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Dueck's responsibilities as head of the Criminal Investigations Division:
Brian Dueck Responsible for most of the detective/plainclothes officers within the Saskatoon Police. Sections within this division include: Special Investigations, Integrated Intelligence, Serious Crime, Major Crime, Polygraph, Identification, Integrated Drug, Break and Enter, Commercial Crime/Arson, Morality, Vice, General Investigations/Stolen Auto, SHOCAP and Pawn Detail. Approximately 90 personnel work in this division. The CID Superintendent is also in charge of the Center for Children's Justice and Victim Services.

In fact Brian Dueck has been responsible for the flow of drugs in Saskatoon in various capacities for a very long time. His first public gig after masterminding the Scandal of the Century as shown on Fifth Estate [CBC.ca] was to become a public decrier of the Ritalin problem. -- Sheila Steele

Something for the pain

First Nations people victims of easy access to drugs

People are abusing prescription drugs in Saskatchewan and the medical system is letting them do it.

Some doctors won't or can't say no to aggressive patients who travel from one physician to the next, piling up more and more prescriptions. An outdated system is too slow to catch these people, and not all drugs are tracked.

Pharmacists who hand out the pills don't have a computer database that lets them easily identify patients who are in danger.

A system that works may still be two years away.

Meanwhile, people addicted to the drugs keep abusing them. Some of them die. Like the two men for whom Lorraine Stonechild grieves.

The thick scent of burning sage fills the air in Lorraine Stonechild's home on Avenue E South.

She's burning it, she explains as she smiles shyly, because it will help her keep her thoughts together as she talks about the deaths of her son and her brother, who died of prescription drug overdoses less than three weeks apart in 2000.

Stonechild was told last Jan. 30 that her son, 32-year-old Gerald "Geronimo" Stonechild, died after taking too many prescription drugs.

"My son, I don't know exactly what he took," she says. "But he died of an OD at my brother's place."

On Feb. 19, Stonechild's 33-year-old brother, Darcy Dean Ironchild, drank about 30 teaspoons of the sedative chloral hydrate, slipped into a coma and died.

"I hate getting phone calls at 4 o'clock in the morning, 'cause there's always something wrong," says Stonechild, 48. "It was so hard. . . two funerals right after each other."

In some awful way, it's fitting Gerald and Darcy would die in nearly identical circumstances. Lorraine Stonechild's mother raised the men as brothers. They did everything together.

"Darcy was very heartbroken when Gerald passed away. He was depressed. He locked himself away in a room for a week, my mom told me, because he was depressed about Gerald leaving," Stonechild says.

"He was talking about 'Well, if I would've been with him, I would've taken half those pills and he wouldn't have had to die.'"

Stonechild's shaking hands clutch pictures: Darcy, who looks serious but youthful with his wavy dark hair and large glasses, and Gerald, with his smiling eyes, stare back at her.

"Darcy and I always got along. He'll always be my favourite brother. "Darcy had gifts to give. He didn't see the gifts. The drugs, they fogged him up too much."

Stonechild brushes away her long, dark hair and stares out the window. She wipes the tears gathering beneath her round glasses, and takes a drag of her cigarette and a long sip of her coffee. Suddenly, she looks older.

At a coroner's inquest last December, jurors heard how Darcy Ironchild was able to collect a stash of more than 160 mind-altering drugs, including Valium, Demerol and chloral hydrate, a sleeping medication that has been used since the 19th century. He also got scores of antidepressants, anti-anxiety drugs, antibiotics, anti-inflammatory medications and over-the-counter drugs such as Gravol, Maalox, Tylenol and ibuprofen.

The six-member jury heard how the medical system allowed Ironchild to collect and fill 307 prescriptions in a little more than a year from dozens of doctors and pharmacists around Saskatoon. All of the drugs were paid for by a federal government health program for First Nations and Inuit people called the Non-Insured Health Benefits Program.

The day after Ironchild died, Lorraine went through all of his personal belongings. She found green, white and yellow pills hidden in containers and clothes stashed around his bedroom.

Weeks earlier, Lorraine had asked her brother to get off drugs and check into a detox centre

"I knew he was using, but I didn't know how much."

On the cold morning of Feb. 18, 1999, Ironchild left his apartment sober. At 4 p.m., he went to see Dr. Renuka Prasad. Ironchild complained about depression and difficulty sleeping. When Prasad asked Ironchild if he used prescription drugs, Ironchild lied, saying he hadn't abused drugs in about three years.

