture of classic Jamie: on the surface smooth and calm, inside cracking.

“He didn’t seem like himself,” Julie says. “He seemed off. I said I needed a break from everything because of everything that was going on and he didn’t want that.”

They argue.

On Sept. 28, an argument prompts Julie to tell Jamie: Find somewhere else to sleep tonight.

But Jamie, who can talk himself into anything, comes by her house and talks to her through the patio door.

“He always thought he could do it, whatever it was,” Julie says. “That is what he always wanted to portray. He will handle it. He wasn’t aggressive. He probably just would have talked all night. He would have wanted to work this out.”

Jamie tries to get in at the same time Julie is on the phone with a relative. Alarmed, the relative calls police.

Jamie leaves, but a few minutes later, at 7:11 p.m, police catch up to him driving on a nearby street.

The exchange does not go well. Jamie is arrested for failing to provide a breath sample.

An officer calls Angie High and starts asking questions. Was her husband using drugs? Was he acting strangely? Has he ever assaulted you?

A week earlier, Sept. 22, he spit on me, Angie tells police. In April, during an argument, he shoved her.

At 12:34 a.m. Sept. 29, Jamie High is arrested on two counts of domestic violence.

He appears in court briefly that same day. Is he confused or purposely obtuse when he answers the court?

“I do not know what I am charged with, no.”

Read aloud is the police account of what happened that night. The Crown requests an “investigative hold,” in order for police to interview Angie High and a witness. That will also give Jamie time to arrange for a surety, someone to put up money and promise to help him follow bail conditions.

The next day in court, Sept. 30, 2014, the detailed allegations are read aloud and a surety is arranged.

There is a complication. Jamie owns a gun, and it’s not clear which police force can get it and how. Jamie is charged by St. Thomas police while his home is under Ontario Provincial Police jurisdiction.

For a moment, the court considers waiting while up to a week while the permit for the gun is transferred from Jamie’s possession.

That prompts paralegal Zeyad Halbouni, acting on behalf of Jamie’s lawyer Keli Mersereau, to raise an issue with the justice of the peace.

“This individual is in custody on allegations that the screening forms don’t even indicate a custodial sentence,” the paralegal says.

In other words, Jamie is facing a week in jail on charges for which he is not going to get jail time on sentencing.

“Yes, I do appreciate that,” Justice of the Peace Cheri Emrich says, “but domestic violence release protocols, looking at two very serious — it’s been awhile since I’ve reviewed them, but two inquest reports.”

Emrich is referring to the 1998 inquest into the shooting death of Arlene May by estranged husband Randy Iles and the 2002 inquest into the shooting death of Gillian Hadley by estranged husband Ralph Hadley.

The high-profile inquests revealed shocking mistakes in how police and the courts handled domestic violence cases, and led to dozens of changes in the provincial justice system.

Fear of repeating those mistakes has led, critics say, to a deeply flawed justice system.

Legal experts, researchers, advocates and defence lawyers across the province charge that:

Despite direction from the Charter of Rights and Freedoms, guidance from Canada’s Criminal Code, case law and falling crime rates:

  • Police in Ontario are throwing more accused than ever into detention to await a bail hearing, rather than releasing them with a promise to appear in court at a later date.
  • Ontario courts are taking longer to process bail hearings, keeping people in jail longer.
  • The courts are releasing fewer people from detention on bail.
  • When someone does get bail, they are put under conditions that set them up to fail.
  • Often the most onerous condition — a surety — is put on a person first, rather than last.
  • All of this makes it more likely a person will end up back in jail and less likely to get back out again.

“Case law says a person’s bail is supposed to be under the least restrictive terms first,” says Mersereau, who represented Jamie for several weeks until he switched lawyers.

The legal community calls the process the bail ladder. The Crown is supposed to first consider placing an accused on the lowest rung of the ladder — a promise to appear in court at a certain date to answer charges.

Mersereau says she’s had similar cases to Jamie High, involving domestic violence and involving ownership of a firearm, where the accused was allowed to make that promise.

In an interview, she repeats the point made in court two years ago by her paralegal.

“If you aren’t seeking jail time, why does a person still get jail time? That just doesn’t make sense.”

The next rung is recognizance, a written declaration to appear in court or pay money.

Higher up the ladder is the requirement the accused find a surety.

A surety puts up a certain amount of money, and promises to ensure that an accused is complying with all the bail conditions, attends court hearings and doesn’t break the law again. If any of those thing happen, the surety can forfeit their money.

“Unfortunately, the go-to position for the vast majority of Crowns in Ontario is there has to be a surety,” Mersereau says. “That is really inappropriate. There is no case law that says there has to be a surety.”

So what’s wrong with a reliance on sureties?

Plenty, says Nicole Myers, a Simon Fraser University criminologist who has authored and co-authored several studies on surety in Canada, many of them cited in other studies.

First, an accused’s search for a surety can delay the court process and keep an accused in jail longer than necessary on bail, she said.

Beside extra costs and workload on the justice system, longer jail stays put extra stress on accused and their families.

Sureties are often parents, other family members or friends, who gain a responsibility and a power that can affect relationships, Myers says.

“The surety has this power given to them and there is no oversight over how they are supervising somebody. The combination of requiring supervision as well as loading on a lot of bail conditions, some of which are very problematic, you are really setting up the accused to fail.”

Set Up to Fail is the title of a 2014 study on bail conditions, a report Myers co-authored with the Canadian Civil Liberties Association’s Abby Deshman.

“You structure these release orders so they are very difficult to comply with, and for long periods of time waiting for trial,” Myers says.

For example, and it is a common example, bail conditions often require an accused suffering from alcohol or other drug addictions to abstain. Immediately.

The John Howard Society of Ontario examined the cases of 158 accused people for a 2013 study called Reasonable Bail?

Of the 158 accused, 62 per cent (99 people) were order to abstain from drugs and 61 per cent (97 people) to abstain from alcohol.

Those conditions are “doubly punishing individuals for what are recognized health concerns,” the report states.

It’s like mandating a person to abstain from a mental illness, “illogical,” and given the side effects of suddenly abstaining for people with severe dependency, “irresponsible,” the report states.

Failure to follow those condition brings further punishment.

The court’s thinking: “It didn’t work last time, so we’re going to have more conditions, more money from surety, or multiple sureties,” Myers says.

“It is like you are upping that ante. They were already having a hard time complying and now we’ve made it even more difficult. We shouldn’t be surprised when they fail to comply and end up right back in the system again.”

Myers’s research confirms Ontario courts rely on sureties far more than in other provinces.

“There’s a real reluctance in Ontario to stop using sureties in absence of any evidence that they are effective or not,” she says. “Since we can’t keep everyone in custody, the surety has morphed into an insurance strategy, as a way of taking the responsibility, if something goes wrong, off the decision makers and onto somebody else.”

There may be changes coming to Ontario’s bail system.

The provincial government has two streams of reviews on the bail system under way, with some recommendations due sometime this year.

“We know that we must do better to improve the speed and effectiveness of Ontario’s bail system,” Ministry of the Attorney General spokesperson Brendan Crawley says in an emailed response to questions.

One review has been in the works for several years. The province created a “bail experts table” in 2012 to look at the bail system. From that, came a “domestic violence bail experts table” that is looking at the first table’s recommendations, Crawley says.

“The domestic violence bail experts table is in the final stages of its review,” he says.

The ministry has also been working with the Ministry of Community Safety and Correctional Services and others in the justice system “to develop a comprehensive bail and remand action plan,” Crawley adds.

“In the coming weeks, we will be releasing an action plan aimed at improving the efficiency and effectiveness of Ontario’s criminal justice system in the area of bail, while maintaining public safety.”

Waiting for bail keeps Jamie one night in police custody and, because it takes longer to resolve the firearms issue than expected, three nights in jail.

Jamie’s father steps forward as his surety.

“I helped Jamie and took him into our home because he was my best friend,” David High says in an email.

“I thought if I got him here, we would know what was going on with him and we could get him through it.”

Jamie must get through the next few months living under conditions considered routine by Ontario courts, and anything but in real life:

He must live with a surety, which means at 39 and almost 20 years on his own, he is now forced to live with his parents, two hours away in Dunnville.

That also he means must live two hours away from his girlfriend, his gym, his friends and his clients.

He has to turn his car over to police, which means he cannot drive to meet clients or show his clients real estate.

He cannot have contact with Angie High except through a third party to arrange child care, which means he cannot see his children with ease.

That also means he cannot contact the woman whom, though estranged, he still relies upon for emotional support.

He cannot drink, buy or possess alcohol, which means he is forced in an instant to overcome his addiction.

All of this, of course, he has to hide from or admit to his friends and associates.

It’s as if the court, faced with evidence of cracks in Jamie’s life — police at his girlfriend’s house, drinking and driving, denying his identity to officers, shoving and spitting on his wife — decides to create some new ones.

Chapter 3: ‘I’m going to die’

Some nights Jamie High — confident, athletic, successful, popular Jamie High — cannot sleep for sobbing.

“There were nights, and he is a strong guy, there were nights where he was on the couch crying,” his girlfriend Julie says. “I don’t know what he was hiding or what happened in there that he would never share.”

“In there” was jail, the provincial Elgin-Middlesex Detention Centre in London (EMDC), or Exeter Road as the inmates inside call it.

A range at the Elgin-Middlesex Detention Centre.

There are any number of ways to measure the extent of the problems there, by the seven deaths since 2007, by the 600 — and growing — number of ex-inmates who’ve joined a $325-million class action suit against the province, by the six inmate-on-inmate assaults and five inmate-on-correctional officer assaults in September 2014 alone.

The numbers only tell part of the story. That September, labour disputes prompt angry guards to refuse work and lock down units, which prompts angry inmates to jam toilets and flood ranges.

When Ontario New Democrat corrections critic Lisa Gretzky tours Sept 26, the second floor erupts.

“It was like thunder,” she said at the time. “It was so loud you couldn’t hear yourself think. They were banging on their cell doors. They kicked and yelled and swore and carried on.”

Three days after her tour, about 1:10 p.m. Sept. 29, an inmate named Keith Patterson hangs himself in his segregation cell.

Jamie High arrives less than an hour and a half after that, about 2:30 p.m. and is put on Unit 4 Right, a holding area for new inmates.

A standard two-bed cell in a unit at the Elgin-Middlesex Detention Centre in London. (Craig Glover/The London Free Press)

A standard cell at EMDC, 7 ½ feet wide by about 11 feet long, contains two beds, a toilet, sink and occasionally a mattress on the floor jammed between the beds and toilet for a third inmate. The ventilation system is suspect. The walls have been sentenced to decades of feces and urine and graffiti.

Noise echoes off the concrete walls, tile floors and metal benches in each unit’s common area, where a television set blares much of the day.

Food comes in trays through a small hatchway from the server, usually the toughest inmate on the range who enforces the rules and can punish by reducing an inmates meals, or if need be, take him to the unmonitored shower area for a beating.

A standard two-bed cell can be seen through the meal hatch in a unit at the Elgin-Middlesex Detention Centre in London. (Craig Glover/The London Free Press)

Jamie spends most of his time in his cell, getting out to shower or use the phone, a correctional officer recalls.

But that offers only limited protection from other inmates, who will shout out threats through the cell hatches or stop at another inmate’s cell on their way to the showers or the phones, the officer says.

A phone hangs on the wall in a range in one of the units at the Elgin-Middlesex Detention Centre in London. (Craig Glover/The London Free Press)

“If they think you’re well-off and by that they mean have a good job, they’ll make threats: ‘Better put money in my account when you get out or I’ll find you,’ ” the officer says.

Jamie doesn’t like to talk about his time in jail when he gets out. To some friends, he says he was threatened by a drug dealer. To others, he doesn’t even admit he was in jail.

“You could tell it was a bad scene. He said it was horrible, wouldn’t wish that on his worst enemy,” friend Steve McVittie says.

Jamie gets bail with his father acting as surety, the person responsible for making sure an accused follows bail conditions.

After two weeks of living at his parents’ house in Dunnville, though, Jamie applies to court to have his surety changed to Julie, his girlfriend, in St. Thomas.

Living two hours away from their home, his work, his children, his friends and his gym, is too much, Julie says.

At an Oct. 15, 2014 hearing, Justice of the Peace Cheri Emrich makes a point of making sure Julie knows the weight of responsibility a surety shoulders.

(READ: What Sureties Need to Know)

“What do you intend to do if Mr. High is breaching any terms of the order?” Emrich asks.

“I am supposed to call the police?” Julie says.

“And is that what,” Emrich says, emphasizing the what, “you’re going to do?”

“Yes,” Julie says.

Is there alcohol at your house? Emrich asks.

“No,” Julie answers.

“None?” the justice of the peace repeats.

“None,” Julie promises.

Jamie High is ordered to live at Julie’s residence.

Jamie High and Julie Ferguson (supplied photo)

Only two weeks earlier, police were called to this same residence for a disturbance involving the same woman.

If anyone in court thinks it is unusual to put Jamie High under the legal care of the woman involved in his legal problems, no one brings it up.

If anyone in court thinks it might be a problem to put a man charged with domestic assault of his estranged wife into the home of another partner, his girlfriend, no one brings it up.

When an expert in domestic violence is about the court’s decision, she sighs in exasperation.

“That is not well thought out at all,” says Barb MacQuarrie, a director of the Centre for Research and Education on Violence against Women & Children at Western University.

“We just don’t seem to understand the importance of getting a handle on risk. It shows a lack of understanding into violence against women. When it happens in an intimate relationship, if problems aren’t addressed, they will be replicated.”

Addressing the problems behind the violence forms the foundation of counselling programs for men across Canada accused of domestic assault.

In Ontario, though, those programs are struggling.

The provincially funded Partner Assault Response program (PAR) takes men facing conviction on a first and low-level offence and ordered by the court to attend counselling to change their behaviour.

Over the past two years, PAR has become mired in controversy about its effectiveness and funding.

The province reduced the program from 16 weeks to 12 weeks in order to cut wait times for men, alarming anti-violence advocates and the community agencies that provide the counselling.

“All the evidence supports a longer time is needed to change the behaviour of men,” MacQuarrie says.

In March 2015, a coalition representing rape crisis centres, probation officers, women’s shelters, family services agencies, anti-violence advocates and researchers in violence against women and women’s health wrote to then Minister of the Attorney General Madeleine Meilleur outlining their concerns regarding “the PAR crisis.”

That crisis was reducing deferrals from the courts to PAR programs, the coalition claimed.

As well, agencies in Windsor and Toronto that provided the counselling ended their contracts with the province over concerns about the ethics of a shorter program and the difficulty in handling more men per year without an increase in funding, the coalition claimed.

Meilleur held a meeting of about 70 advocates and PAR agency representatives in April of this year, and the province has begun an internal review of the program.

Barb MacQuarrie (Mike Hensen/The London Free Press)

That’s not enough, MacQuarrie says.

The province needs a review, based on research and comparisons of other jurisdictions, of its entire approach to treating men involved in domestic violence, she says.

“This is a highly controversial area,” she says. “Even among the service providers there is disagreement whether or not the PAR program is effective and whether or not the money is adequate. I think it’s time to take a breath and stop making decisions until we do a review.”

The NDP’s women’s issues critic, London West MPP Peggy Sattler, has pushed the province to stop the changes to the PAR program and review its domestic violence strategies.

“The PAR program is merely the canary in the mine shaft,” she wrote in an open letter to Premier Kathleen Wynne in June 2016.

“It’s in a crisis,” she adds in an interview with The London Free Press.

Besides the problems with the PAR funding — with two more agencies dropping the service this year — the province’s “one-size fits all approach” is leaving out men who need and want help, Sattler says.

There is no provincially-funded program for men who voluntarily seek help, despite research showing the benefits.

A study conducted by London police, the city’s Changing Ways agency for men, Women’s Community House shelter and the University of Toronto compared two groups of men in the London area charged with domestic violence.

Forty of the men received counselling from Changing Ways after the charges, and 40 did not.

“Results showed that there were significant, substantial, and lasting differences,” between the two groups, concluded the study, published in 2013 in the International Journal of Offender Therapy and Comparative Criminology.

The men who received counselling were far less likely to face new charges of domestic violence or have any kind of further involvement with police.

