Alberta should set standards for addiction treatment centres, judge says in death report

An Alberta judge has recommended that the province establish standards governing medical detox and addiction treatment programs in residential facilities after investigating the death of a 25-year-old man at a rural drug rehabilitation center.

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

He was admitted to the center’s medically assisted detox program at 12:40pm the previous day.

Corbiere’s death was ruled an accident, caused by the synthetic opioid buprenorphine, a drug used to treat pain and opioid addiction. Obesity was also a contributing factor.

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

The death prompted a series of changes at Thorpe Recovery Centre, with the detox unit closed, a call for consultants to be brought in to streamline operations and new management in place.

Derek Keller, the center’s new CEO, said the organization has learned from what happened and has strengthened policies and procedures.

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

In a May 24 report from an inquest into the deaths, Justice Lisa Tchir of the Alberta Court of Justice recommended that the province develop regulations or standards, including best practice benchmarks that could be enforced by compliance officers, for medical detoxification and addiction treatment.

“I hope 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 this week.

Ray Corbiere, who attended the inquest with Joshua’s mother and has read the judge’s report, said his son’s death had turned his life upside down.

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

He wanted help

Joshua was a wild and loving child. He was protective of his siblings and loved camping, fishing and playing soccer. But he became involved with people who took him away from those activities, and by age 20, he could not live on his own and was dependent on others, his father said.

Corbiere said that in 2021, Joshua mostly lived with him in Edmonton and that the family did everything they could to support him.

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

“I remember he was crying and he said, ‘Dad, I need help.’ I remember hugging him and kissing him and saying, ‘We can do this,’” Corbiere recalled.

Joshua Corbiere completed medically assisted detox at the facility on Aug. 5, but was readmitted to the detox program on Aug. 18 and assigned a shared bedroom.

A drug test showed the presence of cocaine and tetrahydrocannabinol (THC), the active substance found in marijuana, in his system.

Two employees, both recently hired, were working the night shift, the report said — a clinical social worker and a licensed practical nurse. The LPN, a recent graduate with a provisional license, was not permitted to work without direct supervision but did so that night.

A medical assistant assessed Corbiere, but some of his assessment forms, such as the Clinical Opioid Withdrawal Scale, were incomplete.

The aide, who spotted him in the early evening as she was coming off shift, testified under questioning that she did not believe he was under the influence of anything at the time.

A registered nurse checked on him five times in the early morning hours of August 19 and noticed he was lying on his bed, snoring loudly.

At approximately 6:20 a.m., the LPN heard Corbiere’s roommate trying to wake him up. She went to check on him and saw that his skin was blue and clammy. He was unresponsive.

The licensed nurse called the social worker because she did not have a manager to call and the supervising nurse was absent.

Two staff members and Corbiere’s roommate attempted to resuscitate him and used a defibrillator, following the instructions of the 911 operator.

Paramedics arrived at 6:45 a.m. and pronounced Corbiere dead within 15 minutes.

During the investigation, it was determined that naloxone had not been used that morning. A toxicologist testified that naloxone could aid in resuscitation.

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

What appeared to be crushed pills and candy were found in his room, while a white powdery substance was found in a nearby bathroom cabinet.

The mounted police informed the center’s manager that these substances were not needed, so they were destroyed.

Skipped steps and non-compliance

The debt collection center’s occupational health and safety (OHS) policy required a root cause analysis to be conducted following an incident involving a customer.

Under the policy, the analysis was to be sent to the OHS committee, which would review the risk and make recommendations to prevent similar incidents in the future.

However, the death investigation report found the facility failed to follow this procedure and failed to conduct a root cause analysis.

In October 2021, Corbiere’s father filed a complaint with the province’s Office for the Protection of Persons in Care, which investigates allegations of abuse against recipients of publicly funded care.

Last year, an investigator found that one of two allegations — that staff failed to ensure the safety of a patient who had recently been admitted to a detox unit — was substantiated and that Thorpe Recovery Centre failed to provide a safe environment for clients.

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

A March 2022 investigation under the Mental Health Services Protection Act (MHSPA) found the facility had failed to comply with regulations and the facility was ordered to make a number of changes.

A year later, compliance officers learned that nurses were prescribing medications based on a pre-printed list of medications to be prescribed for specific conditions.

The province then ordered a halt to patient admissions to the facility and ordered the centre to work with a group of consultants to provide services.

The report into the deaths said a group of consultants had taken over management of the centre and that it was the only inpatient treatment centre in the province with such a role.

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

The inpatient treatment program has been temporarily closed for part of 2023. The detox program, which had already been closed for renovations, reopened in April of this year.

The Center is making changes

Derek Keller, who became CEO of Thorpe Recovery Centre in May, said the facility has made a number of changes since Corbiere’s death, including hiring a team of doctors, increasing staffing levels and improving the patient admission process.

He added that staff are now undergoing more training and rooms are checked more often.

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

“Transparency and higher standards ultimately benefit clients, and the reason we are here is to serve them and help them recover,” he said.

He also apologised to Corbiere’s family.

“We are certainly sorry about the situation, about what happened, and we have certainly learned from the situation,” Keller said.

The standards will appear next year

According to the judge’s report, a series of standards for residential addiction treatment facilities were published last year, but the MHSPA does not include a “specific model of medical detoxification practice” that would be mandatory or could be used as a reference by compliance and licensing officers.

“This makes oversight of programming difficult,” Tchir wrote in her report.

The judge recommends the government develop a plan that would address treatment protocols, locking medications, staff-to-patient ratios, wellness checks, naloxone training and other practices.

In a statement, a spokesperson for Alberta’s Ministry of Mental Health and Addictions said the investigation “found prior failures by the operator.”

The government “has taken significant steps to address these issues and improve the quality of its services,” the statement said.

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