A man who went to a southwestern Manitoba hospital to seek treatment for alcohol addiction died the next day without being seen by a doctor, a case his mother says raises questions about how addiction patients are treated.
Ryan Eamer, 46, went with his mother, Brenda Eamer, to Brandon Regional Health Center’s emergency room seeking detox services on February 18, 2021.
The emergency room was almost empty at the time, his mother says. Brenda says the nurse initially told them Ryan was too drunk to be admitted to a detox bed. They were told to go home and for Ryan to return within 24-48 hours when he sobered up.
She insisted that her son should be seen by a doctor that day because she knew he was suffering from alcohol withdrawal seizures.
She left the hospital after examining him. At some point after that, he collapsed while waiting to see a doctor, a later review of his death found.
Despite internal records showing he was not a threat to others, the decision was made to call the police and place him in a jail cell to sober up under Manitoba’s Intoxicated Detention Act, which gives police powers to detain a person who is intoxicated if they are considered dangerous.
His mother was never informed that her son was being held by the police. She only found out when the police called to tell her where she could get it.
“He was desperate for help,” she said.
“If they didn’t want me to deal with it, just call me and say, ‘Come and get it…’ Why would they put it through all this?”
After four hours in police custody, Ryan asked to return to the hospital.
Although he had a visible scar on his head when he arrived, he was not searched or evaluated by a doctor, according to a review of his death by Prairie Mountain Health, the regional health authority for southwestern Manitoba.
After his previous experience, he felt humiliated and told his mother that he just wanted to go home and sleep.
His mother took him back to his apartment. She promised to return in the morning so they could go back to the hospital and try again to access detox services.
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“We didn’t even have to say goodbye”
The next day, Ryan didn’t answer when she knocked on his door. She came back at 11 am, then at 12:30 pm
It was not unusual for her to go to her son’s apartment two or three times before he answered the door. But on the third try, she looked out the window and noticed that the furniture was upside down.
Worried, she crawled out the window.
She found Ryan unresponsive on the floor and called 911.
“All I wanted to do was just hold his hand and … tell him I was there and just wait for help to come. But he didn’t make it,” she said.
Ryan Eamer on a 2013 family vacation in Alberta. His mother says he was a big fan of the NHL’s Philadelphia Flyers. (Submitted by Brenda Eamer)
His mother wanted to ride in the ambulance with her son, but was told she couldn’t because of the restrictions imposed by COVID.
He was pronounced dead at the hospital where he had been waiting more than 24 hours earlier.
“As a mother, I can’t put into words the loss of a child, no matter what age… You can’t put into words how devastating it is,” said Brenda Eamer.
“We didn’t even have to say goodbye.”
WATCH | Brenda’s son Eamer Ryan died a day after being returned from Brandon Hospital:
Brenda Eamer’s son, Ryan, died a day after he was returned from a Brandon hospital
Brenda Eamer believes that if doctors would have examined her son, he might still be here today. Ryan Eamer was struggling with alcohol addiction when he went to Brandon Hospital’s emergency room last February. He died the next day.
2 reviews
The autopsy report listed his cause of death as blunt force trauma to the head caused by a fall. It said he fell in the emergency room and “may have hit his head,” but did not definitively say when the fall occurred.
In a letter sent to Brenda Eamer, Prairie Mountain Health said a review of the video showing Ryan’s fall in the emergency room determined it was a “directed fall” and was “unlikely” to have caused the head injury that it killed him.
Brenda attempted to obtain a copy of the video from the emergency room, but was denied access.
Prairie Mountain Health apologized to Eamer’s family and reviewed his death. (Riley Lajchuk/CBC)
What happened between Ryan’s visit to the emergency room and his death is the subject of an investigation by both Prairie Mountain Health and the College of Registered Nurses of Manitoba, where his mother filed a complaint about the conduct of the two nurses who examined Ryan.
Internal documents from separate investigations into his death reveal:
- Ryan was never seen by a doctor during his initial visit to the hospital, nor when police returned him there about four hours later.
