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Jail medical staff gave Teresa Gratton methadone doses way above guidelines, and this caused her death

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Teresa Michelle Gratton’s first dose of methadone should have been no more than 10 milligrams.

But the medical staff inside the maximum-security jail where Gratton was being held indefinitely as an immigration detainee started her at 30 milligrams.

Teresa Michelle Gratton, pictured here in an undated family photo, was being held indefinitely as an immigration detainee at the maximum-security jail in Milton. She died of “acute methadone intoxication” after receiving two doses of methadone from the jail’s doctors. Provincial guidelines for methadone treatment say Gratton should have received a much lower dose than she did.
Teresa Michelle Gratton, pictured here in an undated family photo, was being held indefinitely as an immigration detainee at the maximum-security jail in Milton. She died of “acute methadone intoxication” after receiving two doses of methadone from the jail’s doctors. Provincial guidelines for methadone treatment say Gratton should have received a much lower dose than she did.  (Gratton family photo)

That’s what caused her death.

Gratton died of “acute methadone intoxication in the setting of ischemic heart disease,” according to the coroner’s report, which was given to the Star by Gratton’s husband.

Provincial guidelines for methadone treatment say someone in Gratton’s position should have received a much lower dose than she did. The coroner states in his report that other factors may have contributed to her death, including Gratton’s pre-existing high blood pressure. She ultimately died of a heart attack in hospital. Three doctors who reviewed the coroner’s report for the Star say it’s clear she died of a methadone overdose.

Gratton, a U.S. citizen and permanent resident of Canada who lived in London, Ont., was not serving a criminal sentence or awaiting trial, though she was treated the same as those who were. She had been sent to a maximum-security jail because the Canada Border Services Agency was contemplating deporting her and feared she would not show up for her deportation if it were ordered. The agency based its decision on Gratton’s criminal convictions from 2013, for which she was sentenced to six months of house arrest. Some have argued she should not have been detained in the first place.

The 50-year-old grandmother was found unresponsive in her cell at the Vanier Centre for Women in Milton just after midnight on Oct. 30, 2017. About 40 hours earlier she was given her first dose of methadone, a long-acting opioid often used to treat addiction to shorter-acting opioids. Gratton had depended on prescription painkillers for many years, but the jail’s medical staff was trying to wean her off them. She received her second dose of methadone the morning before she died.

“I suspect if the physician who prescribed this could do it over again, he or she would start on a lower dose,” said Dr. David Juurlink, a medical toxicologist and senior scientist at the Institute for Clinical Evaluative Sciences, and one of three opioid-specializing doctors who reviewed Gratton’s coroner’s report at the Star’s request. All agreed she should have been started on a lower dose of methadone or a different drug altogether.

Gratton’s death was ruled accidental. A coroner’s inquest has been ordered but has not been scheduled.

Read More:

Family of immigration detainee who died in jail still waiting for answers

The Star first reported on Gratton’s case last December, and again in March when two women who were incarcerated with Gratton came forward to raise concerns about her treatment in the jail. But this is the first time her official cause of death has been reported.

Herb Gratton, Teresa’s husband and partner of more than 30 years, said he is frustrated and angry, but he mostly just misses his wife. “The system had her,” he said in a recent interview. “They were supposed to be responsible.”

Herb, who is a Canadian citizen from the Caldwell First Nation, says this time of year is particularly difficult. His wife was the one who organized the family get-togethers and did most of the cooking.

“Christmas does not seem like Christmas,” he said. “I can’t find a reason to celebrate. I have my children, my grandchildren. But there’s a void. No matter who’s around or what’s around, I can’t fill it, you know?”

Herb Gratton, the husband of Teresa Michelle Gratton, says he is frustrated and angry about how his wife died. But he says he mostly just misses her. "Christmas does not seem like Christmas," he said. "I can't find a reason to celebrate."
Herb Gratton, the husband of Teresa Michelle Gratton, says he is frustrated and angry about how his wife died. But he says he mostly just misses her. « Christmas does not seem like Christmas, » he said. « I can’t find a reason to celebrate. »  (Anne-Marie Jackson)

A mother of three who had lived in Canada since 2003, Teresa Gratton suffered from osteoarthritis and fibromyalgia, a long-term condition of the central nervous system that causes widespread pain. She relied on the opioid hydromorphone and was prescribed a high daily dose by her doctor months before she was incarcerated. When she couldn’t get her opioids from a doctor she got them on the street, her husband said. A month before her death she pleaded guilty to forging her doctor’s signature in an attempt to get an extended supply of hydromorphone. She also took several other prescribed medications, including ones for anxiety and depression.

