(File photo/ paNOW Staff)

By Nigel Maxwell

Correctional changes

Coroner’s inquest results in eight recommendations to prevent inmate deaths at Sask Pen.

Nov 4, 2022 | 2:02 PM

Additional mental health supports at Saskatchewan Penitentiary, a review of policies related to prescription medications to mitigate diversions, and overall facility upgrades were among the final eight recommendations by a jury at a coroner’s inquest in Prince Albert.

In late February 2020, 27-year-old Curtis McKenzie was found hanging from his cell door, and was pronounced deceased in hospital two weeks later. Meagan Ward represented the family at the inquest and feels the recommendations were thoroughly thought out.

“We all know that mental health continues to be an ongoing concern for [Correctional Service Canada] and something everyone struggles to deal with, so it’s good to see the jury taking that seriously,” she said.

Curtis McKenzie’s history of depression and self harm was discussed in great detail during this week’s inquest. (Facebook)

With relation to those mental health supports, the jury recommended having an addictions counselor, elder, or clergy member on site to assist the team. There was also a recommendation for additional mental health training and to lower the caseload for doctors and parole officers, to allow for more one-on-one time with each inmate.

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Ward noted she personally would like to see individuals with specialized mental health training as the ones making decisions.

“Making sure the inmates have access to those resources on a 24/7 basis as opposed to the evidence we heard here and making sure qualified people are making decisions I think is really important to all of us,” she said.

One of the highlights of the testimony this week was the revelation that the health officer who made the recommendation to release McKenzie from a medical observation cell, just hours before his suicide attempt, had been on the job less than two months. The officer also did not have a medical license, and their training related to self-harm and suicide prevention involved a four-hour online course.

Policy at that time dictated that someone in her position could make the recommendation so long as it was done under the supervision of someone with a provincial medical license, and she did follow that policy as written. The on-site policy has since been changed to dictate only those with a medical license can perform the assessments.

Following the initial news of McKenzie’s death, Kim Beaudin, National vice-chief of the Congress of Aboriginal Peoples, had expressed to paNOW his personal desire to have an inquest.

Now over two and half years later, he said he thinks the jury did a very good job but added he would have liked to have heard a recommendation related to self-harm and policy related to razor blade use.

“And that to me is a huge policy issue, Matter of fact, as an organization we are going to focus on that,” he said.

Prior to his death in 2020, McKenzie had a lengthy history of self-harm, including cutting his own nose off. Reasons given for his dark thoughts related to anxious feelings about his upcoming release and the discontinuation of the anti-depressant medication he had been receiving. The pathologist told the inquest he could not even count the number of slash marks on McKenzie’s body.

While expressions concern that some managers at the inquest appeared disconnected, Beaudin said he was pleased with how many people took the time to get to know McKenzie. Included with testimony this week were descriptions of McKenzie’s passions for drawing, cooking, and music.

“They gave him a personality. They talked about what he was like as a person and that was very important, he said”

Over the course of the past four days, over 20 witnesses testified including the warden, various correctional staff, parole officers, health care professionals, and inmates.

From here, the jury’s recommendations get sent to the Provincial Coroner and will then be shared among all the agencies involved. Beaudin mentioned plans as well to discuss the inquest next week with the national aboriginal advisory committee for Corrections Canada.

“We have to be engaged because sometimes our voices are the only ones the public is going to hear. Even the families want to know there’s somebody in their corner,” he said.

Final list of recommendations

1) to CSC – review of policy and best practices related to diversion of highly valued medications, especially with high risk offenders

2) to CSC – having an addictions counsellor, elder, minister, or clergy member on site to assist the team with decisions

3) to CSC – lower caseload numbers for doctors, physicians, and parole officers to ensure more one-on-one time with clients

4) to CSC – nurses provided with radios to help ensure faster response

5) to CSC – additional mental health training encouraged for all staff

6) to CSC – assess/upgrade facility to include an interview both for assessments with inmates, additional observation cells, and an upgraded elevator

7) to CSC – review online medical records system in order to provide improved medical offender records, and more accurate and detailed notes (especially related to diversion) to ensure improved communication among healthcare staff

8) to Victoria Hospital – provide immediate info and notes related to inmates who are discharged

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nigel.maxwell@pattisonmedia.com

On Twitter: @nigelmaxwell