Followup research in London, Woodstock, Sudbury, Strathroy and Ottawa showed similar results, with potential savings for police, courts and jails because of fewer followup interactions with the accused men.

“We’ve had numerous requests from other municipalities from across this province to look at the results we had, and to try and see if they can replicate that in their own communities,” says Tim Kelly, one of the researchers and executive director of Changing Ways.

His agency provides 16 weeks of counselling, including one-on-one and peer group work, with the flexibility to deal with different crises the men are facing, Kelly says.

His agency also provides the mandatory PAR program, with a less flexible curriculum and shorter time period.

Tim Kelly (Morris Lamont/The London Free Press)

“Change can’t be done in a check-box format in 12 weeks,” Kelly says. About 450 men a year go through the PAR program and about 150 through the voluntary program, including some of those graduates of PAR who feel the need for more help, he says.

The Canadian Association of Chiefs of Police this year endorsed a national framework for domestic violence that includes the kind of early intervention and researched-based strategies identified in the London-based study.

But so far, there’s no move from the province to expand counselling to men beyond the mandated PAR, Kelly says.

In London, where the research originated, the program has struggled because police budget cuts limited the number of civilian social workers who connected accused men to Changing Ways. In Ottawa, the program is on hold pending a review, Kelly says.

The province defends its changes to the PAR program, but acknowledges there’s more work to be done and it may be time to consider funding for services providing voluntary counselling.

The changes to the PAR program added 151 new groups offering the counselling, meaning an additional 2,200 offenders — an increase of 22 per cent — can get through each year, Brendan Crawley, a spokesperson for the Ministry of the Attorney General, says in an email.

The meeting in April 2016 was just a first step in a review of the PAR program, he said.

A meeting with the agencies offering the PAR program is set for October, Crawley said.

As well, the ministry will continue meeting agency representatives, as well as domestic violence experts and others, he said.

One of the discussions in the ongoing meetings will be conducting further research into domestic violence counselling.

In September 2014, the province did launch its own, three-year, in-house study on recidivism rates for people in the PAR program, Crawley noted.

The ministry will also launch client surveys in January 2017 to measure if the PAR program is achieving its objectives,” he said. “The results may help to guide future program improvements.”

Funding for PAR remains only for those mandated by courts to attend counselling, Crawley said.

“However, through our ongoing work with PAR providers we have heard the desire for access to programming for voluntary clients. As we work to strengthen the PAR program we look forward to working with our partners to explore options to address this issue.”

While the reviews and talks continue about the programs that targeted to accused men, many of the other traditional counselling agencies continue to turn accused men away because of long-standing practices.

“Once men have charges before the court, the mental health system won’t let them access treatment services because they question their motivation, ‘Are you just trying to look good?’ ” says Lisa Heslop, one of the London researchers.

A combination of tradition and funding rules has dissuaded many community agencies, including hers, from taking on people facing criminal charges, acknowledges Louise Pitre, executive director of Family Services Thames Valley Services.

Pitre doesn’t agree with the rules, but admits it’s going to take a long time and a lot of work to change the tradition.

Loss of their children, their job and a place to live, growing addiction, mental illness, isolation, shame — all elevate the risk of a man harming himself or others after a domestic violence charge, Kelly says.

“The level of anxiety is tremendous,” he says. “The descent can be really quick. If you already have a tenuous grip on things it wouldn’t be a big leap to a psychotic breakdown.”

Jamie’s grip on his life loosens after his September 2014 arrest.

“He lived in, from October to November, he was terrified,” girlfriend Julie recalls. “He was walking on eggshells about going back to jail. He said he saw police cars driving by at night. He had nightmares.”

Jamie used to talk to his ex-wife after he left their home in the summer. Now he cannot, under his bail conditions.

“If there was anyone that could have helped him through these past few months I know it was me even though I was the brunt of all his anger,” Angie High says.

Jamie keeps working, keeps going to the gym, keeps playing hockey.

“He was starting to look a little more strained. But given everything that was going on his life, you could understand,” hockey pal Steve McVittie says.

“He was pretty good at putting on a game face. I thought if Jamie got through this bump in the road he’d be OK.”

St. Thomas Elgin General Hospital (Morris Lamont/The London Free Press)

Jamie’s been trying. In August, he got a referral from his family doctor for a screening at the outpatient mental health clinic at St. Thomas-Elgin General Hospital. He was assessed Sept. 16, two weeks before his arrest.

At that appointment, according to the medical notes, Jamie reported trouble falling and staying asleep, declining motivation, tearful periods, trouble focusing on tasks and mood swings, and gave himself a five out of 10 for self-esteem.

He said he drinks daily. He wasn’t feeling suicidal. The nurse assessing him reported he was “well groomed, well dressed, appeared relaxed during interview.” His speech was normal and he was coherent. He reported no hallucinations and his cognitive functions and insight were good.

After the Sept. 16 assessment, Jamie agreed to contact an addiction service and gets an appointment to see a psychiatrist. At some point, he gets a prescription for the anti-anxiety medication clonazepam.

He does get counselling, Julie says. She knows this because she drives him to the appointments. But she’s not sure how much good the counselling sessions do.

By the time Jamie sees St. Thomas psychiatrist Dr. Giuseppe Guaiana at the outpatient clinic at St. Thomas Elgin-General Hospital a month later on Oct. 17, he’s been arrested, spent several nights in jail and living under strict bail conditions.

Guaiana is the chief of psychiatry at the hospital, and his connection with Jamie continues almost to the day Jamie dies.

According to the doctor’s notes from that session, released to The London Free Press by Jamie’s estate, Jamie says he’s been anxious his entire life, but the past 10 years and especially the past two years have been worse.

He tells the doctor he worries all the time and sometimes has to pull over his car because of “intense panic.” He gets tired and can’t concentrate, but can’t relax or fall asleep either. He reports losing weight and not eating. Nothing gives him much enjoyment.

I used to drink too much when I was young, two to three drinks a day almost every day. Now it’s about two a night, although I’ve stopped because of the clonazepam, Guaiana reports Jamie saying. His domestic assault charges are noted.

Jamie is diagnosed as having a generalized anxiety disorder, a mild depressive order and is abusing alcohol.

The doctor prescribes the anti-depressant Paxil for anxiety, 10 milligrams a day for the first week and 20 mg a day after. He decides Jamie should see a counsellor and plans to follow up himself in six weeks.

Six weeks later, Dec. 1, 2014, Guaiana sees Jamie for 20 minutes at the outpatient clinic at the St. Thomas hospital.

Jamie is doing better, Guaiana reports. His concentration and mood are better, and he does not have any panic attacks. His appetite is better and he has not had a drink since Sept. 30.

The Paxil gives him some side effects, such as “jitteriness and tremor.” Satisfied with his patient’s progress, Dr. Guaiana decides to cut the Paxil dose back to 10 mg to see if the side effects might be reduced, and plans to see Jamie in six more weeks.

If Jamie is putting on a good show for his doctor, he cannot hide what was become a rapid descent to his friends.

“It wasn’t till closer to Christmas, a couple of times he showed up to hockey it seemed he’d already had a couple of beers,” Steve McVittie says. “I didn’t pick up on that. I just think if you’re having a tough time and want to have a beer. . . .“

In mid-December, his business partner Scott Jarvis begins to worry.

He and Jamie have a meeting over a $15-million real estate deal.

Jamie, the man Jarvis thinks could be on the cover of a magazine, shows up in a wrinkled dress shirt.

You look a little lean, Jarvis says.

Jamie says nothing.

Dylan Eldred breaks his arm and doesn’t see Jamie at the gym or hockey for several months.

Everything seems fine when they talk, except sometimes Jamie loses his place in time. He’d think an event that happened months ago happened yesterday.

“He just couldn’t keep track of the order of when things were happening,” Dylan recalls. “Weird things would just pop up.”

His moods alarmed and frightened Julie.

“He wasn’t making any sense,” she says. “Something was wrong. He could be just super amazing and then he just wasn’t acting appropriately. He was frustrated, really short tempered. He had no patience. It wasn’t the guy I knew.”

She cries even now when she talks about the anger.

“It’d be two in the morning and he’d be going ballistic in the house, just angry, and I’d be sitting in my driveway because I don’t know what else to do.”

Alcohol, steroids and anti-depressants create a toxic mix that can cause high blood pressure, strokes, liver disease, respiratory depression and death.

The mind reels under the onslaught of drugs. Depression, anxiety, impaired thinking and alertness, impaired reaction time, erratic mood swings, delusions, violent behaviour, paranoid jealousy, impaired judgement and suicidal thoughts are listed as effects on the mind in medical literature.

In late December, Julie finds an empty bottle of vodka in Jamie’s hockey bag. Three months ago, she promised a stern justice of the peace to help Jamie follow his bail conditions and keep alcohol out of her house.

She worries about getting in trouble with the police and the courts. She worries if that happens, the Children’s Aid Society will get involved with her children. She worries that Jamie needs help that he’s not getting.

Her friends and her family lawyer tell her the same thing: Jamie has to leave and he has to find a new surety.

She won’t say much about the argument they had Dec. 18, 2014. She kicks him of her house, and the next day, goes to court to remove herself as his surety.

A St. Thomas police officer who goes out with one of her girlfriend sits with her in the courthouse, Julie says.

“I think I cried the whole morning, even in court.”

Jamie High is now wanted by St. Thomas police for a breach of his bail conditions.

They can arrest him and throw him back in jail.

Jamie has said the same thing a dozen times in the past two months.

If I go back to jail, I’m going to die.

Chapter 4: ‘My head is not right’

Jamie High needs refuge.

He’s not sleeping, he’s not eating, he’s wandering the streets and he can’t shake these thoughts that just aren’t right.

His girlfriend has kicked him out, and he spent the night in a motel, and he can’t see his children much and his wife at all, and he’s got multi-million dollar deals waiting on him, and the steroids are probably doing something, and he shouldn’t be drinking on his medication but he is, and where is going to live now?

He isn’t talking himself out of this mess. He isn’t bench pressing these worries out of his system.

But he is Jamie, so he keeps trying. He’s got things to do. He’s got to get some clothes from his ex-wife. He’s got to see his lawyer. He’s got to talk to his girlfriend.

He makes his way out of Room 9 in the Glen Haven Motel in St. Thomas on a chilly Friday morning, Dec. 19, 2014.

The Glen Haven Motel in St. Thomas. Photo by Morris Lamont/The London Free Press

First thing that happens, he gets a text from his girlfriend Julie. She tells him she has gone through with it. She’s gone to court that morning and withdrew herself as his legal surety. That means a bench warrant has been issued for his arrest.

Don’t worry, my business partner will be my surety, Jamie tells her.

Jamie keeps moving. He arranges for his friend Dylan Eldred to get some clothes from his estranged wife, Angie,

That same day, she and his parents are taking his children on a ski trip to New York, and he has to go to his lawyer’s office to sign papers allowing them to cross the border.

Angie High has other papers to sign that day. She drives to the law offices of Hennessy & Hogan in St. Thomas, and signs papers seeking a divorce and custody of their children.

“I hated he got those papers from me, I hated it,” she says when speaking of it now. “I didn’t want that. But we, his family and I, we just needed to do something to snap him out of what he was doing.”

When Jamie arrives at the St. Thomas office of his family lawyer, Bruce Blake, to sign the papers that allow his children to be taken across the border, he is handed the divorce papers.

As Jamie is getting into a cab outside his lawyer’s office, Angie is walking toward that same office to pick up the permission papers for the ski trip.

Jamie and Angie see each other. On this hard day, they cannot, by court order, talk to each other.

A few hours later, Dylan Eldred calls his friend. He’s picked up the clothes from Angie.

I’m at a motel, Jamie tells him.

What motel?

Um, I don’t know. Let me check, Jamie says. He opens the door and looks at the motel sign to figure out where he is.

Dylan drives to the motel and knocks on the slightly open door.

Dylan Eldred (Morris Lamont/The London Free Press)

“He just looked like hell. His hair was all over the place. He was just putting his clothes on like he was just lying there in his underwear. He’s got the divorce papers all over the bed. He was a freaking mess.”

Divorce papers typically begin with little boxes to be checked with an X. Each one is an incorrect answer, a bad mark on your marriage, another slash of a knife.

Divorce: X. Custody of children: X. Restraining/non harassment order: X

After the boxes comes a section of facts supporting the divorce claim, the detailed allegations. It’s a live dissection, a knife cutting through the grit and gristle of a marriage to root out the tumours.

Dylan doesn’t want to leave his friend in the motel room with all of that, but he can’t convince Jamie to stay the night in the nearby but vacant apartment of a friend.

I’m just exhausted. I just want to rest, watch some television, Jamie says,

Dylan leaves him the keys to his friend’s apartment.

The small room at the Glen Haven Motel in St. Thomas where Jamie High lived fora time. Morris Lamont/The London Free Press

Jamie spends a second night in Room 9 of the motel. There is a bed, television set on a stand, a small desk and chair and a bedside table with a lamp. There’s a bathroom with a shower. He looks around the motel room and wonders what to do. How can he get out of this?

The next morning, Saturday Dec. 20, Dylan looks for Jamie in the motel. He’s not there.

Dylan finds Jamie in the apartment, curled up inside a blanket on the couch.

I can’t go to jail. I can’t go to jail, Jamie says.

“That is all he could talk about. How it was hell, how he was scared,” Dylan says.

“He is laying on couch, a grown man, built, scared shitless. He’s barely coherent. He barely has any energy. He can barely stand up and talk and his clothes are stinking. It’s freaking me out.”

Dylan drives his friend to the emergency department at St. Thomas Elgin General Hospital. Dylan spent five years as a manager at the hospital, including one in risk management.

He makes himself Jamie’s contact and he signs Jamie in as anonymous. Jamie needs privacy and protection. He needs medical care, not a jail,

The anonymous designation will protect Jamie from police or anyone else trying to find him, Dylan thinks.

Jamie is seen by an emergency room nurse at 4:39 p.m. Dec. 20, according to hospital records obtained by The Free Press.

Triage nurse Sara Lukacin notes that he was brought in by a friend, feeling depressed and going through a marital separation.

He avoids eye contact and is reluctant to speak, asking for psychiatric help.

Jamie is “very tearful, crying at triage, apparently wandering around the streets, not eating or sleeping for past 3 days,” the triage notes say.

At 161/100, his blood pressure is high, although not off the charts. His pulse is at 100 beats per minute, on the high side. He is showing no signs of dehydration.

The nurse notes Jamie is taking 0.5 mg of clonazepam and 20 mg of paroxetine (Paxil) each day. He’s been complaining of shakiness since taking the paroxetine.

The nurse rates Jamie’s tracking acuity level, basically how long a patient should wait until getting an examination. Jamie’s tracking acuity is rated urgent.

Jamie is sent to a quiet room with Dylan to wait for further assessment.

“He wasn’t talking much,” Dylan recalls. “He just kept saying, ‘Man I don’t want to go to jail.’ He was mumbling a bit. He started to go out, like he was falling asleep.”

Every time an ambulance arrives at the nearby front entrance, Jamie starts, thinking it is the police.

At 5:30 p.m., nurse Lisa Medeiros prepares a psychiatric assessment of Jamie.

A screen shot of the nurse’s notes. See above for full report from the nurse and doctor.

Jamie tells her he stayed in a hotel last night and was wandering the streets today. He hasn’t slept in two days and has slept poorly the past six months.

In her assessment, Medeiros twice records the charges of domestic violence Jamie is facing. She notes his recent thoughts of suicide and that he tried to hang himself in the past couple of days.

Jamie reports no alcohol use, or use of illicit drugs.

One part of the psychiatric assessment form reports on a patient’s ability to care for themselves. That is supposed to be an important consideration for medical staff determining if a patient needs to be in hospital.

The nurse notes on Jamie’s assessment that he lives independently “but impaired late.” She also describes his living arrangements as “homeless” and “wandering the streets today.”

His appearance Medeiros describes as “dishevelled, lack of sleep, laying down, no eye contact.”

His speech: “blocking, pressured.”

His thought form: “blocked.”

In her summary, Medeiros writes:

“Jamie feels suicidal, life has become unmanageable. He feels helpless and hopeless. Marriage breakdown. Very little contact with his children. He describes his thoughts in head not ‘right.’ Denies homicidal ideation, denies hallucinations or delusions.”