The jail’s medical staff decided Gratton should not be on opioids. The coroner’s report references a physician’s note in Gratton’s medical file that reads: “SUD (substance use disorder), I agree, no indication for long-term opioid therapy.”

First they cut her dose by more than half. A week later they tapered her dose further and then withdrew her opioids completely for 10 days before giving Gratton her first dose of methadone.

Thirty milligrams, the amount Gratton received in each of her two doses, is the maximum starting dose for methadone treatment, according to guidelines published by the College of Physicians and Surgeons of Ontario. However, the guidelines state that if a patient has been “recently abstinent from opioids,” as Gratton was, the maximum starting dose should be no more than 10 milligrams. The guidelines do not specify how many days qualify as recent abstinence, but they do say that patients who have not used opioids “even for a few days” are at a higher risk of overdose.

The guidelines also state that patients who are also on benzodiazepines or any sedating drugs, as Gratton was, should be considered at a “higher risk for methadone toxicity” and therefore should be given a lower starting dose.

Two doctors, Dr. Abraham Shedletzky and Dr. Laura Middlestadt, are among the medical staff who work inside the jail. It’s not clear who oversaw Gratton’s treatment or if either doctor administered the methadone. The coroner’s report doesn’t name any doctor as being responsible for Gratton’s treatment. Middlestadt declined to comment for this story. Shedletzky did not respond to multiple interview requests.

Juurlink said he didn’t understand why the jail’s medical staff, even if they believed Gratton should be on a lower dose of opioids, would have tapered her off the drugs entirely. “Her brain and body would have become accustomed to that amount of hydromorphone,” he said. “She would have been physically dependent on it, and when you take it away people get horribly sick.” Tapering should be done slowly and generally with the patient’s consent, he added.

Even if there were compelling reasons to reduce Gratton’s opioid dose and replace it with methadone, Juurlink said someone in Gratton’s position shouldn’t be off opioids for as long as she was. “That’s 10 days of putting this patient through hell.”

Gratton wrote her husband regularly during her time in jail. In her letter she describes the agony of her withdrawal symptoms, which included vomiting, diarrhea, severe muscle pain, constant sweating and depression.

“I’d rather be dead than to keep going through this pain,” she wrote in one letter. “These doctors … think I don’t need to be on any of my narcotics. If something bad should happen to me please sue the hell out of them.”

The coroner’s report says that Gratton filed a complaint to the Office of the Ombudsman of Ontario regarding the reduction of her opioids by the jail’s medical staff. A spokesperson for the ombudsman said that for confidentiality reasons she could not confirm whether a complaint had been filed.

Juurlink also pointed to Gratton’s concurrent use of clonazepam, which she took to treat panic attacks, as a reason she should have been started on a much lower dose of methadone. Clonazepam belongs to the benzodiazepine class of drugs. It is a tranquilizer that, when combined with methadone, increases the risk of overdose.

“You have a one-plus-one-equals-five kind of effect,” Juurlink said. “They’re both depressants of the central nervous system and it’s really quite dangerous to combine opioids with drugs like that, especially for a patient who, for all intents and purposes, is opioid naive.” Juurlink said Gratton would have lost whatever opioid tolerance she might have had during her 10 days without the drug.

A spokesperson for Ontario’s Ministry of Community Safety and Correctional Services, which is responsible for provincial jails, said no one from the ministry would be interviewed for this story. They also declined to answer specific questions about Gratton’s case, citing the pending inquest.

From the 2017 Star Investigation | Teresa Michelle Gratton died Oct. 30 while being indefinitely detained in a maximum-security jail by the Canada Border Services Agency. Her grieving family wonders why she was there at all.

The spokesperson provided a written statement, which reads, in part: “Decisions about health care matters are between inmates and medical staff. The ministry does not interfere with medical decisions or direct medical professionals.”

Dr. Ramesh Zacharias, the coroner, writes in his report that it’s unclear whether Gratton should be considered “a completely naive user in the context of methadone maintenance therapy.” Zacharias notes that although Gratton had not consumed opioids for 10 days before her first dose of methadone, “prior to that period she was a longtime user and abuser of hydromorphone.”

