Alberta must set standards for addiction treatment centres, judge says in fatal crash report

An Alberta judge is advising the provincial government to set standards for residential medical detoxification and addiction treatment programs after she investigated the death of a 25-year-old man at a rural recovery center.

On the morning of August 19, 2021, Joshua Corbiere was found unconscious in his room at the Thorpe Recovery Centre, in the hamlet of Blackfoot, about 240 kilometres east of Edmonton.

He had been admitted to the center’s medically assisted detox program at 12:40 p.m. the day before.

Corbiere’s death was ruled an accident, caused by the synthetic opioid buprenorphine, a drug used to treat pain and opioid addiction, with obesity being a contributing cause.

Toxicology tests revealed that Corbiere, who had a substance use disorder, also had the benzodiazepine alprazolam (sold under the brand name Xanax, among others) in his system.

The deaths led to a series of changes at Thorpe Recovery Centre, which closed its detox unit, was tasked with working with consultants to improve operations and came under new leadership.

Derek Keller, the center’s new CEO, said the organization has learned from the events and has tightened its policies and procedures.

An inquest into Corbiere’s death was held in Edmonton for five days in February and March of this year.

In her May 24 report on the fatal crash investigation, Alberta Court of Justice Judge Lisa Tchir recommended that the province develop rules or standards, including best practice benchmarks that regulators can enforce, for medical detoxification and addiction treatment.

“I hope that these recommendations are taken very, very seriously so that families don’t have to go through the hell that we’re going through,” Ray Corbiere, Joshua’s father, told CBC News in an interview this week.

Ray Corbiere, who attended the hearing with Joshua’s mother and studied the judge’s report, said his son’s death turned his life upside down.

“A piece of my heart has been ripped out and I miss him every day,” he said.

He wanted help

Joshua was an exuberant and loving child. He was protective of his siblings and enjoyed camping, fishing and playing soccer. But he got involved with people who pulled him away from those activities, and by his mid-20s he could no longer live independently and was dependent on others, his father said.

A man holds a fishing rod with a fish on it.
Ray Corbiere said his son loved fishing. (Submitted by Ray Corbiere)

Corbiere said Joshua lived with him in Edmonton most of 2021 and the family did their best to help him.

He said Joshua decided to go to Thorpe Recovery Centre because he wanted help battling his addiction. He had successfully completed a 49-day residential treatment programme at the centre in January 2021, but relapsed and applied for the residential treatment programme six months later.

“I remember him crying and saying, ‘Dad, I need help.’ I remember giving him a hug and a kiss and saying, ‘We’re going to get through this,’” Corbiere recalled.

Joshua Corbiere completed the center’s medically assisted detox on August 5, but was readmitted to the detox program on August 18 and assigned to a shared bedroom.

His drug test found cocaine and tetrahydrocannabinol (THC), the active ingredient in cannabis.

Two staff members, both recently hired, were working the night shift, the report said: a clinical social worker and a registered nurse. The LPN, a recent graduate with a provisional license, was not supposed to work without direct supervision, but did so that night.

A medical assistant had assessed Corbiere, but some of his assessment forms, such as a clinical score for opiate withdrawal, were incomplete.

A counselor who saw him early that evening, just after she finished her shift, testified at the hearing that she did not think he was under the influence at the time.

The emergency nurse checked on him five times in the early morning of August 19 and noticed that he was lying in bed and snoring loudly.

At around 6:20 a.m., the LPN heard Corbiere’s roommate trying to wake him up. She checked on him and found his skin blue and clammy. He was unresponsive.

The LPN called the social worker because she had no manager to call and the nursing supervisor was away.

The two staff members and Corbiere’s roommate tried to resuscitate him and used a defibrillator, following instructions from a 112 operator.

Emergency services arrived at 6:45 a.m. and confirmed that Corbiere had died after 15 minutes.

The inquest heard that naloxone had not been used that morning. A toxicologist testified that naloxone can help with resuscitation efforts.

A man in a suit stands in a grassy field.
Ray Corbiere says his son’s death turned his life upside down. (Peter Evans/CBC)

The same expert testified that Corbiere likely took buprenorphine and alprazolam after being admitted to the facility.

In his room, substances that appeared to be crushed pills and candy were found. A white powdery substance was found in a nearby bathroom cabinet.

The RCMP informed the facility’s operations manager that the substances were not needed and were therefore being destroyed.

Missed steps and non-compliance

The recovery center’s Occupational Health and Safety (OHS) policy required a root cause analysis to be performed following a client incident.

The policy required the analysis to be sent to an OHS committee, which would assess the risks and make recommendations to prevent similar incidents in the future.

But the center failed to follow that process, according to the fatal accident investigation report, and no root cause analysis was conducted.

In October 2021, Corbiere’s father filed a complaint with the provincial Office for the Protection of Persons in Care, which investigates allegations of abuse against people receiving public care.

Last year, a hired investigator determined that one of two allegations – that staff had failed to ensure the safety of a patient recently admitted to the detox unit – was substantiated and that the Thorpe Recovery Centre was an unsafe environment for clients.

Flags and cars are outside a building.
Thorpe Recovery Centre provides residential addiction treatment in Blackfoot, Alta. (Submitted by Derek Keller)

After Joshua Corbiere’s death, the recovery center hired a consultant to assess and recommend structural changes to improve the nursing and detox unit. Renovations were made to improve the nurses’ view.

A March 2022 investigation under the province’s Mental Health Services Protection Act (MHSPA) found the facility was not in compliance. The center was ordered to make a number of changes.

A year later, compliance officers discovered that nurses were prescribing medications based on a pre-printed list of medications that should be prescribed for each condition.

The province subsequently ordered a halt to all admissions to the facility and directed the center to work with a group of counselors to provide the services.

The report into the fatalities states that the advisory group has taken over management of the center and that it is the only residential treatment center in the province to hold that position.

The chairman of the board resigned and the government and advisors worked with the board to remove the previous CEO and find a new one.

The residential treatment program was temporarily closed for part of 2023. The detox program, which was already closed for renovations, reopened in April of this year.

Center makes changes

Derek Keller, who became CEO of the Thorpe Recovery Centre in May, said the organisation made many changes following Corbiere’s death, including hiring a group of doctors, expanding its staff and improving its intake processes.

Staff are now receiving more training and rooms are being checked more often, he said.

Keller said the judge’s recommendations are reasonable and appreciated.

“Clarity and higher standards ultimately benefit clients. We are here to serve them and help them on their path to recovery,” he said.

He also apologized to Corbiere’s family.

“We regret the situation and what happened, and we certainly learned from it,” Keller said.

Standards coming next year

According to the judge’s report, a number of standards for residential addiction treatment providers were published last year, but the MHSPA does not contain a “specific medical detoxification model” that is mandatory or can be used as a benchmark by compliance officers and licensing inspectors.

“This makes it more difficult to monitor programming,” Tchir wrote in her report.

The judge advises the government to draw up such a plan, which should include treatment protocols, medication lock-ups, staffing, health checks, naloxone training and other measures.

In a statement, a spokesperson for Alberta’s Ministry of Mental Health and Addictions said the investigation “revealed past failings by the operator.”

The government “has taken important steps to address these concerns and improve the quality of its operations,” the statement said.

The statement also says the standards being developed for spring 2025 “will significantly raise the standard of care in Alberta for detox, treatment and recovery services.”

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