Medeiros notes she conversed with the emergency room doctor, Terry Evans and the management plan for Jamie High is “recommended admission.”

Jamie is given 2 mg of Ativan for anxiety at 7:21 p.m. and admitted voluntarily.

At 8:15 p.m, Jamie is taken from the ground floor up one level to the newly built psychiatric unit. A sign, Welcome to Mental Health Care, greets patients. To the right are the rooms of the outpatient unit, where Jamie sought help the past three months. To the left is a locked door and a row of inpatient rooms.

Jamie undergoes another assessment in the unit by nurse Amanda Hindley. His vital signs haven’t changed much since he first arrived.

Neither have his fears. In her notes, Hindley sometimes directly quotes Jamie.

“My head is not right,” he says.

Asked to rate the scale of his problems, he replies: “Big I guess. I wanted to hang myself.”

A “health illness perception” form reiterates the earlier assessments of Jamie’s mood and appearance.

Mood extremely low. Tearful. Feeling suicidal the last few days. Not caring for self, not eating and sleeping.

Jamie makes no secret, again, of his legal troubles, telling the nurse he had been charged and had to leave a woman’s house because of bail problems.

He gets a room, Number 9 — the same as the motel room he left — a snack and toiletries. The Ativan has sedated him somewhat but he remains shaky, nurse Hindley notes.

She notes his main problems are suicidal ideation and poor self care.

Dr. Terry Evans files his notes about Jamie High at 10:20 p.m. He notes Jamie is feeling “quite depressed” and “has been wandering around the streets without eating proper meals or sleeping at home.”

Despite nurses’ notes that Jamie has suicidal thoughts, Dr. Evans notes Jamie, though tearful, “denies suicidality at this point in time.”

The psychiatric nurse who assessed Jamie is “concerned he was not safe to be discharged home. . . .”

“Therefore, we are admitting Jamie voluntarily overnight for depression. Dr. Guaiana will see this gentleman in the morning,” Dr. Evans concludes.

Dr. Giuseppe Guaiana is the on-call psychiatrist that night, and the doctor Jamie has been seeing for help before this crisis.

The idea of a discharge is the furthest thing from Dylan Eldred’s mind, as he leaves about 9:30 p.m.. He believes his friend is safe and sound. He gives him a hug, and promises to come back the next morning.

The record of what happens next comes mainly from the notes of nurse Hindley and interviews with Jamie’s girlfriend, Julie.

At 11 p.m., Jamie wakes up and tells the nursing staff he is anxious and shaky. He’s given his clonazepam and gets back into bed.

From the nursing notes, a few minutes into Dec. 21:

“@0005 Police called unit indicating that there was a client on our unit they were aware of that was texting someone who they are not to have contact (with) and sending pictures of the hospital to them.”

It’s not clear whom that note means.

Jamie High is not allowed to have contact with his ex-wife Angie High, because of the domestic violence charges.

There is apparently nothing preventing him from contacting his girlfriend, Julie.

Hospital staff does not give any information to police, nurse Hindley notes.

“Police also indicated that there was a warrant out for said person as he is not residing where he should be. They would follow up later once they had more information.”

The nurse asks Jamie if he’s been texting and he indicates no.

She advises him not to text anyone at this time. Jamie tells her police may be looking for him because he lost his surety.

A few minutes after the first call, police call St. Thomas hospital again, nurse Hindley writes.

Police say “client had texted this person again threatening them saying he knew they called the police. Police indicated they would be coming to the unit to arrest this person (and) they have a warrant. Writer called on call manager and confirmed that police would take pt [patient] warrant (and) this client is voluntary.”

The on call manager’s name is in brackets, Doris.

Police arrive at 12:47 a.m., show hospital staff a warrant and ask to be taken to Jamie’s room. They arrest him and take all his belongings, Hindley’s notes say.

Elgin-Middlesex Detention Centre (Morris Lamont/The London Free Press)

“Police state he won’t likely be in the community over the next week and discharge would be appropriate. Considering voluntary status,” she writes.

Police remove Jamie High from the psychiatric unit at 1 a.m., 13 minutes after their arrival at hospital.

“Writer feels pt [patient] was not forthcoming with staff about his legal struggles,” Hindley writes.

It’s not clear what she means by that. Jamie “remains shaky despite considerable benzodiazepenines” the nursing notes say.

Five minutes after Jamie is discharged, the psychiatrist on call, Guaiana is called and “informed of the situation,” the nursing notes say.

In a Discharge Summary signed Dec. 24, the day after Jamie died, Guaiana gives a brief account of the call he received from Dr. Evans after Jamie was brought to emergency.

“As I knew the patient, I asked Dr. Evans what caused this change in presentation, as I saw him last in early December and he was slight better,” Guaiana reports. “It was not clear what changed his behaviour.”

Guaiana continues:

“In any case, Dr Evans told me that Mr. High was not suicidal and he was willing to be admitted to our Mental Health facility. For this reason, I told Dr. Evans that a Form was not necessary and he agreed with me.”

Guaiana is referring to a Form 1, a document that under Ontario’s Mental Health Act, allows doctors to place a patient involuntarily in care for 72 hours for assessment and treatment.

Guaiana then describes what happened to Jamie on the unit.

“Mr. High was apprehended by police a few hours later, as, from what I can understand, he was texting a person whom she [sic] should not have texted, as he had a restraining order against this person. After Mr. High was apprehended and left the unit, I was called at around 1 p.m. by nurse Amanda Hindley. Nurse Hindley notified me that the police apprehended him and asked me for a discharge order which I gave.”

Dylan Eldred, of course, has no idea any of this is happening. He wonders now if he did the wrong thing by doing the right thing.

“I could have hidden him in the apartment until he saw his lawyer. You have faith in the system and people and then they let you down.”

Dylan insists medical staff told him Jamie was to be put under the Form 1 that would keep him in hospital for 72 hours.

Police can still arrest and take into custody someone who is under a Form 1, says Dr. Andrew Lustig, psychiatrist at the Centre for Addiction in Mental Health (CAMH) in Toronto.

But doctors can at least provide some reassurance to police that the patient isn’t going anywhere and that the hospital will tell police when the patient is to be discharged, he adds.

About 136 people a year are placed under a Form 1 at CAMH, Lustig says.

In the past seven years, about five to 10 times police arrived to take someone into custody who was under a Form One. About half the time, officers have ended up leaving with the person.

“Typically the time they insist on taking is when the crimes are more serious, when they believe a person represents a threat to the community,” Lustig says.

Under the province’s Mental Health Act, a doctor can place someone under a Form 1, in involuntary psychiatric care, by checking off at least one criteria on each of two lists.

Here are the two lists, and how Jamie could have met the criteria.

List one, a person:

  • Is a threat to himself. Check: Jamie High spoke of trying to hang himself.
  • Has attempted to hurt himself, Check: see above.
  • Is behaving or has behaved violently: Check: Jamie was wanted by police on assault charges.
  • Is causing someone to fear being hurt: Check, he was allegedly threatening someone.
  • Has shown a lack of competence in caring for himself. Check, he told medical staff he was wandering the streets and had not eaten or slept.

List two, a person:

  • Is suffering a mental disorder that will cause serious bodily harm to himself or others. Check: see suicide attempts, threats above.
  • The person might unintentionally harm himself through neglect, (such as wandering in the cold). Check: Jamie had been wandering the streets.

Even without being admitted under a Form 1, Jamie should have had some protection under the general guidelines for Ontario hospitals and the specific policies of St. Thomas Elgin Hospital.

The decisions about discharging and admitting patients aren’t easy, notes the Practical Guide to the Mental Health and the Law in Ontario, developed by legal experts for the Ontario Hospital Association.

“Mental health care professionals must exercise reasonable care and skill and take into consideration all relevant factors in arriving at a clinical judgement regarding admission or discharge decisions.”

The guide recommends hospitals develop a procedure telling staff who to contact when given a warrant, how to verify the warrant, and what information should be provided.

In bold letters the guide warns: “As these situations are very fact-specific, health care providers should contact the Hospital’s Risk Management department and/or legal counsel for advice.”

St. Thomas Elgin General Hospital has at least nine different policies guiding staff when dealing with police. The general rule is to put the patient’s care first.

Hospital employees are encouraged to co-operate with police provided “the co-operation does not, in any way, compromise patient care,” states hospital policy.

If police want to arrest someone and remove him from hospital, the staff must contact both the highest ranking physician, what’s called the most responsible physician, and a director or administrator in charge.

“If it will be detrimental to the patient’s health to leave the hospital, inform the officers. If they persist, their Superior Officer should be notified of the health concerns.”

The hospitals communications manager, Nancy Lawrence, elaborated on those rules in a written response to questions from The Free Press:

“With the appropriate arrest warrant, police may remove a patient from hospital premises if the patient’s condition is deemed medically stable by the care team and most responsible physician,” Lawrence said.

“In the event that the patient is too unwell to leave the hospital, the police will stay with the patient in hospital as the patient remains in police custody.”

These steps might have been taken, but it is not clear in the health records obtained by The Free Press that in Jamie’s case:

  • The highest ranking physician was contacted before his discharge.
  • The highest ranking administrator in charge was contacted before his discharge.
  • That police officers were informed it would be detrimental to the health of Jamie High — diagnosed with depression and with thoughts of suicide — to leave the hospital for a jail or police cell.
  • That the superior officer was notified of health concerns about Jamie after police said they wanted to take him.
  • That his condition was “deemed medically stable by the care team and most responsible physician.”
  • That any consideration was given to having police stay with him while he remained in hospital.

These steps might have been taken, but the hospital will not answer specific questions about Jamie High, Lawrence says. Neither doctors Evans and Guaiana respond to requests for comment. Nurse Hindley declines to comment. Nurse Medeiros refers questions to the hospital’s risk manager.

The final notation on the nursing notes is dated at 3 p.m. Sunday Dec. 21, by Lisa Medeiros, the psychiatric nurse who recommended Jamie be admitted.

By the time she writes the note, Jamie is in a segregation cell at the Elgin-Middlesex Detention Centre in London, acting bizarre, unable to keep down his breakfast and about to spend his last hours in coherent thought.

“Left message on cell phone,” the nurse writes, assuming Jamie will be using his phone again some day, assuming Jamie will be able to ask for help.

“Crisis # left if any further support needed.”

Chapter 5: Falling to pieces

Every time he surfaces, Jamie High checks his phone.

Don’t tell anyone where you are, his friend, Dylan Eldred, says, but Jamie keeps checking.

Dylan gets so frustrated he takes Jamie’s phone away and puts on it on a table.

Just to charge it, he tells Jamie.

Jamie slips back into semi-consciousness. Then Dylan phone’s buzzes and Jamie comes to and reaches for his own. Every buzz, Jamie reaches for his phone.

The two are waiting in a quiet room near the emergency department of St. Thomas Elgin General Hospital.

Jamie is falling to pieces and Dylan has brought him there to be fixed. As a former health and safety manager at the hospital, Dylan knows what to do.

He signs Jamie in as anonymous, a designation that will give him some privacy, even from police.

Jamie is wanted by police because his girlfriend withdrew herself as his surety in court on earlier charges. That means his bail conditions have been broken and there’s a bench warrant for his arrest. He will have to return to jail before a new surety can be found.

Dylan believes his friend needs psychiatric care, not a jail cell.

But what good is an anonymous designation if Jamie tells his girlfriend where he is?

At one point, Jamie goes into the bathroom and takes his phone with him.

Don’t tell her where you are, Dylan warns.

But of course, he does.

“I talked to him lots,” girlfriend Julie recalls about Saturday, Dec. 20, 2014. “I still loved him. I wanted him to get some help. I told him, I don’t want you to get arrested, I just want you to get help.”

For a few hours in the evening, she hears nothing from Jamie, Julie recalls.

Then the texts begin again. She won’t show them to a reporter, but she says this is how the conversation went:

About 12:30 a.m, from Jamie: I’m at the hospital.

Julie: For what?

Jamie: Bad thoughts. I’m on the second floor.

Julie, not believing him: Send me a photograph.

He sends a photograph of himself and a hospital door.

Jamie: I love you. I did this for you.

Some of the text messages make no sense to Julie.

Jamie: I’ve written a novel. About children.

She shakes her head at that, but she’s relieved to hear he’s in hospital.

“That’s where he needed to go. If all of this made him hit bottom and he went to get help, that’s perfect,” she says now.

“I called him. He sounded down but he sounded OK. He just sounded done, just upset, tired, done.”

What are you doing? she asks.

I’m here for at least two days, he answers.

Later on, Jamie texts something about the nurses talking about his phone conversations.

I have to go. The police are calling here. They know we’re talking.

The last time St. Thomas police officers met Jamie High, things did not go well.

They arrested him Sept. 28 after getting a call about a conflict at the home of Julie, Jamie’s girlfriend.

The account of the arrest from police, read in court by the Crown two days later, presents a picture of an annoying suspect.

After Jamie leaves Julie’s house that night, police catch up to his car about 7:11 p.m.

The driver appears confused, police report.

Are you Jamie High? An officer asks.

No, the driver answers.

Police check the licence plate, and High can overhear the call from the dispatcher confirming he is the licence holder.

Ya, that’s me, he tells police.

Police smell alcohol on his breath and note in their account, “watery, red-bloodshot, glazed eyes,”

Have you consumed any alcoholic beverages? police ask.

No, Jamie replies.

Police demand a breath test, but Jamie asks they call three friends of his on the police force and promises not to return to Julie’s house.

After officers let him call a lawyer, twice because the first is a real estate lawyer, they ask again for a roadside breath sample.

Jamie pleads again for police to call his friends.

Four times over the six minutes, officers try to get Jamie to give a proper breath sample. He stalls once, saying he’s had two beers in 20 minutes and will fail. Twice, he doesn’t seal his lips on the mouthpiece. Once, his “puffing and huffing” does not register a sample. Once, he doesn’t blow at all.

After police arrest him and put him in the cruiser, Jamie complains he is having an anxiety attack.

Police give Jamie one of the 0.5 mg clonazepam pills he is carrying with him, read him his rights and take him to police cells.

That police account, read in court, does not mention that Jamie makes officers take him to the emergency department of St. Thomas Elgin General Hospital.

According to hospital records, Jamie arrives in police custody at the emergency department at 11:52 p.m. after hyperventilating and complaining of a “sustained panic attack” when he was arrested. He tells medical staff he has a history of panic attacks and is taking clonazepam.

By the time a nurse sees him, he is calm and alert, although his blood pressure is high, 166 over 93.

“He did not smell of alcohol at this time. This gentleman was well dressed, made good eye contact and was quite comfortable in conversation,” Dr. Christopher William Hollingsworth notes in a medical report.

Jamie is given a 1 mg tablet of the anti-depressent Ativan, a lorazepam, before police take him to their cells.

There’s no suggestion police officers mishandled Jamie’s arrest, but there is talk in St. Thomas that naturally enough, they weren’t impressed by his behaviour.

Jamie may have come off as at best a whiner, at worst someone trying to play police for fools.

Now, sometime overnight Dec. 20, police find out Jamie is back at the hospital. And they have a warrant for his arrest.

How did they find out where he was?

Julie has a girlfriend who dates a St. Thomas police officer.

That officer sat with her at the court hearing, two days before Jamie checks into hospital, where she withdraws herself as his surety.

The evening Jamie checks into the hospital, Julie is spending time with that same girlfriend.

Julie insists in interviews she did not tell her friend, or the police officer that Jamie High was in hospital.

The hospital records suggest police find out through someone in contact with Jamie.

From the nursing notes starting at five minutes after midnight, now Dec. 21:

“Police called unit indicating that there was a client on our unit they were aware of that was texting someone who they are not to have contact (with) and sending pictures of the hospital to them.”

Police tell hospital staff they will call back because there is a warrant out for Jamie High and he isn’t residing where he should.

A few minutes after the first call, police call St. Thomas hospital again.

Police say “client had texted this person again threatening them saying he knew they called the police. Police indicated they would be coming to the unit to arrest this person (and) they have a warrant.”

What happens between police and hospitals and mentally ill suspects in Ontario depends not so much on policy and guidelines, but on who happens to be making the decisions at the time.