Dr. Meldon Kahan, medical director of the Substance Use Service at Women’s College Hospital, said it is “unusual” for just two doses of 30 milligrams of methadone to cause death. However, given Gratton’s recent abstinence from opioids and the fact she was on other sedating medications it “might have been more prudent” to start her on a different drug or a lower dose.

Kahan said it would have been better for the jail’s medical staff to prescribe buprenorphine, another long-acting opioid used to treat addiction, rather than methadone.

“It’s much safer than methadone,” he said. “It’s much safer than simply stopping the opioid, and it’s much safer than keeping them on the opioid that they’re already on.”

Juurlink agreed, calling buprenorphine “an infinitely safer medication.”

A ministry spokesman refused to say whether buprenorphine was available to doctors inside the jail.

Gratton died after suffering a heart attack in hospital roughly nine hours after she was found unresponsive in her cell. Zacharias writes in his report that he couldn’t attribute methadone intoxication as the sole cause of death because of uncertainties around Gratton’s tolerance, his inability to determine the peak concentrations of methadone in her blood when she lost consciousness, and because her body did not immediately respond to naloxone — a drug that can reverse the effects of opioids — when it was administered by paramedics. It’s not clear for how long Gratton had been unconscious when her cellmate, who had been sleeping, alerted jail guards.

Zacharias also notes that a methadone overdose can itself increase the risk of a heart attack.

The doctors who reviewed the report for the Star said it’s clear an overdose of methadone was the cause of death, whether or not she suffered other heart complications. Juurlink said that the vomiting and diarrhea Gratton experienced during her withdrawal would have left her with lower potassium and magnesium, which would have “amplified” the effects of methadone on her heart. “Methadone can kill you in more than one way,” he said.

Besides how she died, there are also questions about why Gratton was detained in the first place and why she was held in a maximum-security jail — questions that could be raised as part of the inquest.

The CBSA’s grounds for stripping her permanent residency were for “serious criminality,” which is defined in part as any conviction that leads to a “term of imprisonment” of more than six months.

Gratton came to be in police custody in September 2017 after she was arrested for shoplifting at Walmart, but the CBSA’s finding of “serious criminality” was related to convictions from 2013, when she pleaded guilty to forging a former employer’s signature on cheques for amounts ranging from $100 to $250. (Gratton admitted forging the signatures, but she believed the man owed her the money for house cleaning, according to a court transcript.) She also pleaded guilty to unlawfully being in the man’s house, although she did not break in. She was given a nine-month conditional sentence, which included six months of house arrest but no jail time.

The CBSA interpreted Gratton’s conditional sentence as a “term of imprisonment” of more than six months, meaning she would have no right to appeal her deportation. On Oct. 19, 2017 — 11 days before Gratton died — the Supreme Court of Canada struck down such interpretations, ruling it was unreasonable for immigration authorities to equate conditional sentences, such as house arrest, with jail time.

Immigration authorities have also not clarified why Gratton, who was not considered a danger to the public and had no history of violence, was classified as a “high-risk” detainee and sent to a maximum-security jail. By the CBSA’s own policies her minimal, non-violent criminal record should have made her eligible for the Immigration Holding Centre, a far less restrictive facility.

A CBSA spokesperson has said the agency decided maximum-security jail was a “better choice” for Gratton due to “various case-specific factors.” The spokesman would not explain the factors that led to their decision, citing a need to protect Gratton’s privacy.

The location of detention for immigration detainees is decided solely by the CBSA and not subject to any external oversight.

Brendan Kennedy is a Toronto-based investigative reporter. Follow him on Twitter: @BKennedyStar

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Anglais

‘Business as usual’ for Dorel Industries after terminating go-private deal

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MONTREAL — Dorel Industries Inc. says it will continue to pursue its business strategy going forward after terminating an agreement to go private after discussions with shareholders.

« Moving ahead. Business as usual, » a spokesman for the company said in an email on Monday.

A group led by Cerberus Capital Management had previously agreed to buy outstanding shares of Dorel for $16 apiece, except for shares owned by the family that controls the company’s multiple-voting shares.

But Dorel chief executive Martin Schwartz said the Montreal-based maker of car seats, strollers, bicycles and home furniture pulled the plug on a deal on the eve of Tuesday’s special meeting after reviewing votes from shareholders.

“Independent shareholders have clearly expressed their confidence in Dorel’s future and the greater potential for Dorel as a public entity, » he said in a news release.

