Coroner’s Inquest begins in 2020 CNCC inmate death

The Coroner’s Inquest into the death of a 29-year-old Creemore man, who died after becoming ill in jail four years ago, began Thursday.

Bobby Bristow, known formally as Robert Hardy, died at Georgian Bay General Hospital on January 17, 2020, after an illness at Central North Correctional Centre (CNCC) in Penetanguishene, where he had been an inmate for about three months.

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The Inquest serves to provide insight into the death and prevent future deaths in similar circumstances. 

In an agreed statement of facts read to the jury, the Inquest said Bristow, known formally as Robert Hardy, was shown on security cameras being tattooed by another inmate in late December 2019.

The Inquest heard Bristow had repeatedly requested medical help during his time in custody, including in the days before his hospitalization. He was later taken off life support with his family by his side.

The jury heard Bristow spoke with a nurse on January 11, 2020, about a lump on his arm from a self-tattoo he got a month prior that popped and resulted in a yellow discharge.

The nurse said Bristow told her it had been there for two days. She said tattoos performed in the jail could often lead to infection due to unsanitary conditions.

The nurse who worked on a casual basis at CNCC and assessed Bristow testified he developed an infection on his right forearm the size of a coin, specifically the shape of a quarter.

“The lump is what my concern was,” said the nurse. “Usually, when there’s a warmness to the touch, there is a possibility of infection, which is why I mentioned it in my note.”

The Inquest heard Bristow received antibiotic medication to treat the lump in late December. The nurse said she was unaware of the previous prescription he received following a prior assessment in early December.

“I definitely would’ve wanted to draw the doctor’s attention to the fact that [Bristow] has had this lump ongoing, so we need to be, maybe, a little more aggressive and watching it more closely,” she testified.

The nurse said she would’ve benefitted from knowing about earlier treatments that may not have been successful in dealing with the lump. She noted doctors were only on call at the facility on Sundays.

When asked whether it was important Bristow be seen the following day by a doctor, the nurse replied, “Yes, it was important to me for him to be seen because I guess the abscess was a quarter size and I was concerned about the redness and the warmth and I wanted to make sure that infection wasn’t progressing.”

According to records, the request for treatment didn’t happen the following day.

“I requested the evening staff to call the doctor,” she testified, in order for a nurse to obtain a prescription for Bristow following her assessment of the inmate earlier in the day.

The nurse told the Inquest she was upset to learn of Bristow’s passing.

“I just didn’t realize, I guess, how sick he was. I had no idea it would progress quickly. I guess I don’t know the cause. But yeah, I was shocked to hear of the abscess and that he had died.”

She also said she was not part of a de-briefing session following Bristow’s death, noting the practice of meeting with colleagues and management after negative patient outcomes are standard in institutional health care settings.

When asked to offer recommendations to the Inquest, the nurse testified that the facility would’ve benefited from an electronic charting system for patient records as opposed to paper charts. 

She also added that there could have been a better and more precise booking system to ensure patients requiring a doctor visit are able to see one.

Staffing level, and continuity, challenges at the facility as well as safety concerns and access to inmates were cited as barriers to patient care. The nurse then offered her condolences to Bristow’s family.

The proceedings continue Friday and resume next week.