That’s the only conclusion that can be drawn from speaking to defence lawyers, a leading psychiatrist in Toronto and reading the reports prepared by researchers over the past five years.

Ontario’s policing standards manual requires police departments to develop polices on how to respond to people with mental illness and ensure officers receive appropriate training.

But there’s a lack of standardized policies across the province for the way police and hospitals interact, the province’s joint committee on mental health and justice identified in its 2011 report.

Based on surveys and input from more than two dozen community agency and police representatives, the report identified 15 concerns in how police and mental health agencies work together.

Since the 2011 report was released, there has been some progress in improving how police and hospitals in Ontario work together on mental health issues, says Uppala Chandrasekera, director of public policy for the Canadian Mental Health Association Ontario.

For example, a task force has begun creating a standard policy on the memorandums of understanding police and hospitals can create to guide interactions between officers and health care staff.

However, that task force is focusing on the much more common situation of when officers arrest someone and bring the person to hospital, not when someone is in already in hospital, she said.

And, “there remain no standards for training of police in mental health or mental health providers in policing,” she says.

“As a mental health policy expert, it is not good enough. We want to see the province put in standards for education (of police)”

The lack of standards and policies turns a key moment for someone in crisis into a matter of who is working where that particular moment, says Keli Mersereau, a defence lawyer in St. Thomas who represented Jamie a few times after his September 2014 arrest.

“There is no consistency. There is no provincial protocol,” Mersereau says. “That is very alarming.”

On occasion, she has notified police that clients wanted for arrest are in hospital for psychiatric care.

In some cases, police will simply ask for updates on the person’s treatment and discharge.

“It is usually a very insightful officer, usually a sergeant, someone who is compassionate and someone who understands the issue and people with mental health issues,” she says.

Other times, police have come into hospital and demanded a client be put into their custody, she says.

“There are some of them who don’t follow appropriate procedures and do whatever they want. With some, it is about thumping their chests and saying, ‘I am the police. You are going to jail.’ ”

Especially when police are forceful, hospital officials don’t necessarily follow their own procedures, Mersereau says.

“The other difficulty, and I’m going to speak very plainly, is that . . . when the care providers are aware the individual is in custody, the hospitals are not as interested in having that person stay in the hospital as they would someone who is not in custody. That for me is a big problem.”

By the time St. Thomas police show up to arrest Jamie High the night of Dec. 20, 2014, hospital staff are under the impression he’s been breaking the law by contacting a woman he shouldn’t.

By court order on his earlier domestic violence charges, Jamie is not allowed to have contact with his ex-wife Angie.

Angie insists she received no texts from Dec. 19 to Dec. 22, because her phone was off while on a skiing trip with her children and Jamie’s parents in New York State.

There was no court order to prevent Jamie from contacting his girlfriend, Julie.

Julie says she was receiving texts from Jamie in the hospital but there were no threats.

The apparent misunderstanding is repeated in an investigation of Jamie High’s death by the regional supervising coroner, Dr. Rick Mann.

“While settling for the night at the hospital he had apparently contacted his ex-wife against a restraining order,” states the coroner’s report, dated August 2015. “The hospital staff were informed and indicated to him that the police had been contacted by her and he was not to be getting in touch with her. It is alleged that he then contacted her again in a threatening manner, upset that she had called police.”

There may have been threatening texts to someone. But during the court hearings that followed Jamie’s arrest at the hospital, there is no mention of the texts and no mention of new charges based on those texts.

How did the misunderstanding about the texts arise? How did the belief that a man was breaking the law by threatening a woman shape how hospital staff acted?

There are many questions about how police handled the arrest of Jamie in the hospital.

The London Free Press sent St. Thomas police a list of 12 questions about the department’s general policies and guidelines for search warrants, surety revocations and suspects under psychiatric care.

Here is a selection:

  • Do officers actively search for a person on a bench warrant because of a surety revocation?
  • Or, is it more a matter of keeping an eye out for someone?
  • Do officers frequently, or as a rule, attend hospitals while searching for someone on a bench warrant for a surety revocation?
  • What are the policies and practices guiding officers arresting psychiatric patients who are under hospital care?
  • What factors are taken into consideration when taking psychiatric patients under hospital care into custody?

St. Thomas police deputy chief Jeff Driedger will answer only some questions about general policy regarding warrants, citing the need to keep the way police operate a secret.

The department provides officers training on dealing with people with mental illness and, at times, will call on the city’s community mental health crisis unit for help, Driedger says.

But, “when a bench warrant is issued, that takes away any discretion a police officer can have. There is no discretion. That person has to be arrested,” he says.

Does the person have to be taken into custody?

“If the person is in medical distress, he doesn’t have to be taken into custody at that point. The person’s well-being is first and foremost,” Driedger answers.

“Chances are very good we are going to leave the person there (in hospital) until their treatment is completed, or until medical staff say they can be released. If there are concerns of (the person) possibility getting away, we will just leave someone (an officer) there . . . as long as need be.”

At the time of his arrest, Jamie High showed no signs of “getting away” according to his medical records.

He was admitted, voluntarily, for depression and had revealed thoughts of suicide and an inability to take care of himself.

His treatment was hardly completed; it had hardly started. He had been given a few pills and his psychiatrist was to visit him the next day.

Given all that, why did police remove Jamie High from hospital?

He can’t comment on that, Driedger replies.

Police will not answer questions specific to Jamie High’s arrest, he says.

They do answer one about the case.

Did St. Thomas police review what happened in Jamie High’s case?

Yes, Driedger says.

“We are certainly satisfied at our end.”

The London Free Press sent 28 questions specific to Jamie High to St. Thomas police.

They include:

  • When and how did the St. Thomas police services receive information about this bench warrant?
  • How and when was this information shared with officers?
  • After receiving the information about the bench warrant, did St. Thomas police actively begin seeking Jamie High?
  • Did that search continue all day and overnight?
  • Did St. Thomas police check the St. Thomas General Hospital for Jamie High either Friday, Friday night, Saturday morning or Saturday afternoon?
  • How many officers searched for him?
  • How and when did St. Thomas police become aware he was at the hospital on Saturday night/Sunday morning?
  • Did an off duty police officer become aware Jamie High was in the hospital Saturday night/Sunday morning from a personal contact?
  • What information did that officer receive?
  • Did the officer receive information of threats made by Jamie High to anyone?
  • Did he/she notify on-duty police officers about his presence in hospital?
  • Did on-duty police officers receive information he was making threats to anyone?
  • Did only on-duty police officers attend the hospital?
  • How many officers attended the hospital?
  • Did officers have a warrant based on threats made by Jamie High?
  • What was the reason for arresting him and removing him from hospital?
  • Did officers make that decision at the hospital or did they get permission from superior officers on duty?
  • Did Jamie High resist arrest?
  • Was there any consideration by the officers to leave him in hospital?
  • What was physical and mental state while in police custody on Sunday?

Chapter 6: ‘He’s dead. He’s dead.’

Medical record of Jamie High
Elgin-Middlesex Detention Centre

Dec. 21, 2014
1:54 a.m.:

  • elevated heart rate (tachycardic -110 beats per minute)
  • blood pressure hypertensive (137/102)
  • upper range for normal respiratory rate (mildly tachypneic -18 breaths per minute)
  • no fever
  • acting in bizarre manner
  • placed on suicide watch

3:20 p.m.:

  • reports being cold, vomiting breakfast
  • reports off medications (Paxil 20 mg and Clonazepam 0.5 mg) for five days

Dec. 22, 2014
2:50 a.m.:

  • reports not feeling well
  • reports coming off steroids, recently drinking
  • requests Tylenol

Start of business day

  • appears in St. Thomas court
  • able to state name and age
  • duty counsel expresses concerns about him
  • justice of peace requests placement in “medical needs unit” and “assessed by proper medical staff upon return to EMDC.”

During day:

  • standing naked in his cell
  • sweating profusely

5 p.m.:

  • Seen in health car ward, reporting genital discomfort
  • anxious, unable to hold still, sweating
  • heart rate normal (92 beats per minute)
  • blood pressure 130/80
  • respiratory rate 16 beats per minute
  • symptoms attributed to Paxil withdrawal

8 p.m.:

  • receives Paxil (20 mg) for first and only time

Sometime that night or day:

  • last reported moments of coherence

Dec. 23, 2014
overnight, early morning:

  • pacing cell
  • talking to self
  • naked

8:25 a.m:

  • naked on floor beside toilet
  • making “grunty noise”
  • checked by health-care staff
  • determined to be drug withdrawal, OK to remain in cell
  • unknown if vital signs taken

8:37 a.m:

  • naked on cell floor in fetal position
  • “bubbling and incoherent”
  • small pupils
  • refuses to go to video room
  • unsteady on feet, put in wheelchair
  • placed under heavy protective gown.
  • taken to video room for court appearance

10:20 a.m.: leaning on bunk

10:30 a.m.: lying on floor

10:43 a.m.: vital signs absent, CPR begun

11:30 a.m.: pronounced dead

Sources: Coroner’s Investigation Statement, Post Mortem Examination Report

Room 9 in the mental health care wing of St. Thomas Elgin General Hospital provides a patient with privacy, a single bed with a regular mattress, and a personal bathroom with a toilet and sink.

The hospital’s website notes the “natural light,” and “state-of-the-art technology for enhanced patient safety and security.” As well, patients have a dining room, group activity area and gym connected by a walking loop.

The mental health care team includes, according to the hospital’s website, “psychiatrists, a psychologist, registered nurses, registered practical nurses, an occupational therapist, social workers, a recreational therapist and support staff, all working together to ensure the best possible mental health care.”

Cell 15 in Elgin-Middlesex Detention Centre (EMDC), in nearby London, contains a concrete bed with a thin mattress and a toilet and sink beside it.

The mental health care team at EMDC consists of a mental health care nurse, who works from 8 a.m. to 4 p.m. weekdays, and a psychiatrist on duty Tuesday and Wednesday mornings and Friday, roughly two days out of seven.

The team also includes two correctional officers with, according to testimony at inquests and interviews, limited training and limited refresher courses in the awareness and treatment of mental illness, addiction, suicide and drug withdrawal.

Five cells in the segregation unit have closed circuit cameras inside. Cell 15 only has cameras outside. Correctional officers monitor all nine cameras in segregation on one small screen. The screen is so small, they testify at an inquest, they cannot make out what is happening if all nine cameras are playing at once. So they pick and choose which cameras to monitor.

From Room 9 in the hospital to Cell 15 in the jail Jamie High is taken the early morning of Dec. 21, 2014.

Three nurses and two doctors prepare at least 35 pages of medical information about Jamie.

None of those hospital records follow Jamie to EMDC, according to court transcripts and records from the jail itself.

That is common practice at EMDC, correctional officers tell The Free Press.

It is common enough practice across the rest of Ontario that in the past 10 years, six inquests into jail deaths have raised the issue.

“This was someone who had been taken from the hospital, had been placed under arrest and taken into custody. So one would think the more information the better,” says St. Thomas lawyer Lisa Gunn, who is representing Jamie’s family.

The jail’s health care staff do their own assessment of Jamie after he arrives from hospital, at 1:54 a.m. Dec. 21.

On his admission file is noted bizarre behaviour.

“He was off, not behaving badly, just off,” a correctional officer recalls.

His heart beat is elevated, his blood pressure high at 137/102 and his breathing slightly rapid, according to EMDC medical records contained in a post-mortem report.

The coroner’s investigation statement and post-mortem examination were released to I by Jamie’s estate. Though not nearly as detailed as correctional officer logs, which will likely be available at an inquest, post-mortem provides an outline of Jamie’s condition over the next two days that forms the basis of medical information in this story.

After his health assessment, Jamie is put on suicide watch in cell 15 in the segregation unit.

On Sunday afternoon, Dec. 21, Jamie complains of being cold, of throwing up his breakfast and being off his medications.

At the jail’s health care office at 3:20 p.m., Jamie says he’s been off Paxil and Clonazepam for five days. His pharmacy is contacted and arrangements are made to get his medication.

Early Monday, Dec. 22, at 2:50 a.m., he complains he’s not feeling well, that he had been drinking and was coming off steroids. He asks for Tylenol. It’s not clear from the records when or if he gets any of the medication he request.

Later that morning Jamie appears briefly in St. Thomas court.

State your name and date of birth, he is asked.

“It’s Jamie David High,” he replies, then clears his throat to make himself clearer and louder, “and it’s October 7, 1974.”

Duty counsel Nicole Keating tells the court that Jamie was arrested on a surety revocation and needs another day to arrange one. She suggests he appear by video the next day to make it easier on him and the court.

Keating is worried. She’s briefly interviewed Jamie before the hearing. She will not provide details of that conversation to The London Free Press.

But in court, she expresses her worries.

“I am concerned in regard to his presentation today and I would ask that if you could, could you please note on the remand if he could be assessed by the medical special needs unit at Elgin-Middlesex?” she asks Justice of the Peace Robert Seneshen.

Justice Seneshen says he can’t direct an assessment by the jail.

“But I will make the request in writing on the remand that he be put in the medical-needs unit and be assessed by a proper medical staff when he returns to Elgin-Middlesex Detention Centre.”

Elgin-Middlesex Detention Centre

EMDC does not have a medical-needs unit.

In 2011, two separate inquests into the deaths of inmates at the jail recommended the province built female and male infirmaries there, with around-the-clock medical supervision.

The province agreed to have a nurse on staff for 24 hours, but rejected the idea of a separate infirmary to look after inmates needing medical attention.

The jail does have a special-needs unit with 32 beds for inmates with mental illness.

An inmate’s cell in Unit 10, which is designated for inmates with mental health issues, at the Elgin-Middlesex Detention Centre. (Craig Glover/The London Free Press)

The first day Jamie High spent in jail, there were 17 men in those 32 beds, according to figures provided by the province.

But it wouldn’t matter if every cell was empty.

The special-needs unit houses only inmates who are mentally ill, but stable, well-behaved and on their medication, says a veteran correctional officer.

Inmates who are mentally ill and acting up stay in segregation.

“Segregation is not just a simple time out in jail,” says Jacqueline Tasca, a researcher at the John Howard Society of Ontario and co-author of a report released in August called Unlocking Change: Decriminalizing Mental Health Issues in Ontario. “You are kept in a concrete room not much bigger than a closet for 23 hours of the day.”

A solitary cell at the Elgin-Middlesex Detention Centre in London. (Craig Glover/The London Free Press)

You have to eat, relieve yourself, sleep, think, wander, talk to yourself because there’s no one else there, she says.

“Segregation is especially damaging for those with pre-existing mental health issues, as it can aggravate or lead to other psychiatric symptoms,” her report notes.

“Research has shown that prolonged periods of isolation can cause a variety of negative physical and mental health effects. Hallucination, cognitive disabilities, insomnia, self-mutilation, paranoia, and suicidal tendencies are only some of the reported effects. . . . ”

In theory segregation, or solitary confinement, appears to be doomed practice in Ontario.

The federal Correctional Investigator, Howard Sapers, has been highlighting concerns about the practice for years and in March 2015, Ontario’s then-Corrections Minister Yasir Naqvi announced a review of segregation to be completed by the end of 2016.

The goal is to use segregation as a last resort, Naqvi said.

In jails crowded with mentally ill people — an estimated 30 per cent of the inmate population in Ontario — and with correctional officers under pressure to keep the peace at all times, it’s not clear yet how the province’s goal will be accomplished.

In segregation, Jamie’s condition deteriorates. He’s observed in his cell sometime after that Monday Dec. 22 court appearance “standing naked in his cell and sweating profusely,” the coroner’s investigation notes.

About 5 p.m., he asks to be transferred to the hospital because he has a surface infection.

Two nurses examine him and find nothing wrong. His vital signs are normal. But, they report him being very anxious, restless and sweaty.

The nurses determine Jamie is withdrawing from Paxil and should be given some at bedtime. The only time he gets Paxil at EMDC is about 8 p.m. that day.

Back to segregation he goes.

Correctional officers are supposed to observe and log what they see every 10 minutes in segregation.

Lawyer Lisa Gunn has obtained and read through the logs of the correctional officers on duty while Jamie was in segregation at EMDC.

“There are observations recorded. Based on what I’ve seen to date I don’t know if I have everything. I have concern about the responses I have seen already (to these observations).”