Dorel’s board of directors, with Martin Schwartz, Alan Schwartz, Jeffrey Schwartz and Jeff Segel recused, unanimously approved the deal’s termination upon the recommendation of a special committee.

The transaction required approval by two-thirds of the votes cast, and more than 50 per cent of the votes cast by non-family shareholders.

Schwartz said enhancing shareholder value remains a top priority while it stays focused on growing its brands, which include Schwinn and Mongoose bikes, Safety 1st-brand car seats and DHP Furniture.

Dorel said the move to end the go-private deal was mutual, despite the funds’ increased purchase price offer earlier this year.

It said there is no break fee applicable in this case.

Montreal-based investment firm Letko, Brosseau & Associates Inc. and San Diego’s Brandes Investment Partners LP, which together control more than 19 per cent of Dorel’s outstanding class B subordinate shares voiced their opposition to the amended offer, which was increased from the initial Nov. 2 offer of $14.50 per share.

« We believe that several minority shareholders shared our opinion, » said Letko vice-president Stephane Lebrun, during a phone interview.

« We are confident of the long-term potential of the company and we have confidence in the managers in place.”

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Anglais

Pandemic funds helping Montreal businesses build for a better tomorrow

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Many entrepreneurs have had to tap into government loans during the pandemic, at first just to survive, but now some are using the money to better prepare their businesses for the post-COVID future.

One of those businesses is Del Friscos, a popular family restaurant in Dollard-des-Ormeaux that, like many Montreal-area restaurants, has had to adapt from a sit-down establishment to one that takes orders online for takeout or delivery.

“It was hard going from totally in-house seating,” said Del Friscos co-owner Terry Konstas. “We didn’t have an in-house delivery system, which we quickly added. There were so many of our employees that were laid off that wanted to work so we adapted to a delivery system and added platforms like Uber and DoorDash.”

Helping them through the transition were emergency grants and low-interest loans from the federal and provincial governments, some of which are directly administered by PME MTL, a non-profit business-development organization established to assist the island’s small and medium-sized businesses.

Konstas said he had never even heard of PME MTL until a customer told him about them and when he got in touch, he discovered there were many government programs available to help his business get through the downturn and build for the future. “They’ve been very helpful right from day one,” said Konstas.

“We used some of the funds to catch up on our suppliers and our rents, the part that wasn’t covered from the federal side, and we used some of it for our new virtual concepts,” he said, referring to a virtual kitchen model which the restaurant has since adopted.

The virtual kitchen lets them create completely different menu items from the casual American Italian dishes that Del Friscos is known for and market them under different restaurant brand names. Under the Prasinó Soup & Salad banner, they sell healthy Greek options and their Stallone’s Sub Shop brand offers hearty sandwiches, yet the food from both is created in the same Del Friscos kitchen.

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Downtown Montreal office, retail vacancies continue to rise

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Some of downtown Montreal’s key economic indicators are heading in the wrong direction.

Office and retail vacancies in the city’s central core continued to climb in the fourth quarter of 2020, according to a quarterly report released Thursday by the Urban Development Institute of Quebec and the Montréal Centre-Ville merchants association. The report, whose first edition was published in October, aims to paint a socio-economic picture of the downtown area.

The survey also found office space available for sublet had increased during the fourth quarter, which may foreshadow even more vacancies when leases expire. On the residential front, condo sales fell as new listings soared — a sign that the downtown area may be losing some of its appeal to homeowners.

“It’s impossible not to be preoccupied by the rapid increase in office vacancies,” Jean-Marc Fournier, the former Quebec politician who now heads the UDI, said Thursday in an interview.

Still, with COVID-19 vaccinations set to accelerate in the coming months, “the economic picture is bound to improve,” he said. “People will start returning downtown. It’s much too early to say the office market is going to disappear.”

Public health measures implemented since the start of the pandemic almost a year ago — such as caps on office capacity — have deprived downtown Montreal of more than 500,000 workers and students. A mere 4,163 university and CEGEP students attended in-person classes in the second quarter, the most recent period for which figures are available. Border closures and travel restrictions have also brought tourism to a standstill, hurting hotels and thousands of local businesses.

Seventy per cent of downtown workers carried out their professional activities at home more than three days a week during the fourth quarter, the report said, citing an online survey of 1,000 Montreal-area residents conducted last month.

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