"He didn't set off any alarm bells," Prasad would testify at the coroner's inquest.

Prasad then prescribed about 150 ml of chloral hydrate to Ironchild. It was Ironchild's 18th prescription for the drug in 14 months.

Shortly before 5 p.m, Ironchild left the appointment at the Medical Arts Building on Spadina Crescent. By 5:30 p.m. he was stoned on the medication and was falling down on the floor of Shopper's Drug Mart in the Midtown Plaza. He was arrested at 6 p.m. and taken to the police drunk tank. Guards said that while Ironchild appeared to be intoxicated, he didn't smell of alcohol, and at times he seemed lucid.

Ironchild slept off and on in the police cell, and was monitored by a video camera. At 9 p.m., special constable Mark Tataryn found him crying. Tataryn said Ironchild seemed sad and mentioned his brother had died.

Just before midnight, Ironchild was released from police custody. His mood was better and he appeared to be sober. The taxi driver who drove him home said he was friendly and personable.

When Ironchild arrived at his Borden Place apartment, he hung up his coat and sat down with his 29-year-old brother, Corey, to watch television.

But soon Darcy's speech started to slur and he passed out on the floor. Corey Ironchild helped his brother into his bedroom.

When a crank call awoke Corey around 3:30 a.m., he checked on his brother and found that Darcy had stopped breathing.

"He's grey," Corey told a 911 operator as he attempted to perform CPR on his brother.

A dozen fire, ambulance and police personnel arrived and tried for 45 minutes to get a pulse.

Ironchild died sometime before 3:40 a.m. on Feb. 19, a few hours after leaving police custody.

Lorraine Stonechild understands her brother's prescription drug addiction. "I was hooked on codeine drugs for quite a while, because of my operations. I had a hysterectomy. They gave me medicine to take home, and I just started taking it and taking it.

"The street drugs, they weren't a big problem in my life, I could take them or leave them. But it was the codeine. It was an easy way to hide out. "People carry around too much garbage, and they're ashamed about what they're carrying inside. I carried a lot of garbage around for years."

But one day, Stonechild's grandmother told her "to make something of herself." "So I did. I went to university and started talking to people, and healing within."

Stonechild obtained a bachelor of education in 1995, and works as a youth leader in an inner-city school.

While she understands the dynamics of addiction, she doesn't understand how the federal government allowed her brother to rack up more than 300 prescriptions before poisoning himself with a sleeping medication.

"I think doctors need to be familiar with all the health organizations that are around them, so they can refer patients instead of just writing out prescriptions.

"'I can't sleep, I need this to sleep.' Well, there's a reason why you can't sleep. Go talk to someone about it. Don't put a Band-Aid over it, 'cause it's only going to get worse."

Stonechild, who also lost her brother-in-law and her son's father to prescription drug abuse, says a detox centre based on Native spirituality should be built in Saskatoon.

Raynie Tuckanow, an addictions counsellor at New Dawn Valley Centre near Fort Qu'Appelle, says prescription drug abuse is nearly an epidemic in First Nations communities.

While First Nations people face certain social barriers that can contribute to addiction, he says easy access to the drugs adds to the problem.

"Doctors are really eager to write prescriptions out. The First Nations people are a money-maker when it comes to doctors and pharmaceutical companies," says Tuckanow, who is aboriginal.

"I went to a doctor and told him I wasn't feeling well. Right away, he wrote me out a prescription for Valium. And I just felt like I had the flu."

While doctors need to use common sense, Tuckanow says that pharmacies also need to have tighter controls on how and when they fill prescriptions.

"I'm not putting all the blame on the professional people, but something has to be done."

In addition to prescription drug abuse, Tuckanow notes that in some First Nations communities, over-the-counter drugs are also a problem. Like prescription drugs, over-the-counter drugs are covered under the NIHB program, providing the client has a prescription for the over-the-counter drug.

Because some over-the-counter drugs contain small amounts of codeine, there are people who will take between 200 to 300 pills a day in order to attain a state of euphoria.

"The tolerance level is really high among some of these individuals," he says. Tuckanow adds that while many people need the drugs they are prescribed, he worries about the increasing number of First Nations people using the NIHB program.

Dr. Peter Cooney, director general of the program, says there are slightly fewer than 700,000 Native and Inuit people across the country who get most of their drugs and medical supplies for free.

The NIHB plan covers prescription drugs, over-the-counter drugs, dentistry, medical supplies and glasses.

Any person of First Nations or Inuit ancestry can apply for coverage. Anyone who is registered with the Department of Indian Affairs is automatically covered under the program.