The evening of Dec. 22, the day before his final court appearance, there “appeared to be increasingly concerning and disturbing behaviour,” Gunn says.

“It doesn’t look like there was any, from what I’ve seen so far, direct interaction with him in that one overnight period leading to the court appearance in the morning. There was behaviour exhibited that the family feels was of a concerning nature that demanded more attention than it received. It did not appear to improve.”

The treatment of inmates struggling with addiction, drug withdrawal and mental illness has been the focus of dozens of coroner’s inquests into deaths in provincial corrections centres over the past 10 years.

A third of the 61 coroner’s juries that made recommendations called for improvements in treatment of addiction and drug withdrawal.

The logs and reports from correctional staff in December 2014 suggest Jamie’s deterioration was attributed to drug withdrawal, Gunn says.

“There are questions in the minds of the family — who makes the call? Who decides yes, it is just withdrawal we are not going to do anything, or who decides this needs a doctor?” Gunn says.

“And do those people understand. Presumably they have training what to look for and what to do. We have concerns that wasn’t done.”

Half of the 61 coroner’s juries over the past 10 years also called for improvements in mental health treatment.

At an inquest last year into the death of inmate Keith Patterson at EMDC in September 2014, a veteran correctional officer testified he had received little mental health training over his career.

A new correctional officer testified he had received very little mental health training at the province’s correctional officer school.

In response to a landmark 2013 Ontario human rights decision involving the solitary confinement of Christina Jahn in the Ottawa-Carleton Detention Centre, the provincial government agreed to make several changes to the mental health screening and assessment of inmates, conduct a review of psychiatric care within its facilities and improve training in mental health.

It remains to be seen how well the new strategy works.

Already there are concerns among correctional officers about the new mental health training session.

It takes about a day and half to work through a 60-page booklet and the session, says Tammy Carson, a correctional officer in Penetanguishene and the chair of the health and safety committee for corrections for the Ontario Public Services Employee Union.

“It doesn’t tell correctional officers anything they don’t already know,” she says.

Ontario is facing a “growing crisis” in the health care system inside its correctional facilities, concluded a 2016 John Howard Society of Ontario report, called Fractured Care.

“People incarcerated in provincial institutions are returning to our communities — after a short stay — with unmanaged physical and mental health conditions,” the report said.

If they get to return, of course.

“Not only are incarcerated persons more likely to have unmet health needs, but the conditions of correctional institutions have a negative impact on (their) health,” the report noted.

Inmates are sicker than the general population, the health care provided is not equal to that provided the general population, and the constant movement of staff, visitors and inmates in and out of correctional centres is creating a serious public health risk, the report said.

The report concludes there are simply not enough health care professionals, not enough planning, not enough expertise, and not enough technology used within correctional facilities.

“Without electronic records, communication regarding patient health information between correctional staff and external medical institutions is difficult and inefficient,” the report noted.

Given the difficulties inside jails, why not just send patients suffering a medical crisis to the hospital, or in Jamie’s case, back to the hospital?

Apparently, it’s not that simple.

At an inquest in 2011 into the death of Londoner Laura Straughan at EMDC, the jury recommended health care staff in jails take “stringent training” to identify when an inmate should be taken to hospital.

To that, Ontario’s corrections ministry replied that nurses already have professional training and “are responsible for ensuring they have the knowledge, skill and judgement to provide competent cares for their clients.”

At an inquest in 2015 into the death of Londoner Keith Patterson at EMDC, Linda Ogilvie, manager of health care for the Ministry of Community and Correctional Services, was asked how sick patients in Ontario jails are supposed to be treated.

“If you are sick you would be in a hospital,” she declared.

A ministry spokesperson elaborated in response to questions from The London Free Press.

“Every correctional facility has polices and procedures in place for responding to situations where an inmate is ill or in medical distress,” Andrew Morrison said in an email.

“Inmates will be taken to hospital by correctional officers whenever a further assessment of the inmate’s medical needs is required. Just like in the community, 9–1–1 is used by corrections staff for medical emergencies and, when necessary, inmates are taken by paramedics to local hospitals.”

To all the talk of policies and procedures an experienced correctional officer at EMDC scoffs.

Inmates who cover themselves in feces or wash themselves in urine, inmates naked on the floor of their cell, inmates in every kind of mental distress, he has seen it all.

None of them were taken to hospital, he says.

“It’s not a medical emergency so we can’t take them to hospital.”

It once took jail staff five weeks simply to get a man who washed himself in his own urine into court before a justice of the peace to get a transfer order to a hospital, he says.

“We’re a dumping ground for the mentally ill. All we do is throw them in segregation. ”

As midnight Monday Dec. 22 approaches, Jamie is nearing two full days segregation. “The deceased was reported to be last coherent on December 22,” the coroner’s investigation states.

Overnight and into the early morning of Dec. 23, Jamie experiences a “restless night,” the investigation says and quotes directly from correctional officers logs: “pacing, at door, at sink, at bed, at toilet, talking to self, being naked.”

Sometimes, Jamie shakes and talks nonsense. Sometimes, he lies on the floor naked.

At 8:25 a.m. Tuesday Dec. 23, Jamie is observed lying naked on floor of the cell beside the toilet and making what correctional officers call a “grunty noise.”

A nurse with a specialty in mental illness is in the area and correctional officers ask him to take a look.

The nurse believes Jamie is coming off drugs and can remain in his cell until the next cell check.

“It is not clear to me,” regional coroner Dr. Rick Mann writes in investigation statement, “if he was actually examined at that point or any vital signs taken.”

When correctional officers enter Jamie’s cell about 8:40 a.m. to take him to a video appearance for court, they find him lying naked on the floor in a fetal position “bubbling and incoherent” with small pupils.

This is the morning, Dec. 23, 2015, Jamie appears in court via video, in a wheelchair and under a heavy suicide gown.

Court is Jamie High’s last chance.

A video interview room, used by inmates that are making court appearances via video, is located just off the range in each unit at the Elgin-Middlesex Detention Centre. (Craig Glover/The London Free Press)

He will be seen by a justice of the peace, Crown counsel, his lawyer or the day’s duty counsel, other court officials and members of the public in the courtroom. Maybe someone can help.

Justice of the Peace Susan Whelan spends most of the hearing trying to understand why Jamie is not in hospital and why kind of treatment the jail offers.

“ . . . he was in a Mental Health Care wing receiving treatment for mental health care issues. . .” Whelan starts.

“This will be over in a minute OK,” a correctional officer tells Jamie.

“. . . on a voluntary basis . . . “ Whelan continues. “And he’s been removed from that facility and placed — Is there a mental health care win in the Detention Centre where he’s at?”

There is a health unit, but not a mental health unit, she’s told.

“And so there are no instructions that came with him from the hospital that we’re aware of even though he was removed from the Mental Health Care unit at the hospital. I just want to make sure I understand what happened here.”

Whelan decides to hand the matter down until someone can reach his lawyer “because I’m not sure what Mr. High’s situation is or where he should be right now.”

As Whelan talks to the correctional officers, Jamie tries to get their attention and the phone between the court and jail keeps cutting out while the loudspeaker in the jail keeps cutting in.

A television with a camera mounted on top is what inmates appearing in court via video see during the proceedings in a soundproof from located just off the range in a unit at the Elgin-Middlesex Detention Centre. (Craig Glover/The London Free Press)

Listening to the finale of the court hearing is like listening to a orchestra of competing instruments reaching a discordant cacophony.

“We’re going to stand this matter down so do you want us to call back in an hour, half an hour? What works for you?” Whelan asks the correctional officers.

“What, we’re going to run this video again?” one officer says.

“She wants to run it again,” another officer with him answers.

Jamie mumbles something.

“I don’t know if we’re going to be able to get him back here again,” one officer Whelan.

“Well he’s obviously not in a condition right now . . .” Whelan starts to say.

“What she say?” Jamie asks.

“ . . . where he’s able to communicate,” Whelan finishes.

“Ok, relax,” one officer tells Jamie.

“He’s going to be in the same condition,” the second officer tells Whelan.

“I don’t think it’ll change,” the first agrees.

“It’s not going to change,” the second says.

“That’s my concern is that he needs some type of treatment and he’s obviously not getting it where he’s at right now,” Whelan says.

“We’re — we’re a jail . . .” the second officer says.

“I understand that,” Whelan says.

The second officer continues, talking over Whelan’s voice: “. . . ma’am we don’t have much . . .”

“I understand,” she says.

“We don’t have much.”

“I understand.”

“We don’t have a psychiatrist on call, he comes . . .

High says something indiscernible.

“ . . . they come . . .” the second officer continues.

“Hold on,” the first officer tells Jamie.

“. . . on call when they can,” the second officer finishes, then talks to Jamie: “It’s OK, just take care. Promise to stay calm, OK.”

Whelan turns to Nicole Keating, duty counsel.

Whelan wants to see if there is someone, anyone, at EMDC she should be asking for to get Jamie High some help.

Keating says she’s trying to get help from the Crown’s office, direction from Jamie’s lawyer and suggests the forensic psychiatrist at EMDC assess Jamie.

“I can’t just remand him in custody for another 24 hours in the condition that he’s in,” Whelan says.

The two officers suggest that Jamie appear again at 1 p.m. when another video court is scheduled.

Keating doesn’t want to wait that long. As she protests, the correctional officers struggle with High and try to talk to him and her at the same time.

Jamie mutters, “Shut up.”

The two correctional officers tell the court they have to take Jamie back to his cell because “he’s obviously in some distress.”

“Obviously in some distress,” Whelan agrees and says she doesn’t want to wait until 1 p.m. to connect with the jail again.

“OK. Feel free to call,” the second correctional officer says.

To this day, Keating expresses concerns about what happened in the courtroom that day, especially the clashing communication between Justice of the Peace Whelan and the correctional officers at EMDC.

“The justice of the peace appeared very concerned about Mr. High’s presentation and his inability to stand up and inability to speak and give coherent instructions. She was certainly pressing for more information and more time with him,” Keating says.

“The attendant (corrections) staff was resistant to that.”

Keating says she’s never seen corrections staff address an officer of the court as they did Whelan, interrupting her, addressing her with the informal “miss.”

“I definitely felt the staff was resistant to her trying to get more information about the situation and what was going on.”

A justice of the peace has the power to order an inmate be brought into court in person, say defence lawyers.

A justice of the peace has the power to vary a person’s bail to ensure they get medical treatment.

But the justice of the peace usually relies on being asked by the Crown or a defence lawyer to make that order, defence lawyer Lisa Gunn, representing Jamie’s family says.

“We operate within in a system where there are defined roles and parameters and we try to do our best within that system but having said that there are so many moments in this situation where questions arise as to how we as a community can do better.”

Kelli Mersereau (Morris Lamont/The London Free Press)

Too much relies on who is in a courtroom on any particular day, says Keli Merserau, another veteran St. Thomas defence lawyer. She represented Jamie High when he was first charged and was in the courtroom Dec. 23, 2014 when he appeared by video.

The experience and forcefulness of the personalities of the players in the courtroom — the justice of the peace, Crown, defence counsel, police officers, corrections officer — determine how a situation will unfold, Mersereau says.

“On a different day with different players . . . Jamie would have been taken to hospital or brought into court,” she says.

“Sometimes people just don’t want to rise up and say I am going to assume charge of the situation. Because there are all those players involved and all those things in flux, no one wants to stand up and say, OK, here’s what we need to do.”

There are no protocols, no checklists, no rules in place to guide those players when an accused is in crisis, Mersereau says.

“To me it would be a wonderful protocol if in those kinds of situations, everyone involved was supposed to err on the side of caution.”

Ultimately, however, an Ontario court — including a judge — has little power over a jail. A judge can only recommend treatment for an inmate.

“The jails don’t have to act on a recommendation, which is astounding to me,” says London lawyer Kevin Egan, who represents more than 400 inmates and former inmates in a class action suit against the province over conditions at EMDC.

“I would like there to be a mandate that if a judge sentences somebody and says this is what they should get as part of their rehabilitation, it happens. Because the purpose of sentencing is not just to punish, but to rehabilitate. The mandate of the ministry is to create an environment that is conducive to rehabilitation. So they are not fulfilling their mandate and nobody seemingly has any authority to force them to.”

In the final moments of Jamie’s court appearance Dec. 23, it appears there are answers.

Duty counsel Keating brings instruction from Jamie’s lawyer to bring him to bail court the next day where a new surety will over and Jamie can be released to get treatment.

The court awaits Jamie’s return via video.

At 9:51 a.m., a supervisor, a sergeant, from EMDC appears via video and informs the justice of the peace that Jamie High is refusing to come out of his segregation cell.

“He’s acting aggressively right now so I wanted to come before you and let you know that we’ve made every effort to get him come out of his cell and he’s refusing to come out, ma’am.”

Whelan’s confused. She thinks he was in a medical-needs unit.

No, the jail sergeant says. Jamie is in segregation and on a suicide watch “being observed by health care regularly, ” the sergeant says.

Whelan decides to call Jamie High back at 9 a.m the next day, Dec. 24, in person, to allow his lawyer time to arrange a new surety or have a new bail hearing.

“But either way, he is to be brought in person here tomorrow,” Whelan declares.

By the time Whelan makes that declaration, Jamie’s family and friends have been trying to see him for three days.

Dylan Eldred wakes up Sunday morning, Dec. 21, and learns to his horror his friend has been pulled out of the hospital bed, where he left him safe and sound, and thrown into jail. He contacts the jail but gets a voice message telling him there are no visitors allowed on weekends.

Visitors must book an appointment 24 hours in advance. In order to see Jamie the next day, Monday, he would have had to book Friday.

So Dylan books the earliest available time, Tuesday afternoon.

He also calls Jamie’s lawyer and offers to become his friend’s surety.

Jamie’s girlfriend, Julie, gets a call from her lawyer Monday. Her lawyer was in court that morning and saw Jamie.

Jamie wasn’t right, her lawyer tells her. He’s saying crazy things.

Julie calls Jamie’s lawyer to see what can be done, and calls EMDC to see her boyfriend.

Tuesday’s time-slot is already booked by Dylan Eldred, so Julie has to book Wednesday’s.

Jamie’s criminal lawyer, Glen Donald, sends an associate of his firm to visit Jamie Monday evening. Donald and his staff start arranging for a new surety for Jamie.

That information comes from the hearing transcripts. Donald will not make any comments on the record about Jamie High.

When Jamie’s sister, Jessica Jackman, learns Monday her brother is in jail, she calls both Donald and jail staff. Jail staff tell her appointments must be made 24 hours in advance.

“I spent hours on the phone with lawyers, the facility, nurses and friends of Jamie’s trying to get Jamie the help he needed,” she recalls.

“I spoke with the head nurse at the nursing station at the jail and expressed my concern. I was worried Jamie was experiencing dehydration and told her he needed extra care. She assured me that Jamie was being checked on every 20 minutes. I begged her again to allow me to visit my brother but was denied.”

Asked about the denial of the visit, the Ministry of Community Safety and Correctional Services’ spokesperson, Morrison, said it would be inappropriate for the ministry to make a comment about an individual case that is the subject of a coroner’s inquest.

“Anyone wishing to visit an inmate at a provincial correctional facility is required to contact the facility to arrange a visit. Some institutions, including EMDC, provide visiting only by pre-arranged appointment,” Morrison confirmed.

Jamie’s estranged wife Angie High, her children and Jamie’s parents come back from a ski trip in New York State Monday. As soon as she crosses the border, her phone buzzes with stacked up texts and voice messages looking to land: Jamie’s in jail. He was in the hospital and now he’s in jail.

Angie High (Supplied photo)

Angie calls her victim witness counsellor and says her husband shouldn’t be in jail. What can we do? He is ill.

“They said they’d relay everything to the Crown. They didn’t know who the Crown was going to be that day.”

It’s not clear what messages were given to the Crown on Monday Dec. 22 or Tuesday Dec. 23. The court transcripts mention nothing about it.

“We all knew something was wrong,” Angie says. “We all knew that wasn’t the place for him. He told everyone if he went back there he was going to die.”

No one gets to see Jamie on time.

Dylan Eldred gets a call from EMDC about noon on Tuesday Dec. 23, the day he is to visit.

The message strikes him as odd: “Jamie High has declined your visit.”

