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

An Alberta judge is recommending the provincial government set standards for governing residential medical detoxification and addiction treatment programs after she examined the death of a 25-year-old man at a rural recovery centre.

On the morning of Aug. 19, 2021, Joshua Corbiere was found unresponsive 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 centre's medically supported detox program at 12:40 p.m. the day before.

Corbiere's death was determined to be accidental, caused by the effects of the synthetic opioid buprenorphine, a medication used to treat pain and opioid addiction, with obesity as a contributing cause.

Toxicology testing showed Corbiere, who had a substance use disorder, also had the antidepressant alprazolam (sold under the Xanax brand name and others) in his system.

The death prompted a series of changes at the Thorpe Recovery Centre. It closed its detox unit, was ordered to work with consultants to improve operations and came under new leadership.

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

A fatality inquiry into Corbiere's death was held over five days in Edmonton in February and March of this year.

In her May 24 fatality inquiry report, Justice Lisa Tchir with the Alberta Court of Justice recommended the province develop rules or standards, including best-practices benchmarks that could be enforced by compliance officers, for medical detoxification and addiction treatment.

"I would hope that those recommendations are taken very, very seriously so that families don't go through the hell that we are going through," Ray Corbiere, Joshua's father, told CBC News in an interview this week.

Ray Corbiere, who attended the inquiry along with Joshua's mother and reviewed the judge's report, said his son's death turned his life upside down.

"A part of my heart's been torn out and I miss him every single day," he said.

He wanted help

Joshua had been a rambunctious and loving child. He protected his siblings and loved to camp, fish and play football. But he became involved with people who took him away from those pursuits and by his mid-20s, he could not live on his own and was dependent on others, his father said.

Ray Corbiere said his son loved fishing.
Ray Corbiere said his son loved fishing. (Submitted by Ray Corbiere)

Corbiere said Joshua was primarily living with him in Edmonton in 2021 and that the family did their best to help him.

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

"I remember he cried and he said, 'Dad, I need some help,' and I remember giving him a hug and a kiss and I said, 'We're going to get through this,'" Corbiere recalled.

Joshua Corbiere completed the centre's medically supported detox on Aug. 5 but was again admitted to the detox program on Aug. 18 and assigned to a shared bedroom.

His drug screen was positive for cocaine and tetrahydrocannabinol (THC), the active ingredient in cannabis.

Two staff members, both recent hires, 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 licence, was not permitted to work without direct supervision, but was doing so that night.

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

A counsellor who spotted him in the early evening, as she was going off shift, testified during the hearing that she did not think he was under the influence of anything at the time.

The provisional LPN checked on him five times in the early hours of Aug. 19, noting he was lying on the bed and snoring loudly.

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

The LPN called the social worker, since she did not have a 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 911 operator.

EMS arrived at 6:45 a.m. and pronounced Corbiere dead after 15 minutes.

The inquiry heard that naloxone was not used that morning. A toxicologist testified that naloxone may help in resuscitation efforts.

Ray Corbiere says his son's death turned his life upside down.
Ray Corbiere says his son's death turned his life upside down. (Peter Evans/CBC)

The same expert testified that Corbiere had likely ingested the buprenorphine and alprazolam after he was admitted to the facility.

Substances that appeared to be crushed-up pills and candy were found in his room, and a white powdery substance was found in a nearby bathroom cupboard.

The RCMP told the facility's operations manager that the substances were not needed, so they were destroyed.

Missed steps and non-compliance

The recovery centre's occupational health and safety (OHS) policy required a root-cause analysis be completed after a client incident.

According to the policy, the analysis was supposed to be sent to an OHS committee that would review risks and make recommendations for preventing similar incidents in the future.

But the centre did not follow that process, according to the fatality inquiry report, and a root-cause analysis was not done.

In October 2021, Corbiere's father complained to the province's Protection for Persons in Care office, which investigates allegations of abuse against people receiving publicly funded care.

A contracted investigator determined last year that one of the two allegations — staff failing to ensure the safety of a patient newly admitted to the detox unit — was founded, and that the Thorpe Recovery Centre was an unsafe environment for clients.

The Thorpe Recovery Centre offers residential addiction treatment services in Blackfoot, Alta.
The Thorpe Recovery Centre offers residential addiction treatment services in Blackfoot, Alta. (Submitted by Derek Keller)

After Joshua Corbiere's death, the recovery centre hired a consultant to review and recommend structural changes to improve the nursing and detox unit. Renovations were made done to improve nurses' sightlines.

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

A year later, compliance officers learned nurses were prescribing medication based on a pre-printed list of what to prescribe for each condition.

The province then ordered all admissions to the facility to stop and ordered the centre to work with a consultant group to deliver services.

The fatality inquiry report said the consultant group took over leading the centre and that it was the only residential treatment centre in the province to be in that position.

The chair of the board stepped down and the government and consultants worked with the board to remove the previous CEO and find a new one.

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

Centre makes changes

Derek Keller, who became CEO of the Thorpe Recovery Centre in May, said the organization made many changes after Corbiere's death, including contracting a physician's group, increasing staffing and improving its intake processes.

Staff now receive more training and rooms are checked more frequently, he said.

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

"Clarity and stronger standards, at the end of the day, benefit the clients and the reason that we're here is to provide service to them and get them onto the road to recovery," he said.

He also offered an apology to Corbiere's family.

"We're certainly sorry for the situation, for what has occurred, and certainly we've learned from that situation," Keller said.

Standards coming next year

According to the judge's report, a number of standards for residential addiction treatment providers were released last year, but the MHSPA does not include a "specific medical detoxification model of practice" that is either mandatory or could be used as a benchmark by compliance officers and licensing inspectors.

"This makes oversight of the programming more difficult," Tchir wrote in her report.

The judge is recommending the government develop that blueprint, which would include protocols for treatment, locking up medication, staff ratios, wellness checks, naloxone training and other practices.

In a statement, a spokesperson for the Alberta ministry of mental health and addiction said the inquiry "showed the previous deficiencies of the operator."

The government "has taken significant steps to address these concerns and improve the quality of their operations," the statement said.

The statement also said standards that are in development for the spring of 2025 "will significantly raise the standard of care in Alberta for detox, treatment and recovery services."