Of the program's 690,151 users, 104,161 live in Saskatchewan. The average age of Saskatchewan's client population is 25.

The program costs the federal government about $545 million each year, Cooney says. The pharmacy component makes up about $207 million.

Richard Truscott, provincial director of the Canadian Taxpayer's Federation, says the costs of the program are going to keep going up as more people use it, drug costs rise and inflation increases.

He thinks federal policy exacerbates the addictions problem.

"Anytime there's a service that's free and largely uncontrolled, you're asking for trouble. The government has to implement some measures to identify cases where there is suspected drug abuse."

Truscott says the government did "very little" to prevent the deaths of Ironchild and others in similar situations.

"They know the problems, but they haven't been acting," Truscott said, adding that the federal government was warned three years ago the system needed fixing.

In 1997, an auditor general's analysis of drug use over a three-month period revealed that in Saskatchewan there were 2,960 NIHB users who were going to three or more pharmacies at a time. There were also 199 clients who were getting more than 15 different drugs, and 22 clients who were getting at least 50 prescriptions in that three-month period.

Saskatchewan is in particular trouble, Truscott said.

"This is a problem because the aboriginal population in Saskatchewan is growing exponentially," he says. "Addiction is not just an aboriginal problem, but they're the ones who are most affected by this program."

As a result of Ironchild's death, Cooney says Health Canada is trying to limit how much one person can get of a particular drug.

"We identify specific drugs and develop a range of what one person should have of that drug. If a person gets more than the range, that would generate a question on our part."

As well, Health Canada is implementing a countrywide electronic system to prevent double-doctoring, Cooney says.

"All physicians have a number, and pharmacists will have to enter doctor's numbers into a computer on the claim form they're submitting. Then pharmacists will know how many doctors a patient is seeing."

Until May 1999, Health Canada had a drug utilization review process that red-flagged heavy drug users and brought them to doctors' attention.

But due to privacy laws, the process was discontinued. Health Canada also doesn't allow a patient's history to be shared between pharmacies, Cooney said.

Dr. Dennis Kendel, college registrar for the College of Physicians and Surgeons of Saskatchewan, says that while there are some computer safeguards in place in Saskatchewan pharmacies, they aren't good enough.

Kendel says the pharmacy computer systems for the NIHB program and the Saskatchewan Drug Plan both are inefficient because they are not linked. As well, pharmacists can still fill prescriptions at their discretion, Kendel adds. While a better pharmacy database is needed, doctors and pharmacists need to exercise sound professional judgment, he says.

"Some doctors, frankly, don't seem to have the capacity or inclination to say no when they feel it's inappropriate to prescribe drugs.

"Many of these patients are quite assertive in asking for these drugs. They're not passive people, and they claim they need the drug. So they get prescriptions repeatedly from the same doctor. From the evidence I saw, there's some doctors that prescribed too frequently to Darcy Ironchild."

For 10 years, the College of Physicians and Surgeons has maintained its own drug-tracking system for a group of drugs known as narcotic and control drugs, which includes drugs like Demerol, codeine, morphine and Ritalin. But the system, which keeps track of the prescription narcotic drugs through a duplicate prescription pad system, is narrowly focused and slow, Kendel says. As well, the system doesn't track tranquilizers, which are being abused in increasing amounts, he added.

"The reason narcotics were focused on is because there's no doubt that of all the drugs, narcotics are the most likely to cause drug dependency the most quickly," Kendel says.

However, Ironchild died from a drug the college doesn't track. Kendel says the college's drug tracking system is "less than ideal" because it isn't fully automated. A fully functioning pharmacy database and drug-tracking system won't be available in Saskatchewan for about two years, he says.

Lorraine Stonechild says she called the College of Physicians and Surgeons before her brother's death to alert doctors that Darcy was abusing the system. "It's ironic that we did send letters to a number of doctors alerting them to the fact that we had evidence Darcy was getting drugs from multiple sources. But when we actually sent the letters out, Darcy was already dead," Kendel says.

"Unfortunately, the amount of money invested in information technology in health care hasn't been very large."

Kendel says that limits what the college can do to help. "Just last week, for instance, I got a call from a director of health services from an aboriginal community very distressed about the level of apparent drug abuse on the reservation. She's asking for help and we would like to do whatever we can to help, but we contacted the federal officials who run the drug database and we can't get the information," Kendel says.

"And without accurate information, it's very hard to go to a doctor and say we have serious concerns about your prescribing habits, because what basis would we have to do that?"