A half hour later, Dylan gets a call from Jamie’s lawyer. Jamie’s being taken to the hospital in London.

“I think this is great, everything is good, he is going to mental health unit,” Dylan recalls.

Dylan heads to London Health Sciences Centre to see his friend.

He arrives about the same time as Jamie’s family. They’ve driven up from Dunnville, three hours away, after learning their beloved Jamie is in hospital.

By the time everyone arrives, Jamie is already dead. His body has been stored and sealed.

At 2:38 p.m., the seal is broken for the family to view his body.

Jamie High and Julie Ferguson (supplied photo)

Julie doesn’t hear about Jamie’s death until she calls Dylan shortly after 2 p.m. She wants to hear how his visit with Jamie went at the jail. Dylan calls her back an hour later.

He’s dead, Jules, he’s dead, Dylan tells her.

“I hit the floor,” Julie says.

Angie learns that morning her estranged husband is in hospital but she is under court order not to see him, so she calls everyone she can to go instead.

She waits to hear how Jamie is doing.

A few hours later, Angie gets a call from Jamie’s sister, Jessica Jackman, who is at the hospital.

That same moment a police officer knocks on her door.

Chapter 7: ‘Nothing is going to change’

The autopsy of the body of “a muscular and normally developed adult male” begins at 9:15 a.m. Christmas Eve day and continues into Christmas Day 2014.

By the time her postmortem report on the death of Jamie High is filed eight months later on Aug. 10 2015, London Health Sciences Centre staff pathologist Dr. Elena Tugaleva has also consulted police reports, medical records, documents from Elgin-Middlesex Detention Centre, photographs, toxicology tests, and witnesses or witness statements. Her 14-page summary is supplemented by 14 pages of medical test results.

Her conclusion seems straightforward to the regional supervising coroner for the West-Region London office, Dr. Rick Mann.

“The cause of death was felt to be sudden death in a man with delirium and left ventricular hypertrophy,” Mann concludes in his investigation statement, based on the post-mortem. (Left ventricular hypertrophy is thickening of the heart wall.)

“This was likely on the basis of withdrawal from Paxil, steroids or a combination thereof. The manner of death is natural.”

To his family and friends, nothing about Jamie’s death is natural.

“We, as a family, feel that the hospital, the jail and the court failed Jamie,” his parents and siblings write in an email, with increasingly expressive punctuation revealing their anger.

“There was a lack of care provided from each facility. Jamie never should have been removed from hospital. He should have been provided with care at the jail and taken to the hospital if he was in the condition we are lead to believe he was in. If he was taken to the court in a wheelchair, why was he taken back to the jail if he was that weak and unresponsive???????? Was he on IV when he was first taken to the hospital? Why was he in a straitjacket if he was so weak he couldn’t walk? HOW DID HE GO FROM THAT TO THAT????”

The regional coroner, Mann, calls Angie High at the end of August 2015 to say there will not be an inquest.

“He said he was satisfied with the information he had and didn’t deem it necessary,” Angie says.

Bound by the ethics of the coroner’s office, Mann politely declines to speak to The London Free Pressabout Jamie High’s case or any decisions his office makes.

When someone dies in custody of natural causes, there is no legal requirement in Ontario to hold an inquest. It is up the regional coroner’s discretion.

When Mann tells her there won’t be an inquest, Angie expresses shock.

The coroner asks Angie to call the rest of the family and see what they think. She calls Jamie’s parents and siblings. A devotion to Jamie overwhelms their devotion to privacy.

“I called the family and they said, ‘Yes, we want to know. There are so many loose ends.’ ”

After she talks to the family, Angie calls the coroner and requests an inquest be called.

Mann says he will consider the request.

In a letter dated Aug 25, 2015, the family’s lawyer, Lisa Gunn writes:

“I believe that there are serious issues with respect to the lack of attention to Mr. High’s medical care and treatment requirements while being held at the Elgin-Middlesex Detention Centre (EMDC) just prior to his death. Further, this is a situation where Mr. High was removed on by the Police from the Hospital where he was seeking medical and psychiatric treatment on an urgent basis and apparently prior to his discharge by the attending physician at the Hospital.”

Gunn elaborates her many concerns in an interview.

“There were so many opportunities along the way where things might have gone differently and it didn’t. We operate within a system where there are defined roles and parameters and we try to do our best within that system but having said that, there are so many moments in this situation where questions arise as to how we as a community can do better,” Gunn says.

This particular situation engages so many issues that are important.”

On the bail system:

“What happens to individuals with no criminal records who are accused of domestic violence, what bail conditions are appropriate, when is too much too much? The bail system in Ontario in terms of dealing with sureties and variations to terms and remembering that people on bail are innocent until proven guilty.”

On the authority of the court:

“Everybody says they’re concerned as Jamie is appearing in court and yet nothing is happening. Do the words of the justice of the peace mean nothing? Is it even noted in the jail file this man should be getting medical attention? Does any of it matter? Does what we say in court not matter?

I think the public needs to understand how helpless we all are, including the court, when it comes to requiring that things happen in a custodial facility.”

On help for accused:

“Bail and facing allegations in court is not only stressful for the complainants but also for the accused person. What resources are available for dealing with allegations, or what help you might need to support yourself through allegations whether in the end you are acquitted or convicted?”

On help for anyone struggling with mental illness:

“When you need urgent medical help whether for physical symptoms or mental health issues, what resources are immediately available in the community for people and do people always know where to look and when they do, do find what they need?”

On the St. Thomas Elgin General Hospital:

“One, what are the policies and protocols in place for hospital staff and doctors regarding what to do when the police show up with a warrant to arrest a patient, and two, were those policies and procedures followed? Finally, do the procedures that any of those parties have in place ensure that people, like Jamie High, are going to receive appropriate medical care and attention notwithstanding that there may be a warrant outstanding for their arrest?”

On the St. Thomas police:

“What are the policies and procedures when it comes to going to the hospital to arrest a patient who has been admitted for urgent and emergency treatment? Were those procedures followed? This isn’t unfortunately as unique as one might think. Police often track down individuals at the hospital when those individuals are seeking out medical attention. How do we balance the need for the police to discharge their duty by executing the warrant with the needs of the person subject to the warrant to receive the appropriate medical attention?”

On Elgin-Middlesex Detention Centre:

“The family is concerned regarding the level of medical care and attention he received when he was admitted to EMDC and perhaps even more so concerned regarding the lack of response to what appeared to be increasingly concerning and disturbing behaviour that he was exhibiting while in custody.”

It’s not clear what factors Mann considers while making a final decision about an inquest. In his official Investigative Statement of August 2015, he does note the family’s concerns.

In April 2016, Mann contacts Lisa Gunn and Angie High to tell them there will be an inquest after all.

“I just want to know what happened. How does a 40-year-old man go into jail on a Saturday night and is dead on Tuesday?” Angie says.

“All we know is that Jamie had been seeing a psychiatrist, he went to the hospital on his own free will saying he needed help, he was admitted to the hospital, for whatever reason he was allowed to be taken from the hospital when they could have just parked someone outside his door and not let him leave.”

In a later interview she wonders if the pain on an inquest will be worth the hope of change in a system that failed her ex-husband.

“Do you know what’s frustrating about all this is that nothing is going to change,” she says. “Why would it?”

If repetition is a sign nothing changes over time, Angie is right to question the impact of yet another inquest into a jail death.

The London Free Press examined 86 inquests into deaths in provincial adult correction centres from 2007 to 2016.

At 61 of those inquests, coroner’s juries made recommendations to prevent similar deaths.

How well are those inquests and recommendations working?

In 2007, coroner’s juries at nine inquests made 17 recommendations to improve mental and physical health care in Ontario jails. The recommendations focused on better screening for mental health, suicide and addiction, better training of staff in mental health, suicide and addiction awareness and prevention, better communication among corrections staff about inmate’s medical conditions and needs, better communication between jails and outside agencies and institutions about an inmate’s medical conditions and needs, and better access to medical treatment.

In 2016, so far, coroner’s juries at five inquests have made 18 recommendations that are the same as or similar to those made 10 years ago.

Time and time again over the past 10 years, coroner’s juries have identified gaps in training, screening and awareness of mental health and addiction issues in correction centres, as well as in monitoring and treatment of patients suffering both mental and physical illnesses.

The total number of those recommendations is 181.

The province of Ontario has no obligation to implement any of them.

“The recommendations unfortunately have very few teeth,” says London lawyer Kevin Egan. “The province can just dismiss them out of hand, and it is answerable to no one.”

That is just one of the problems with the inquest system in the province, says Egan, who has represented two families at custody death inquests the past six years, and is one of the lawyers at McKenzie Lake in London taking on the province over conditions at EMDC in a $325 million class action suit involving inmates and former inmates.

The timing alone of inquests causes problems for families, Egan says.

“One of the principal concerns is that it’s not done on a timely basis. Generally speaking you are several years out from the event before there is any kind of inquest and so the family is left bereft of any information about what happened to their loved one. That is one of the toughest aspects of it.”

Lawyers face their own tough aspects.

“The system itself is tainted,” Egan charges.

The coroner is an employee of the the Ministry of Community Safety and Correctional Services.

The jails in the province are operated by the same Ministry of Community Safety and Correctional Services, he notes.

“I think there is a reasonable apprehension of bias when the coroner is an employee of the same ministry that is running the institution,” Egan says.

Before an inquest, and without input from lawyers who have official standing by representing other parties — such as the family, or police or corrections officers — the coroner and the Crown meet and set the inquest’s scope, he says.

The Crown has a special standing at an inquest, leading the evidence and addressing the jury last when it comes time to suggest recommendations, Egan adds.

Reporters who attend many inquests — I am one — are used to seeing the Crown and other lawyers lock horns over what evidence can be admitted, what questions can be asked and the extent and depth of recommendations the jury is asked to consider.

“The Crown is a employee of the province, and that ministry (of the Attorney General) would respond to any civil claim that might follow the inquest,” Egan says. “I think it tends to erode people’s confidence in the process. It should be a more open opportunity to get to the facts. It’s a frustrating system.”

An inquest offers a family both relief and pain.

“I think that for most people it is cathartic, it helps somewhat. But it would be much more so if the inquest came earlier in time, and if the families felt that the process was fair and not designed to protect people, or the ministry,” Egan says.

“It’s a painful thing to got through and publicly hear for the first time what happened. It’s extremely painful.”

The family and friends of Jamie High will spend the next few weeks bracing for more pain.

The coroner’s inquest is set to begin Nov. 7 in London.

For two years, Angie has sought answers about her husband’s death; at the same time trying to keep her children from hearing too much.

“I want to be a good mom,” Angie says. “I want to protect our kids. I want them to remember their dad in a good light.”

The inquest and accompanying media coverage threaten the balancing act she’s performed.

With 20 witnesses scheduled to testify over five days, the inquest will answer some of her questions.

But those answers may include details about Jamie’s last days that are harsher than those revealed in this series, and suddenly much more public.

In this photo published Dec. 27, 2007 in the St. Thomas Times-Journal, Angie and Jamie High celebrate the birth of their son on Christmas Day in St. Thomas Elgin General Hospital. (Supplied photo)

Chapter 8: Last Words

Well known in life, Jamie High is a secret in death.

His name is not released to the media when he dies.

The London Free Press story the day after he dies offers few details:

“Another inmate has died at London’s provincial jail, but there wasn’t any sign of foul play and the cause of death remains unknown.

Police were called at 10:45 a.m. Tuesday and found an ‘unresponsive male,’ who was pronounced dead at hospital later, London Const. Ken Steeves said.

‘There’s no indication at this time that foul play is suspected. This is now a coroner’s investigation,’ he said. “We’re assisting the coroner.’ ”

Yasir Naqvi, minister of Community Safety and Correctional Services, said the safety and security of jail staff and inmates is a top priority.

“I am saddened to learn of the passing of an inmate at the Elgin-Middlesex Detention Centre, and my thoughts and condolences are with the family and the loved ones of the deceased,” he said in an email statement.

It takes five hours after Jamie’s death and a flurry of emails within the Ministry of Community Safety and Correctional Services to prepare and release Naqvi’s statement. The superintendent of Elgin-Middlesex Detention Centre (EMDC), David Wilson, learns about the death from an emails sent at 11:40 and 11:48 a.m.

To which, Wilson replies: U got to be kidding me.

The emails reveal nothing about the death itself and only a bit about the response of the ministry and the jail itself. The ministry’s own correctional oversight team is assigned to launch an investigation. The response of media to the story is tracked. Questions about the number of cameras in the cells are answered.

At 6:17 p.m, Dec. 23, the end of the busy day, Paul Lipke, the deputy superintendent at EMDC emails three colleagues.

“Once again Gentlemen nice team work by all.”

Within a day and Christmas coming, the death at EMDC is no longer news. The dichotomy that runs through Jamie’s life — a private man and a very public man — continues in his death. His family says a quiet goodbye by themselves, then hold a celebration of his life.

Jamie High, early high school (supplied photo)

At that celebration Sunday Dec. 28 2014, the line stretches out of the Royal Canadian Legion in Dunnville and around the block, family and old high school buddies and girlfriends in a small town where everyone knows everyone, and the many people Jamie has befriended in the years and places since he moved away.

(Read Jamie High’s Obituary here).

The family clamps down on any rumours, so much so that months later, some friends from Dunnville still do not know Jamie died in a jail.

“We made a decision as a family at that time, not knowing what all this was going to lead to, we don’t want to tarnish him in any way because we knew the way he was acting wasn’t the guy that we knew,” Angie High says.

“He’d always been a stand-up guy and very well loved and liked and . . . first and foremost we just didn’t want the kids to hear anything negative about their dad.”

At the memorial service, Jamie’s business partner and friend Scott Jarvis meets Jamie’s parents and he has heard so much about them, it feels like he already knows them. He holds the hand of Jamie’s father for a long, long time.

“It was just terrible, the saddest day,” he says. “To not have answers drives you nuts. It’s just a hole, a hole in my world. ”

There are holes everywhere.

“When this happened I pulled his jersey out of the rotation. I didn’t know what to do with it,” says Steve McVittie, organizer of the Friday Afternoon Classic: Bruins Vs. Flyers hockey league, in which Jamie played.

The Midtown Tavern in St. Thomas, where the players sometime go for beers, hangs Jamie’s number 9 Johnny Bucyk Bruins’ jersey and some photographs of Jamie for the rest of the season. The players wear a black patch with the initials JH for the rest of the season.

At the end of the season party, Steve takes the display down and gives it to Angie.

Friends call this photograph ‘Classic Jamie.’ (supplied photo)

Two weeks after the end-of-the-season party, Steve organizes a tribute night at the bar to raise money for Jamie’s children.

The children don’t really need a fundraiser as much as his friends need to feel they are doing something.

Many months after High’s death, Steve says he thinks every day about his friend and how they have all been cheated.

“He wasn’t my best friend or my only friend but we were close. I have a big hole. Now what?” he says.

“What the hell happened. He had the world by the tail. How does this happen?”

The next hockey season, 2015/2016, the fronts of the players’ jerseys on both teams carry the initials JH.

One of Jamie’s best friends, Dylan Eldred, wears the number 9 Johnny Bucyk jersey.

A few days after Jamie’s death, Dylan takes Angie and Jamie’s sister Jessica Jackman, to the motel and the apartment where Jamie stayed. On the couch of the apartment is a blanket Jamie huddled under.

“I went to the apartment where Jamie briefly stayed because I felt like I would find a piece of him there,” Jessica explains months later in an email. “I was searching for an answer to the most confusing and upsetting question of my life — what happened to my big brother?! The only thing I found in the apartment was the last blanket my brother laid his head on. I will continue to search for answers.”

Shattered, Jessica and the rest of the family take almost a year after Jamie’s death before reluctantly agreeing to meet me. She, her brother Jason, mother Joanne and father David agree to a conversation in October 2015 in the office of St. Thomas lawyer Lisa Gunn.

The conversation is off the record as they struggle for an hour and half trying to decide if they want to say anything on the record at all. Anger, tears, doubt, fear, distrust tinge the negotiations, yet they remain courteous and even warm, at times. In the end, they agree they will consider questions by email. They will answer as one.

