Verdict at Inquest - Candice Pete

Ministry of Public Safety and Solicitor GeneralVERDICT AT CORONER’S INQUESTFile No.: 2006:255:0052An Inquest was held at Office of the Chief Coroner , in the municipality of Burnabyin the Province of British Columbia, on the following dates October 7-8, 2008before Owen Court , Presiding Coroner,into the death of PETE Candice 22 Male Female(Last Name, First Name)(Age)and the following findings were made:Date and Time of Death:January 9, 2006 at 2246 hoursPlace of Death: ICU Ward at St. Paul’s Hospital Vancouver, BC(Location)(Municipality/Province)Medical Cause of Death(1) Immediate Cause of Death: a) Multi-Organ FailureDUE TO OR AS A CONSEQUENCE OFAntecedent Cause if any:b) Acute Cocaine IntoxicationGiving rise to the immediatecause (a) above, statingunderlying cause last.(2) Other Significant ConditionsContributing to Death:DUE TO OR AS A CONSEQUENCE OFc)Classification of Death: Accidental Homicide Natural Suicide UndeterminedThe above verdict certified by the Jury on the 8th day of October AD, 2008 .OWEN COURTPresiding Coroner's Printed NameOriginal signed by O. CourtPresiding Coroner's SignaturePage 1 of 2

VERDICT AT CORONER’S INQUESTFINDINGS AND RECOMMENDATIONS AS A RESULT OF THE INQUESTINTO THE DEATH OFPETESURNAMECANDICEGIVEN NAMESPursuant to Section 38 of the Coroners Act, the following recommendations are forwarded to the ChiefCoroner of the Province of British Columbia for distribution to the appropriate agency:JURY RECOMMENDATIONS:To:BC Corrections BranchMinistry of Public Safety and Solicitor General1. All live/working video cameras to be actively monitored by appropriate staff.2. Ensure staffing levels are such that all monitors are viewed continuously.3. All emergency response kits to be checked for completeness at the beginning and end of each shiftand that after each use, to be replenished immediately.4. An appropriate delivery system to be attached to each medication.Page 2 of 2