Cops failed Ironchild: brother

Inquest debates extent to which police should help intoxicated people

Saskatoon police officers were told to bring unconscious drunks to the hospital, following the death of Darcy Dean Ironchild, the coroner's inquest into his death heard Tuesday.

A police officer testified Tuesday that after Ironchild's death a few hours after leaving police custody, police Chief Dave Scott told officers that any drunk or stoned person who was unconscious or who soiled themselves should be taken to hospital. Until February, officers each set their own standards for when to call an ambulance.

However, the change would not have helped Ironchild, who was both conscious and able to control his bodily functions when he was picked up by police.

Darcy Ironchild was pronounced dead, about five hours after leaving police custody, early in the morning of Feb. 19.

Just how far the police should go to save intoxicated people from themselves quickly became the focus on the first day of the inquest Tuesday.

"Why didn't the police just take my brother to the hospital when they had the chance?" said Ironchild's 29-year-old brother, Corey Ironchild.

The same answer came from several police officers, mall security guards and even Corey Ironchild himself: While Darcy Ironchild was quite stoned for about 10 hours before his death and came into contact with about a half-dozen people who tried to help him, no one saw any reason to call an ambulance until it was too late.

The lawyer for the police force asked Ironchild if he ever thought of calling an ambulance when his brother became incoherent and started falling asleep earlier that night.

"It wasn't bad enough that you thought you should call an ambulance or that you should call 911?" Barry Rossmann asked Corey Ironchild. He agreed.

Darcy Ironchild, 33, took between six and 60 teaspoons of chloral hydrate, a sedative, and died sometime before 3:40 a.m. on the cold morning in February. The drug was prescribed to him by a doctor to help him sleep. Ironchild's prescribed amount was one teaspoonful before bedtime.

A pathologist testified Tuesday that the drug works within about an hour. The liver requires four to 13 hours to break down the drug.

Ironchild left home sober in the afternoon of Feb. 18. A few hours later he was lying on the floor of the Shoppers Drug Mart in Midtown Plaza, telling a friend there that he just wanted to sleep.

Mall security took him into custody. Guards noted that while he seemed intoxicated, he didn't smell of alcohol. Surveillance video showed Ironchild was unsteady on his feet.

"When I asked him if he had been drinking, he said, 'Yes, his medicine,' " said Shawn Penner, a member of the mall's security detail. "Sometimes he seemed lucid. Sometimes he didn't seem to understand what we were asking him to do."

Penner called the police. Const. Shaun Landry picked up Ironchild at about 6 p.m. and transported him to the police station.

At police cells, Wade Bourassa, who was then a civilian member of the police force, searched Ironchild and took his outer clothing, his shoes and his belt. He placed Ironchild in a cell with a surveillance camera so he could monitor Ironchild's condition. Bourassa checked in on Ironchild just before his shift ended at 6:30 p.m.

"He was a person who I thought I should watch a little closely. When I put him in the cell, he had trouble walking."

This morning, the officers who released Ironchild later that night and the taxi driver who drove him away are expected to testify.

Just before midnight on Feb. 18, Ironchild arrived home. He used his own keys to get into the apartment on Borden Place, which he shared with his mother and brother. He moved easily under his own power, hanging up his coat before sitting down in front of the television with his brother, Corey.

Before long Ironchild's speech began to slur again. He fell asleep in the living room. His brother helped him to his bedroom and lay him on his side on the floor.

"I laid him down on the floor in a safer position on his side in case he vomited or something," Corey Ironchild said.

Around 3:30 a.m. a ringing phone woke Corey Ironchild. After answering the crank call, he checked in on his brother.

"He's grey," Ironchild told a 911 operator moments later as he frantically performed CPR on his brother, who by then had ceased to breathe.

The first of about a dozen fire, ambulance and police personnel arrived after three minutes and worked unsuccessfully for 45 minutes to get a pulse or a breath from Ironchild.

"My other brother died from an overdose on the 30th of January," Ironchild told the 911 operator as the first firefighters arrived.

A six-person jury, including three aboriginal people, will determine the cause of Ironchild's death and can make recommendations on how to avoid similar deaths in the future.


Sister blames doctors in drug deaths

Coroner hints Ironchild double-dipped, collected prescriptions from various doctors

Darcy Dean Ironchild was the fourth member of his family to die in a string of prescription drug overdoses, an indication the medical profession overprescribes dangerous drugs to unstable people, the inquest into his death heard Wednesday.