“We, as a family, have collectively decided to answer these questions about Jamie,” they write back in an email. “We have always been a close-knit family holding the utmost respect, love and friendship toward each other. We have been each other’s rocks throughout this nightmare and will remain having each others backs while we try to grieve and get through losing our best friend.”

The email comes from his sister Jessica Jackman. She answers a few followup questions, but the family makes it clear there is no point trying for a phone interview, never mind an on-the-record conversation in person.

Dylan will not stop talking about Jamie, not for a year at least. For a year, he will meet whenever asked to talk about Jamie.

“Somebody has to be his voice. He was the best guy you will ever meet. His perfect life became a perfect nightmare,” he says.

He takes me to the motel where Jamie stayed two nights, the apartment where Jamie stayed on the couch the morning before going to the hospital, and the hospital itself where he shows the window to the room where Jamie waited for an assessment.

“I’ve been trying to make sense of it,” he says in an early interview. “It seems it went wrong is so many different ways when the guy just wanted help and needed help. How do we prevent if you or I, if we have a meltdown, and we get sent to jail and end up dead?”

Dylan feels helpless.

“It is weighing me down trying to figure things out,” he says. So he gets shirts made with a silhouette of a body builder and the words Reps for Jamie, and sells them to friends.

On Oct. 7, 2015 Jamie’s birthday, Dylan puts on one of the workout shirts and heads to the gym before work. He does Jamie’s favourite routine, especially the bench press.

“The hospital fell apart, the police fell apart, the jail fell apart, even the justices of the peace fell apart. Anyone of those could have helped him but they didn’t.”

As 2015 turns into 2016, Dylan becomes less willing to meet and talk about Jamie.

Finally, he decides he wants to move on. What else is there to say?

Julie knows people blame her. She broke up the marriage, people will say. She became his surety and pulled it. She was talking to him the night he was taken from hospital and put in a jail cell. His friends won’t talk to her now, Julie says. His family never did.

“Trust the system, everyone said. OK, that is why I pulled the surety, trust the system. He gets put in the hospital and I am so relieved. The hospital is supposed to keep him safe. That is the point of a hospital, especially the psych ward,” Julie says.

“He’s delusional in court, why did no one get him help? He continues to go downhill and they still don’t get him help. He’s in a wheelchair, he’s drooling, he can’t talk. And then nobody gets him help? They just put him back in a cell. How many professionals saw him the last days before he died and did nothing for him? They just neglected him. Everyone did.”

How do you move on?

“I don’t know,” she says in a quiet voice and cries. “I don’t know.”

Julie agrees to be interviewed once at her home in St. Thomas, and once in an office in the newspaper, where she listens to a tape recording of Jamie’s final court appearance.

“I couldn’t tell you how many thoughts I have in my head every day because I can’t figure it out. I’ll never know,” she says.

There are some holes in the story of Jamie High only Julie can fill. As the months pass, she texts now and then, but declines any more requests for interviews.

Angie High meets for the first few times in the presence of lawyer Lisa Gunn and the initial long conversations are all off the record.

She goes back to work a few months after his death.

“I’m a sales rep, so I have to do this,” she says, showing a smile, “every day. You just take the day as it comes.”

As the year passes, she makes do. She learns to drive the boat Jamie bought the family. She makes sure the regular family scramble of school, sports, vacations, visits to Dunnville continues.

Over time, she agrees to meet and talk now and then on neutral ground, a south-end London restaurant.

She speaks in a warm timbre, and often as she talks about Jamie, the outgoing girl who was prom queen and joined just about every club in high school comes to the surface. She is open about the love they shared, the struggles they endured.

But around the subject of her children, Angie erects a wall. She never offers to meet in the family home. She is adamant her children’s names and photographs not appear in print. Out of respect for her wishes, The London Free Press does not take a photograph of the home where she and the children live. She refuses to appear on a video or allow audio recordings of her interviews to be broadcast online. She worries about what she reveals.

She worries what Jamie might think about all this attention.

“Jamie always liked to hold his cards close to his chest,” she says.

Perhaps, then, he would have appreciated the difficulties in bringing this story to light.

It takes weeks after his death for his name to leak out.

It takes one month to arrange the initial interviews with his wife and his friends and his girlfriend.

It takes nine months to persuade his family to meet and weeks after to get the emailed set of comments and answers.

It takes even more time to obtain his health records and autopsy report, and for lawyer Lisa Gunn to obtain his jail records.

It takes more than a year for a Freedom of Information request to be processed and most of the details about Jamie’s stay in jail are blanked out.

This story has taken so long it has taken on uneasy status in my newsroom.

Each day an electronic version of every reporters’ assignments is emailed out. Off and on, for two years, the assignment “jail guy” appears on my schedule.

It’s appeared and disappeared and re-appeared so often, other reporters have long given up teasing or asking me about it.

Jamie’s name does not appear on the assignment. It does not seem right until his story is ready to be told.

The words “jail guy” has appeared on the schedule so often, and this story has taken so long to write I’m no longer sure it is worth writing anymore.

And now, there is going to be an inquest, starting Nov. 7.

It’s a bit unusual for a news organization to publish a series only days before an inquest examines the same or some of the same issues.

The five-day inquest is expected to hear from 20 witness. People who refused to speak or felt they could not speak to a reporter about Jamie’s case will have to explain their role in his death at the inquest.

But an inquest is limited in scope. It will likely not tell the entire story either.

This series has raised a range of questions about Ontario’s justice, corrections and mental health care system that are beyond what any one inquest can answer. The series has given The London Free Press a map of problems in Ontario to follow for years, including:

  • A bail system that puts people under the strictest rules first, and under conditions that will set them up to fail.
  • A mentality among police forces, in part directed by the province, to hold men accused of domestic violence in jail and thereby in the bail system, regardless of the nature of the charges.
  • A lack of help for accused men seeking help to change their behaviour.
  • A lack of help for anyone seeking help for mental illness.
  • A lack of provincial standards and training guiding police when dealing with mentally ill suspects, especially in hospital care.
  • A lack of provincial standards and training for hospitals when treating a suspect wanted by police.
  • The ongoing and persistent failure of correctional facilities to help people with addictions and mental illness.
  • The persistent failure of the province to recognize correctional facilities cannot ever fully help those with mental illness, especially when segregation is used for treatment.
  • The inability of the courts to direct correctional centres to help, and truly rehabilitate inmates.
  • The reliance on personalities of those involved, not policies, for courts to direct what happens to mentally or physically fragile accused.
  • The concerns about the independence and effectiveness of coroner’s inquests, the recommendations from which the provincial government need not follow.

Here is what I wrote in an email to Jamie’s mother, father, sister and brother a full year ago when I tried to explain why I wanted to interview them.

“Jamie High was a deeply loved, very successful and much admired father, husband, brother and son with a strong network of loving family and friends.

He took a step off his path and had some struggles.

Instead of getting the proper help for those struggles, he ended up in court, jail, hospital and jail again.

Somehow this man, so loved, so strong, so successful, died alone in a jail cell.

How in the world did this happen? How can we stop it from happening to someone else? Because if a Jamie High can get caught in the system and die like this, so can anyone.

His death raises serious questions and concerns about how he, and others, are treated by the institutions and agencies that are supposed to help.

His death left a hole in the lives of many people, who want answers.”

Then I added:

“You might wonder why I am doing this story, and given some of the challenges, I have wondered that myself.

It would have been easier to let it go and do nothing.

But there is something about your son and brother, and the love he collected, that has driven me. I can’t really explain it, but there it is. Perhaps you all understand that more than anyone.”

The reason The Free Press and I have been driven to tell Jamie’s story, and stick with it, is because he never should have had a story like this.

He never should have been “jail guy.”

He should have had the chance to become, at least, some guy who had some trouble once and got some help and moved on.

He should have had the chance to become again some guy you played hockey with, or saw in a gym, or met in a bar watching football and liked because of his cockiness or didn’t like because of his cockiness, maybe a good friend, or a business partner, maybe your brother, or son, or husband, or ex-husband, boyfriend or ex-boyfriend, or father.

Jamie’s last days should not have been spent naked and alone on the floor of a jail cell.

His last words should not have been incoherent mutterings.

He never should have had a story written about him called Indiscernible.

No one should.


We, as a family, have collectively decided to answer these questions about Jamie. We have always been a close-knit family holding the utmost respect, love and friendship toward each other. We have been each other’s rocks throughout this nightmare and will remain having each others backs while we try to grieve and get through losing our best friend.

We remember everything great about Jamie:

He had the ability to light up any room he entered whether it was full of friends and family, colleagues or complete strangers. He had the unique ability to capture everyone with a simple glance, smile or joke. People were naturally drawn to him and were quickly addicted to his warmth, his sense of humour, his fun and energetic personality.

We, as a family, were in love with him. We all looked up to him and shared many sacred secrets and memories with him. We loved everything about him. He was the funniest guy you could ever meet. His ability to protect us, especially his children, was remarkable. He was the best big brother in the world. As a child, he tucked me in at night and told me bedtimes stories, even if he had a handful of friends waiting to hang out with him. He spent every Sunday watching football with Jay and their boys and communicating long distance with Steve over their latest fantasy football players.

As a child he loved playing hockey and baseball. He used to bring home as many kids from his hockey team as he possibly could. They would spend the entire weekend playing pond hockey outdoors or ball hockey in the basement.

We had so many incredible memories together. He loved paintball so much he designed a paintball course in mom and dad’s backyard and gathered people from the community to play each week.

We were together, all of us, not only on holidays but on every weekend we possibly could. We didn’t take time or our relationships for granted. We would propose toasts to tell each other how much we loved each other every single time we were together. We always showed gratitude to our family who we considered more as friends.

All we did was laugh. We had so much fun together as a family. Every year Jamie, Jason and I would sleep together on Christmas eve, anxiously awaiting Santa’s arrival. I think Angie felt weird the first Christmas we invited her to sleep with the three of us on Christmas Eve but she quickly settled into the tradition, just like she quickly settled into being our sister and daughter. Our yearly annual cottage trips were always adventurous and entertaining and always brought us together, regardless of where we were living in the world. Our weekend kitchen dance parties where always packed full of karaoke singing, dancing and lots of fun. We travelled extensively as a family- trips to BC and Mexico were annual, Nicaragua, Galapagos islands, Ecuador, Bahamas, Jamaica, Buffalo football games as well as countless travelling throughout North America.

What did everyone love most about Jamie:

Jamie had a huge heart. He was often described as the man who was so compassionate he sometimes cared more about others than he did about himself. He was always worried about everyone and treated others with respect. He was fun, kind, witty, hilarious, energetic and the master of one-liners. He always came equipped with the best hugs in the world and was one hell of a cook.

Originally published by The London Free Press at

For coverage of the coroner’s inquest into Jamie High’s death, look here:


There are small moments during inquests that do not make it into newspaper stories.

Two nurses who testified at the inquest into the death of Jamie High walked into the hallway afterward and, with tears flowing, hugged members of his family.

After the inquest was over, some members of the coroner’s jury made a point of walking out of their way to the family and expressing their sorrow.

If nothing else, that inquest showed High’s family that ordinary people cared.

It remains to be seen if the province’s leaders do.

As part of this newspaper’s commitment to continue exploring the issues raised by the death of High — first highlighted in a London Free Press series called Indiscernible — we’re providing an analysis of that inquest.

Here’s what we learned, what issues and questions were raised, what questions remain unanswered, and where repair work is needed. (This analysis and a summary of inquest testimony that fills in some gaps of the story appears online at

— — — — — -

An early misstep:

The inquest did not explore, as did our series, problems in Ontario’s bail system.

But the inquest did obliquely touch on bail, a starting point for High’s decline.

On Oct. 17, 2014, High told psychiatrist Dr. Giuseppe Guaiana he was drinking up to four times daily. But at some point afterward, High called the doctor’s office, said drinking was not a problem and asked that to be rectified on his record.

At a Dec. 1 follow-up meeting, High told Guaiana he drank less than first reported and hadn’t had a drink since Sept. 30. Guaiana believed him.

The change in his story in October should have been a clue there was something wrong, testified an alcoholism expert, Dr. Jeff Turnbull.

Medical professionals must be highly suspicious of the stories people say about their alcohol abuse, Turnbull said.

The belief High did not drink to excess, reinforced at times by his own contradictory statements, played a key role in his death.

Sept. 30 was when High was put on bail conditions not to drink, after being arrested for failing to provide a breath sample and for domestic assault.

Bail experts in Ontario note that requiring an addicted person to immediately stop, without any help, is unreasonable, sets up people to fail and forces them to lie.

The bail system surfaced at another point in the inquest. St. Thomas police Const. Steve Bogart testified that police had to weigh the fact High was on a form of release, a surety, when they found him in a mental health care unit.

Bail experts say Ontario’s over-reliance on that form of bail release causes all kinds of problems for accused people that often sends them back to jail.

The province’s Ministry of the Attorney General is expected to release a review of bail in Ontario by the end of this year.


At the hospital: Communication lapses.

High smelled of alcohol when his friend brought him to the hospital, that friend, Dylan Eldred, said.

But High told nurse Amanda Hindley several hours later he did not drink and she did not think he was under the influence.

The same medication hospital staff gave to High for anxiety likely masked early symptoms of alcohol withdrawal without being in large enough doses to actually ease that withdrawal, Dr. Turnbull testified.

In any case, it would have been difficult to diagnose at that point.

However, the inquest testimony did raise concerns, also expressed in the Free Press series, about communication and policies at St. Thomas Elgin General Hospital.

When releasing a patient to police, the physician in charge must be contacted.

Nurse Amanda Hindley testified she felt rushed by police, and was buzzing them and High out the door as she called the psychiatrist on call, High’s own doctor, Guaiana, to get a discharge.

That discharge came after police removed High from the unit, and Guaiana testified it was an administrative procedure.


The medical trail: There wasn’t one.

Nurse Hindley says she told police High needed treatment and offered a list of his medications. She also told police he was a voluntary patient.

The two arresting officers told a different story. Sgt. Jeremy Lapadat said his partner, Const. Steve Bogart, spoke to the nurse. Bogart said he didn’t talk to the nurse at all.

The inquest confirmed the suspicion raised in the Free Press series that no medical information went with High to police or to EMDC.


Police: Arrest first, ask nothing later

St. Thomas police have policies requiring police to pay attention to a person’s medical history, medications, mental state, suicidal tendencies, depression or euphoria and possible drug or alcohol use when making an arrest.

There was little consideration of High’s mental health when police arrested him.

Sgt. Lapadat testified High was in the mental health unit on a voluntary basis and was steady on his feet.

“He was likely there to get counselling the next day,” he said.

Const. Bogart testified, “I didn’t know what level of assistance he was seeking.”

A more important consideration for police: High was arrested on charges of domestic violence and his girlfriend had removed herself as his surety.

In order to protect his ex-wife and girlfriend, and even himself, it was necessary to bring him into custody, Lapadat said.

Unanswered at the inquest were questions about the decision by superiors to send two officers to the hospital, and questions about how everyone got the impression High was somehow threatening someone.

In none of the testimony was there any proof High was threatening his girlfriend.

The officers at St. Thomas police headquarters who received information High was in hospital, and who made the call to arrest him, were not called to testify.


Health care in jail: Overwhelmed, understaffed and undertrained

It was confirmed that no one at EMDC in health care received information about High’s medical condition or medications from the hospital or police when he arrived at the jail shortly after 1 a.m. Dec. 21.

In order to get records, EMDC staff would have to wait until Monday, Dec. 22, to request his records — and only with his consent.

At one point, a nurse had to check on High by talking to him through the meal hatchway of a cell door because there wasn’t enough correctional staff to allow him to go to the nursing station.

A mental health care nurse testified he couldn’t give High the attention he deserved because understaffing forced him to spend his days filling prescriptions rather than helping inmates.

High told nurses he did not drink and, as a result, was not given an assessment for alcohol withdrawal. At one point, he sarcastically told a nurse he did drink, raising her concern.

That nurse flagged alcohol abuse for a doctor’s appointment High was to have on Monday, Dec. 22. Because High had to go to court, and spent the day in courthouse cells, he missed the appointment.

Nurses testified they had little training in alcohol withdrawal management.

At the same time, the institution was short one doctor for several months. The inquest heard that few doctors in the London area want to help out at EMDC.


Courthouse appearance: Chance to live.

