ManitobaA Manitoba provincial court judge says the Winnipeg Remand Centre should address lack of medical oversight and “clear and persistent” nurse understaffing in a new inquest report into a man’s drug withdrawal death at the facility in 2021. Darren Wood, 28, died on June 3, 2021, after experiencing drug withdrawal at remand centreLauren Scott · CBC News · Posted: Oct 09, 2025 8:00 PM EDT | Last Updated: 3 hours agoDarren Wood, 28, was found unresponsive on the floor of his room at the Winnipeg Remand Centre on June 3, 2021, after being taken into custody a few days earlier. (Trevor Brine/CBC)The Winnipeg Remand Centre needs to address a lack of medical oversight and “clear and persistent” nurse understaffing, a Manitoba judge says in a new inquest report into a drug withdrawal death at the facility in 2021.The inquest was ordered in July 2023 into the death of Darren Wood, 28, who died at the remand centre nearly four years ago.Between January and April, Manitoba provincial court Judge Heather Pullan heard testimony from family members, nurses, doctors, corrections officers and provincial officials. Wood was admitted to the remand centre on May 30, 2021, telling officers he had taken “down” — heroin laced with fentanyl or benzodiazepines — and methamphetamine the night before his May 29 arrest, according to Pullan’s 161-page inquest report, released Thursday.Wood had told corrections and nursing staff that he expected to go into withdrawal. Over the next few days, Wood experienced many bouts of vomiting and reported pain in his legs, resulting in him being transferred to the centre’s medical observation cells on the morning of June 2, the report said. Paula Ewen, a registered nurse at the remand centre, testified she was working the night shift on June 2 and provided care to Wood. When she entered his cell, she said there were “massive amounts of drying vomit on the floor,” and noted that she was unaware how long he had been vomiting at that point, as key information was missing from his file. She gave him Gravol anti-nausea medication and a Boost meal-replacement drink — treatment she said she would have reconsidered if she had known he was experiencing opioid withdrawal. Later that night, a duty officer alerted Ewen that Wood was not breathing. He was found unresponsive in his cell, which staff was monitoring via camera, and Ewen began performing CPR. Winnipeg paramedics pronounced him dead at 1:55 a.m. on June 3.An autopsy the next day was unable to determine a cause of death. Little training on opiate withdrawalHowever, Pullan’s inquest report concluded that Wood died of an opioid withdrawal, based on new evidence presented during the inquest by Dr. Jason Morin, who conducted the original autopsy.The toxicology report referenced in the inquest report showed trace amounts of fentanyl and methamphetamine, which Wood likely consumed before he was admitted to the centre. At the time of Wood’s death, remand centre staff used a checklist for alcohol withdrawal, but did not have one for opioid withdrawal. The remand now uses the clinical opiate withdrawal scale to assess the severity of withdrawal symptoms.Multiple nurses testified that most people who come through the remand centre are coming down from some sort of substance, the report said, yet nurses did not receive much formal education about opiate withdrawal at the time of Wood’s death. Nurses are forced to monitor people in serious withdrawal and treat it with inadequate, less than gold standard, treatment.- Judge Heather PullanDr. Erin Knight, medical director of the addiction services program at the Health Sciences Centre, testified that the recommended treatment for opioid withdrawal is opioid replacement therapy medications, such as methadone or buprenorphine. Knight said the remand centre must update its policy around opioid replacement therapy, as “nurses are forced to monitor people in serious withdrawal and treat it with inadequate, less than gold standard, treatment,” according to the report.Judge Pullan suggested hiring more nurses, addressing understaffing at the remand centre, and increasing inmates’ access to a doctor could help prevent similar withdrawal deaths in the future. 1 nurse to 200 inmatesThroughout the inquest, multiple nurses working at the remand centre said the facility is understaffed, with licensed practical nurse Murray Olafson estimating that the ratio was one nurse to 200 inmates. According to Travis Hoemsen, the province’s director of talent acquisition, there were 20 open nursing positions at the remand centre when he spoke to the inquest earlier this year. “Nurse understaffing was a clear and persistent theme throughout the evidence of the nurses,” Pullan wrote, noting that charting “tends to slip under these circumstances.””Not everything that should have been charted in Mr. Wood’s case was, and this is a sadly common occurrence,” Pullan wrote, recommending the centre consider replacing paper charts with an electronic system that would reduce strain on staff.Pullan also called on Manitoba Justice to work with the province’s talent acquisition team to create a plan to recruit and retain nurses at the remand centre. She also recommended that inmates at the remand centre have greater access to a physician, as multiple nurses raised concerns that the primary doctor contracted at the facility is often unavailable.Physician staffing ‘insufficient,’ nurse testifiesRegistered nurse Malgorzata Koscian testified that the time a doctor is available at the remand is “insufficient for the needs of the inmates.”Dr. Paul Doucet, who has been contracted to provide clinic work at the remand centre since 1996, sees patients in a morning “doctor’s parade” — an hour-long block of time where officers bring in inmates that the nurses identified as needing Doucet’s care the day before — the inquest heard.According to the inquest report, Wood was twice put on the list, but Doucet never saw him.Koscian testified that there are times when a patient is on the list but the doctor leaves without seeing them, causing an ongoing issue where “sometimes issues remain unaddressed and wait for days,” Pullan wrote.Doucet testified that he didn’t know why Wood never saw him, adding that some people put on the list refuse care. Pullan recommended that Manitoba Justice formalize its process for how inmates at the Winnipeg Remand Centre are seen by a doctor “to ensure reasonable and ready access to a physician.”She also suggested that the province review its current physician contract for services at the remand centre, to determine whether it adequately meets inmates’ needs. The report also recommends that the remand centre’s medical unit have its operations transferred from the Justice Department, which currently oversees it, to Manitoba Health. Other recommendations include creating and implementing appropriate policies for inmates experiencing drug addiction and withdrawal.“I sincerely hope the recommendations made in this inquest report into the death of Darren Wood will prevent future deaths in similar circumstances,” wrote Pullan.ABOUT THE AUTHORLauren Scott is a Winnipeg-based reporter with CBC Manitoba. They hold a master’s degree in computational and data journalism, and have previously worked for the Hamilton Spectator and The Canadian Press.
Lack of medical oversight at Winnipeg Remand Centre, inquest into drug withdrawal death finds