"These prescription drugs have taken my brother, my son Gerald Stonechild, my brother-in-law and my son's dad," Ironchild's sister, Lorraine Stonechild, told the coroner and the jury sitting on the case.

"That's why I hate these damned prescription drugs. I'm mad at the doctors who hand out these prescriptions."

The day after Ironchild died, Stonechild went through his personal belongings. She found small caches of pills scattered all over his bedroom. She found green, white and yellow pills in cassette-tape cases, shirt pockets and other small containers throughout the room.

She collected the pills and flushed them down the toilet.

Stonechild called for the creation of a detox centre with components of Native spirituality to deal with people like her brother.

Hugh Harradence, the coroner appointed to sit on the case, pointed out that Ironchild likely would not have gone voluntarily to such a facility. His sister had asked him to get off drugs and to sign up for detox outside the city only weeks earlier. He had rebuffed her request.

Harradence also hinted in his questioning that more evidence will emerge today that Ironchild was seeing several doctors and collecting a variety of prescriptions.

Other witnesses who testified at the second day of the coroner's inquest described how Ironchild joked around, tied his own shoelaces and offered a tip to a friendly cabby after he sobered-up, straightened out and left police custody as midnight struck on Feb. 18.

Within four hours Ironchild slipped into a coma and died after he likely drank about 30 teaspoons of a powerful sedative.

It was the second bender for Ironchild, who was prescribed the sleeping medicine earlier that day by his psychiatrist.

At 4 p.m. on Feb. 18, Ironchild went to see Dr. Renuka Prasad. He complained of depression and trouble sleeping. Prasad prescribed about 150 millilitres of chloral hydrate, a 19th century sedative that comes in syrup form.

Prasad asked Ironchild about his history, whether he had any suicidal thoughts or if he used prescription or illegal drugs. Ironchild lied, telling Prasad that he had been straight for three years.

"He did not present any alarm bells," Prasad testified Wednesday.

Ironchild left Prasad's office in the Medical Arts building on Spadina Crescent just before 5 p.m. By 5:30 p.m., Ironchild was stoned, stumbling and falling in the Midtown Mall. He was arrested and taken to the city police drunk tank, where he spent six hours.

John Hudson, an RCMP toxicologist, described Wednesday how high doses of the drug will produce effects within minutes. At toxic levels the drug will take effect within minutes, putting someone to sleep within an hour or two. Coma and death follow soon afterward.

Hudson said the minimum amount of the drug consumed by Ironchild ranged between 111 and 138 millilitres, or about 22 to 30 teaspoons.

"That's well within the lethal level and is about the average lethal dose we see in these cases," Hudson said.

Hudson said he doesn't see too many overdoses on choral hydrate any more. He said the drug has fallen out of favour because it is dangerous and more modern drugs are more effective with fewer toxic components. Prasad said he still uses the drug frequently for short-term sleep difficulty.

When Ironchild was arrested at 6 p.m. and taken to police cells, an officer who searched him found no drugs in his clothing.

By about 9 p.m., Ironchild slept off and on. At one point, special constable Mark Tataryn found him crying in his cell.

"He seemed quite sad from what I could tell. He made mention that a brother had been previously deceased," he said.

None of the officers who handled Ironchild that night knew what caused his intoxication or that he was prescribed the drug. One officer, special constable Renee Reimer Horner, said she might have sent Ironchild to the hospital if he'd remained emotionally unstable or if she'd known he had taken too much of a prescription sleeping drug to get intoxicated.

However, by all accounts Ironchild's mood improved steadily and he was sober by midnight.

Just before midnight Ironchild was released. The taxi driver who drove him home said he was friendly and seemed in good spirits.

Three hours later, Ironchild was dead.


FSIN wanted more from Ironchild inquest

SASKATOON - The Federation of Saskatchewan Indian Nations says it's not completely satisfied with a series of recommendations made at a coroner's inquest into the death of Darcy Ironchild last week. The jury recommended a province-wide database of health information and changes to the way the police deal with intoxicated people.

Ironchild died in February from an overdose of prescription sleeping medication, shortly after leaving police custody.

Lawrence Joseph of the FSIN says there also should have been a directive to the province to seek imput from aboriginal people.

"I think the governments, the federal, provincial, even municipal could make inroads if they would work with First Nations leadership, and start saving these lives. Include us in your deliberations and how to prevent further deaths from occurring."

The coroner's jury recommended that a task force be set up to ensure some of its suggestions are implemented. The FSIN wants to be part of that process.