When High appeared delirious via video in a St. Thomas court hearing Dec. 23, 2014, he still had a chance to live.

“A transfer (to hospital) might have changed this outcome,” testified alcohol withdrawal expert Dr. Turnbull.

Issues raised:

  • The inquest skipped over the role of the court and court officials in overseeing the health care, rehabilitation and treatment in custody of individuals.
  • There was no suggestion at the inquest that court officers take training in recognizing signs of withdrawal, or in mental health awareness.


Correctional staff: Overwhelmed and understaffed

The inquest reiterated the lunacy of using a segregation unit, staffed by correctional officers, as an infirmary for mentally ill inmates.

Among the many problems raised in the inquest, some highlighted as well in the series:

  • The camera system in segregation, which monitors only some of the 15 cells, remains in place today.
  • Correctional officers have little training in recognizing drug and alcohol withdrawal, or mental illness.
  • The unit faces staffing problems that can prevent direct aid to inmates.
  • Officers often work with only basic information about the health of inmates, usually provided verbally by health care staff
  • Communication within the unit itself has gaps. An overnight crew told one officer on a morning shift that High had slept through the night. A glance at the overnight logs would have told him a much different story.
  • The inquest provided harrowing details about the last hours of High’s life, after he returned from video court shortly after 9 a.m. Dec. 23. Nine of the 15 inmates were on suicide watch and two were trying to cover their cell windows and were threatening to harm themselves. One of the standard three officers on duty was called away for other business, and one had to take a break. That left correctional officer Matt Hopkins alone in a crisis and unable to go into High’s cell when he noticed High on the floor and unresponsive at 10:30 a.m.
  • Only when one officer returned, were they able to go into the cell. High was found lifeless on the floor at 10:43 a.m.


Does anyone really understand mental illness yet?

That question has to be asked because of testimony by medical and police officials.

Dr. Guaiana testified he had some “generic concern” about High being taken away from hospital care to police custody. On the other hand, High was not suicidal and he was “medically stable.” He was not “extremely concerned.” Observation in a jail’s medical facilities should be good enough, he thought.

Nurse Hindley also believed it would not be detrimental to High to leave the hospital and go into custody for up to a week because he had been cleared physically by the emergency room doctor, had suicidal thoughts but reasons to live as well. The fact he was a voluntary patient indicated he was not a risk to himself or others.

The arresting officers believed he might be a risk to others because he was a voluntary patient and could leave at any point. But they also believed High would be fine because he was “medically cleared” and showing no signs of stress.

It became apparent that ‘medically cleared’ refers only to a person’s physical health, but not mental health.


The inquest itself: Some catches, some misses:

The inquest jury asked dozens of relevant questions and made some strong recommendations.

But as can only be expected of five people faced with a myriad of concerns, key witnesses missing and direction to offer concrete suggestions, some opportunities for recommendations were missed.

The jury directed St. Thomas police, the hospital and the jail to develop a plan for safe transfers of patients.

But there were no recommendations to:

  • Improve the training of hospital staff in the policies around patient transfers to police, or in ways to reinforce those policies.
  • Ensure hospital staff are up to date on recognizing signs of alcohol withdrawal.
  • Improve the training and ensure awareness of St. Thomas police in mental health and addiction issues.

The coroner’s jury did make 12 recommendations to improve health care at EMDC.

There has been much media attention lately on the issue of segregation, or solitary confinement, and rightly so. The damage caused by the practice is well researched and well known, and the province appears committed to at least looking at putting money into infrastructure to reduce the need for segregation.

But there’s a danger of simplifying the problem by labelling it as only one of segregation, and thinking if segregation is reduced, problems will go away.

Accompanying more space or more beds or more correctional officers, must be more health care staff, more health care training, better health care record-keeping — in effect, a total change in how inmates in Ontario are medically treated.

Aside from this inquest, over the past 10 years in Ontario, coroner’s juries have made 181 recommendations to fill gaps in mental and physical health care of inmates.

Little has changed.

It’s clear it will take more than a series and more than an inquest to effect the necessary changes in Ontario’s health care and justice systems.

The key question raised by both The Free Press and the coroner’s inquest remains the same: Which politicians, opposition critics or otherwise, and which advocates and provincial leaders will take on the task of forcing change?

— — — — — -



— — — — — -


  • Jamie High was a 40-year-old successful realtor and father of two who struggled with mental illness and alcoholism. His marriage broke apart in July 2014 and he moved in with his girlfriend in St. Thomas.
  • In September 2014, he had an argument with his girlfriend and police were called. They spotted him driving away and requested a breath sample. He did not comply, and after his arrest police called his estranged wife and charged High with two counts of domestic assault.
  • High was released from jail from those charges on conditions he no longer drink, and was eventually under the supervision of his girlfriend as his surety.
  • He continued to struggle and saw a psychiatrist for help. On Dec. 19, 2014, his girlfriend removed herself as his surety, meaning police had a bench warrant for his arrest by breaking his bail conditions.
  • On Dec. 20, 2014, a friend took him to St. Thomas Elgin General Hospital where he checked in voluntarily to the mental health ward, suffering suicidal thoughts, anxiety and depression.
  • Early the morning of Dec. 21, police told hospital staff he was illegally texting someone and arrested him for breaching his bail conditions.
  • Police took him to Elgin-Middlesex Detention Centre (EMDC), the provincial jail in London, where he was kept in segregation.
  • He was found lifeless in his cell Dec. 23, 2014, and was declared dead at the London Health Sciences Centre at 11:30 a.m.
  • A coroner’s inquest from Nov. 7 to 11, 2016, focused on his time in hospital, his removal from hospital to jail and his rapid deterioration in jail.
  • The inquest determined High died from delirium as a result of alcohol withdrawal, complicated by an enlarged heart chamber.
  • His death was preventable, two expert witnesses concluded.


Testimony at the inquest also provided some new details about the last three days of Jamie’s life.

Here is a summary of that updated information for readers.

Dec. 20/21, 2014

At St. Thomas Elgin General Hospital.

Mental health nurse Lisa Medeiros and emergency room Dr. Terry Evans did not testify.

Mental health nurse Amanda Hindley, who transferred Jamie to police custody, did testify.

“He seemed sad. He had some worries about Christmas but he wanted to be there and wanted help,” she said.

By 10 p.m. he was asleep in room 9 in the mental health care unit.

Hindley got a call from St. Thomas police after midnight that she saw as a “friendly heads up” that someone on the unit was texting someone they shouldn’t.

She suspected Jamie and called her manager, whom she noted as Doris on her notes but whose name was actually Delores.

The second call from police gave her the impression police believed Jamie was threatening someone he knew. That texting didn’t stop so they were coming with a warrant.

The lights were off and Jamie was in bed when police arrived. He was calm and cooperative and dressed before walking on his own.

Hindley testified that she told police Jamie had thoughts of suicide and needed treatment, and offered a list of his medications. Police did not take her up on that, she said.

But she also said she didn’t feel it was detrimental to Jamie for police to take him. Because he had not been admitted involuntarily under a Mental Health Act Form 1, he had been medically cleared and was not a risk to himself or others.

Hindley testified she felt rushed by police and wished she’d had more time to call the psychiatrist on call, Dr Dr. Giuseppe Guaiana.

Hospital policy required a call to him before a patient was discharged.

“I’m dialing the phone (to Guaiana) as I’m leeting them (police) out the unit,” she said.

Guaiana testified at the inquest that he was told about that removal and wrote up an official discharge only after High had already left.

“Before he leaves, he should be discharged by a physician, correct?” Lisa Gunn, the family acting for the High family, said.

“That’s correct,” Guaiana replied.

“That physician should assess him before he leaves, correct?,” Gunn continued.

“Correct,” Guaiana said.

The hospital has written policies stating that if police want to arrest someone and remove him from hospital, the staff must contact both the most responsible physician — on this night Guaiana — and a director or administrator in charge, Gunn noted.

“The policy . . . doesn’t specify if this is before or after the patient leaves,” Guaiana said.

“Well, let’s sort of apply some common sense to the policy here,” Gunn said. “If law enforcement wants to remove the patient from the hospital, they must notify the most responsible physician and the director or administrator on call. That doesn’t say after it happens.”

Guaiana testified he was surprised to learn High, whom he’d seen as an outpatient Oct. 17 and Dec. 1, was in hospital.

Guaiana also said he was not concerned about the transfer from hospital because High was not suicidal, in stable medical condition and heading to jail, where there would adequate medical services and constant observation.

St. Thomas police department

The officers who received the tip that Jamie was in hospital, who directed his arrest, and may have given nurse Hindley the inaccurate belief Jamie was texting someone he shouldn’t be did not testify.

Sgt. Jeremy Lapadat testified he arrived at hospital at 12:46 a.m. Dec. 21 under orders to arrest Jamie. His supervising officer told him the tip Jamie was in hospital came from Jamie’s girlfriend (Julie Ferguson), Lapadat testified.

Lapadat and Const. Steve Bogart arrested Jamie at 12:51 a.m., and by 1:01 a.m., were back in the police cruiser.

Jamie was quiet but articulate. He was handcuffed with his hands in front of him because he was cooperative.

Because Jamie was in on a voluntary basis, Lapadad no concerns about Jamie’s state of health. He was aware of St. Thomas police policies requiring extra care with persons suffering from addiction or mental health issues, Lapadat said.

But Jamie was there likely for counselling the next day and seemed fine, Lapadat said.

As well, Lapadat said, he was worried because Jamie had been charged with domestic violence. He could check himself out at any time and was a potential risk to his “original victim” (Angie High), his girlfriend and himself.

He had no conversation with any nurse, but his partner did, Lapadat said.

Const. Bogart testified he had no conversation with any nurse about Jamie. He too expressed concern Jamie might check himself out and harm someone, and noted Jamie was on a high form of release — a surety.

Police took no medical information with them to EMDC. Jamie was quiet, looking out the back window on the 15 minute ride to EMDC.

At Elgin-Middlesex Detention Centre

Nurse Diane Allingham prepared a two-page assessment of Jamie about 2 a.m. Dec. 21 after his arrival at EMDC about.

Articulate, he stated he did not drink or use drugs, but that he had an anxiety disorder and was “extremely suicidal, and would do anything to hurt himself.” He spoke about how he was getting a new surety the next day.

Even so, she was going to flag possible alcohol use for the doctor who was arriving the next day, Monday.

He was taken to the segregation unit and put under a suicide watch.

Health care staff at the jail received no medical information with Jamie. In order to do so, they needed to get his consent and contact the records department of the hospital Monday, Dec. 22.

At 2:50 a.m. Dec. 22, Allingham got a call that Jamie was complaining of coming off steroids.

She was unable to go into his cell or bring him to the health care station to assess him because there wasn’t enough correctional staff on duty to accompany her. She had to talk to Jamie through the meal tray hatch in his celld oor.

Jamie told her he was coming off steroids and had a headache.

Allingham asked if he was using any drugs or drinking. It’s the only way we can help you, she told him.

Jamie got angry, sarcastic and said, Oh I drink a 50-pounder a day, and I had a drink Sunday (while in jail) Then he said he didn’t drink and he just wanted to sleep.

That information did not prompt Allingham to start using an alcohol withdrawal scale available at EMDC to guide health care staff in treatment. But it did prompt her to flag alcoholism for a doctor’s appointment Jamie was to have during that day.

About 7:40 a.m., Monday Dec. 22, security manager Sgt. Tim McFadden was contacted by segregation staff about an inmate refusing to go to court.

He found Jamie standing naked on his bunk and “sweating profusely.”

McFadden testified he talked Jamie down from his bunk, suggesting at one point he might be released if he went to court.

Jamie was sweating “like a person that just stepped out of a shower.”

He did not question his mental health or withdrawal from alcohol or drugs.

“I saw a very anxious man. I talked him down. And he came to be, in my opinion, just another offender.”

McFadden told the inquest nothing has changed since 2013 in the camera monitoring of segregation. Most cells are still not monitored by cameras.

Jamie spent most of the day Dec. 22 in the cells at the St. Thomas courthouse. He did not get out of jail through his hearing that day.

At 5 p.m. Dec. 22, nurses Linda Hamilton and Deb Barnes checked Jamie in the health care department after he complained of infected genitals. They found nothing physically wrong with him. His vital signs were normal. He had the shakes now and then but not in the way alcohol withdrawal usually causes, nurse Barnes testified at the inquest. The nurses considered the withdrawal of Paxil as a reason for his anxiety, tremors and suicidal thoughts.

Jamie was upset because he thought he was going to be released while at court that day.

From 7 p.m. to 11 p.m. Dec. 22, correctional officer Matt Hopkins was one of three watching over Jamie in segregation. He made rounds every 10 minutes and tried to talk to Jamie. There was little response and Jamie was “looking almost beyond me,” he said.

“He was extremely unfocused. He did seem very disoriented.”

Hopkins testified he had not training in recognizing the signs of alcohol withdrawal. Nor did he have any information about Jamie’s previous interactions with health care staff.

He called health care. “I was told he had been withdrawing from something and this was expected at this time.”

Someone from health care came down at one point and said Jamie would be fine, he just needed to sweat it out.

Shortly after 7 a.m. Tuesday Dec. 23, Hopkins arrived on shift again. The overnight crew told him Jamie slept through the night with no change. Hopkins didn’t check the observation logs, which told a different story of a night of agitation.

Jamie was on the floor a lot, often naked, and speaking nonsense that morning. After seeing Jamie seemingly unresponsive on the floor, Hopkins called the health care station at 8:21 a.m.

Mental health nurse Mike Moretti was filling prescription orders when he was told to head to segregation to check on someone possibly withdrawing from drugs. The checkup interrupted his medication rounds. There were three nurses on that day, and there should be five, Moretti said.

Moretti went into Jamie’s cell to assess him.

“He was on the floor between his bed and the toilet. I could see his face. I introduced myself and started asking questions, ‘Can I help you?’,” Moretti testified.

“Angrily he shouted out ‘no!’

He asked if Jamie had taken drugs and again got an angry, No!

Moretti said he assumed Jamie was coming off street drugs. An officer tried to get Jamie to sit up and Jamie grew agitated and started screaming. So Moretti decicded to come back later.

Jamie was breathing fine, perspiring but not excessively and wasn’t shaking, Moretti said.

Moretti testified he didn’t look at any correctional officers’ logs from the night

That was the morning Jamie appeared by video in St. Thomas court, incoherent. About 9:15 a.m., a worried correctional officer Hopkins called Moretti again.

Moretti testified Jamie was standing in his cell and walking. He seemed fine so Moretti did not go into his cell. He arranged for Jamie to be first on the list when the EMDC psychiatrist visited at noon that same day.

Some people wait to the three months to see the psychiatrist, Moretti said.

He expressed his frustration at having little time to consult medical charts or take other steps to help Jamie.

“I was hired as a mental health nurse. . . to take certain steps. I went through three superintendents, three program managers and one health care manager requesting that I want to do the job that I was hired for,” he said, his voice thick with frustration.

Instead, he became an overpaid medication dispenser, he said.

“I could have went in there (High’s cell) as a true mental health nurse,” he said.

Time and time again, “That didn’t happen so it was a time for me to resign and I left.”

“I feel guilty,” Moretti said. “I really do.”

After Moretti left, correctional officer Hopkins continued to make regular checks on Jamie. There were supposed to be three officers on duty, but one had been called away to do a search.

Another officer, Rob Fraleigh, did a check on Jamie at 10:20 a.m. A check is just a look inside.

There were nine suicidal inmates in a unit of 15 cells. That morning, two of them were trying to cover their cells windows and threatening to hurt themselves.

Fraleigh left the unit to take a breather, leaving Hopkins alone.

Hopkins testified he call for extra help. He checked Jamie at 10:30 a.m and saw him on the floor and seemingly unresponsive.

But without help and two other inmates in crisis, he could not enter the cell to make sure.

Only 11 minutes later, after an officer had arrived back in the unit, could Jamie be checked in person.

He was found without vital signs and efforts to revive him began.

Welcome to a place where words matter. On Medium, smart voices and original ideas take center stage - with no ads in sight. Watch
Follow all the topics you care about, and we’ll deliver the best stories for you to your homepage and inbox. Explore
Get unlimited access to the best stories on Medium — and support writers while you’re at it. Just $5/month. Upgrade