- No attempt was made to contact Ryan’s mother before the police were called.
- The medical staff used the wrong form to release Ryan to custody due to the lack of policy in situations like Ryan’s.
- He was not violent or aggressive towards patients or hospital staff and was not considered a risk to others before the police were called.
- Nursing and triage staff at the hospital did not receive training on the Intoxicated Detention Act as part of their general or triage training.
I “couldn’t break free” from the addiction
Brenda Eamer told CBC News that she and Ryan went to the hospital in February 2021 because he knew he needed help.
He struggled with alcohol addiction for more than a decade. He got sober in 2017, but when the COVID-19 pandemic hit, addiction took over again.
“He couldn’t get rid of it,” his mother said. “He was struggling in the days before he went to the ER.”
Eamer graduated from Crocus Plains Regional High School in Brandon in 1993. He later earned a degree in psychology so he could devote his life to helping people, his mother said. (Submitted by Brenda Eamer)
Her son loved meeting people, Brenda said, and earned a degree in psychology so he could devote his life to helping people.
He got a job at a personal care home, where the adults loved him and called him “Vick” — his middle name — because he was a friend to them, Brenda said.
His last few years were spent as a children’s helper, helping troubled children deal with their pasts.
But when he was 24, he lost a very good friend and “he never got over that,” his mother said. Eventually, the addiction took hold.
He was the older of her two children. Now Brenda and her daughter Melanie are left to figure out life without him.
“It’s always been the three of us,” Brenda said.
Eamer with his sister, Melanie Corby, at his birthday lunch in January 2021, just weeks before he died. (Submitted by Brenda Eamer)
College of Nursing Review
In April 2021, Brenda filed a complaint with the College of Registered Nurses against the two nurses who played a role in Ryan’s care and the decision to call the police.
The college did not discipline them, according to a decision sent to Brenda on Jan. 12 of this year. Instead, a letter of guidance was added to both their files “to address inadequate client-centred care and the associated professional responsibilities and obligations”.
Prairie Mountain Health’s review found questions remain about what assessments were done to rule out head injury as the cause of death. But the college’s investigation found that the required triage assessments were completed and a comprehensive post-fall assessment was carried out by nurses.
A nursing expert hired by the college’s grievance investigation committee to provide an independent opinion on the removal of an intoxicated patient from the emergency room said a doctor should have examined the patient medically before police were called.
An assessment had to be made to ensure the patient did not have any immediate health needs other than intoxication, the expert told the committee.
She said Brenda should have been called to the police and that using the DUI Act should be “a last resort after all other treatment options for the patient have been considered,” according to the commission’s final report.
A college spokesman said he could not comment on specific cases, but that guidance letters could be used “to address potentially objectionable conduct” identified in an investigation.
One of the nurses, in her reply letter, wrote that they deeply regretted not calling Brenda before calling the police.
Prairie Mountain Health apologizes
Prairie Mountain Health has launched its own review of Ryan’s case.
“Please accept our sincere apologies for your son’s experience while seeking detox services,” wrote Amy Foster, the regional health authority’s patient safety and quality improvement coordinator, in a letter sent to Brenda Eamer on March 25, 2022 .
The review found that nurses improperly used a medical assessment form to assess Ryan’s suitability for police custody. It was never intended to assess anyone coming to the hospital for care, the health authority said.
Instead, it was intended to assess people brought by police to the hospital to be medically examined before being taken to a sobering cell.
The health district is committed to taking action on several things to prevent another death like Ryan’s, including:
- Creation of a permanent Mental Health Liaison position to work in the Emergency Department in Brandon.
- Provide additional training to patient triage staff.
- Updating policies related to supporting substance-using clients and providing clear guidance on how to assess and treat those who are intoxicated and seeking cessation services.
- Discontinuing the use of the nurse assessment form used for Ryan’s medical release for detention.
In a statement to CBC News, Prairie Mountain Health CEO Brian Schoonbaert said he could not comment on the specifics of the case, but said the health authority is “very…
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