Extensive drug scam netted 307 prescriptions

Inquest hears Ironchild frequented multiple doctors

Darcy Dean Ironchild ran an astonishing doctor-to-doctor, pharmacy-to-pharmacy campaign around the city - fully funded by the federal government - to net more than 300 prescriptions in the year before his drug habit finally killed him.

In the 14 months prior to his death from an overdose of sleeping medication, Health Canada paid for 307 prescriptions for Ironchild, prescriptions that were handed out by dozens of doctors and pharmacies scattered around the city.

Ironchild consumed about two-thirds of his final prescription, a mickey-sized bottle of a dangerous sedative used to assist sleep. He drank a portion of the medicine on the afternoon of Feb. 18 and ended up in the police drunk tank. When he was released around midnight, he drank more and died within three hours. About 130 millilitres remain in the 340-ml bottle he was given.

The coroner's inquest into Ironchild's death heard Thursday that a pharmacist with eight years experience at the Medical Arts pharmacy mistakenly dispensed double the prescribed amount after a mathematical error.

It was Ironchild's 18th prescription for the drug, chloral hydrate, in 14 months. Over that period he received enough of the drug to last about two years at normally prescribed doses.

This was in addition to the 164 other prescriptions for mind-altering drugs he was given in the year.

A period in 1999 provided a chilling example of Ironchild's simple plan.

Nearly every other week through that autumn, Ironchild visited Dr. Glen Jonat, a physician at a minor emergency clinic.

Ironchild presented a litany of ailments, including rashes, infections, respiratory illnesses, diarrhea and back, knee, ankle, rib and head injuries. Near the end of his visits he frequently complained about trouble sleeping.

On several occasions the doctor gave Ironchild Tylenol with codeine and a sleeping medication called Resterol. Twice the doctor gave prescriptions for sleeping medication within days because Ironchild said he had lost his pills.

At the same time Ironchild was seeing several other doctors. One was prescribing Demerol to him, another chloral hydrate. At one point Ironchild had appointments or was dropping in on at least five doctors simultaneously, including a psychiatrist, an orthopedic surgeon and a variety of general practitioners.

The federal government financed Ironchild's drug habit through the First Nations and Inuit health branch of Health Canada.

Gary Hysuik, an officer from the department, testified at the inquest that until May 1999, Health Canada had a drug utilization review process that red-flagged heavy drug users and brought them to the attention of doctors.

"It was discontinued because of privacy issues," Hysuik said. "We were directed to stop the utilization reviews by legal advice."

More than 700,000 aboriginal people have their prescription drugs financed through the plan.

About 120 of the prescriptions given to Ironchild were for non-mind-altering drugs, including antibiotics, Gravol, Tylenol and anti-diarrhea medicine.

Status Indians require prescriptions to have the government pay for non-prescription drugs.

Several witnesses, including Hysuik, doctors and a pharmacist, described how they operate in a vacuum when they prescribe drugs. Haphazard systems are in place to prevent abuse, relying mainly on luck, unsophisticated drug users or extremely specific computer systems designed to catch financial problems more than drug abuse.

The more than 200 pharmacies in the city have a "calling tree" where suspected abusers are brought to the attention of other pharmacies by organized word of mouth.

"If a patient goes from doctor-to-doctor or pharmacy-to-pharmacy, he could go a long time without getting caught. There is no organized system for catching this, it's a matter of chance or luck," said Raymond Bannister, a pharmacist with more than 40 years experience in the city.

When pharmacies dispense medication under the aboriginal drug plan, they submit funding requests by computer modem. If the prescribed drug is an exact match with a drug recently prescribed, it might be rejected immediately, red-flagging the prescription to the pharmacist.

Often the funding rejection takes 24 hours, long after the patient has left the pharmacy with the drug.

The Saskatchewan College of Physicians and Surgeons keeps track of the prescription of narcotic drugs through a duplicate prescription pad system.

College registrar Dr. Dennis Kendel said the system is narrowly focused, outdated and slow. Kendel said he hopes the proposed Saskatchewan Health Information Network (SHIN) will keep track of all prescriptions handed out in the province. Kendel, who sits on the SHIN board, said a system for Saskatchewan is at least 18 months away.

"The current system is inadequate and has a huge time lag. It is for a narrow band of drugs and doesn't catch drugs that are very troublesome and most common, such as so-called sleeping pills," he said.

Alerts were sent out twice to doctors over Ironchild's prescriptions for codeine-containing drugs, including Tylenol. The final notice was sent out in April, two months after he died. No warnings were ever sent about the more dangerous sleep medication.