Inquest gets details on Pine Grove inmate’s death & ways it may have been avoided

Timeline of Events

Cassandra died on July 29, 2020, five days after being imprisoned for suspected arson, a charge her family disagrees with.

When she was being processed, she told a responding nurse she didn’t want to continue taking her prescribed medication for depression, ADHD, and schizophrenia. This was confirmed by Jackie Valois, a former nurse at Pine Grove, who said Cassandra ended up asking her for a refill on the morning of July 29^th. Ross was apparently hearing voices and going through withdrawal symptoms.

During this interaction and another one later that day, Valois denied seeing any signs that Cassandra was planning on taking her life.

Thanks to a video camera in her cell, we know exactly what happened later that day.

Around 5:19 p.m. Cassandra wrapped a bedsheet around her neck and tied a knot on the other end, securing it through a small gap between the top half of her bunk bed and the wall to keep it tight. Roughly five minutes later, she stopped moving.

It wasn’t until approximately 5:47 p.m. that Brett Savage, a correctional officer in a different unit, entered the cell and attempted to remove the bedsheet.

Jennifer Desjardins, the CO who was responsible for Cassandra’s unit was holding the door open. She was alerted by another inmate that Cassandra was attempting to take her life around 5:45 p.m. At the time, she claims she was watching YouTube.

An hourly check was supposed to happen at 5:30 p.m. but Desjardins didn’t specify why it wasn’t done, even though it had been signed off by a fellow CO. Though it wasn’t mentioned by any witness, the checkup may have been moved to 5:45 p.m. as the previous one was held at 4:45 p.m.

Paramedics eventually arrived at 6:06 p.m. and took over CPR from several nurses and COs including Valois, Savage, and Crystal Ingram.

She was officially removed from her cell at 6:23 p.m. and taken to the Victoria Hospital where she ended up being pronounced deceased.

Family’s Reaction

One of the people asking witnesses questions is Cassandra’s brother Cole. Initially, it was going to be their mother speaking on the family’s behalf, however, she passed away last month.

“This was the one thing she wanted to have done before she passed away,” he said. “It’s hard being here alone but I’m doing it for her.”

While he doesn’t blame anyone for his sister’s death, Cole does believe there were opportunities missed that could have stopped her.

The biggest was not putting her on suicide watch as she had previously attempted to take her life at Pine Grove during a different stay. This could have included 15-minute checks or 24/7 monitoring.

“She was suicidal… it was a surprise they didn’t put her on that list,” said Cole.

At the time of her death, COVID-19 was in its first wave of infections. This ended up limiting the time inmates got out of their cells. Though he understands why they did this, Cole believes this isolation may have played a part in her decision.

Cole was also disappointed no one was able to pick up on signs that his sister was in distress.

“(They) don’t have much interaction throughout the day, but during your rounds, you should be able to tell what a person is doing when you look in their cell,” said Cole “Their body language, vibes, their aura that they’re showing. Is she crying on the bed or is she reading a book, there are signs.”

No one who interacted with Cassandra on that day said they saw any signs. The COs who spoke at the inquest explained they have gotten very little training in mental health and how to spot signs of someone being suicidal.

The last thing that upset Cole was hearing that at least one CO was watching YouTube when they could have been watching his sister.

“I’m honestly not shocked. I’ve been in corrections before, and I know how (COs) get sometimes and they don’t always pay attention to what they’re supposed to be doing,” he said.

Cole did clarify that he doesn’t mean every CO is like this. He explained that he’s met ones that took their jobs very seriously.

Recommendations

While the inquest’s jury will come back with recommendations, several potential ones were mentioned during witness testimonies.

This included ensuring there were no more gaps between the bed and the wall, hiring more staff, and mental health training for employees.

It was also noted by several witnesses that they believe they should have a 9-1-1 tool on hand at all times. This is a roughly four-inch blade which in Cassandra’s case was used to cut the bedsheet.

At the time of her death, the 9-1-1 tool was in a separate room from the unit and had to be grabbed by another CO before any CPR could be administered. It’s kept under lock and key since it can be used as a weapon.

Meanwhile, the inquiry will continue on Tuesday starting at 9:30 a.m.

If you or someone you know is in immediate danger of self-harm or experiencing suicidal thoughts, please contact:

Canada Suicide Prevention Service (1-833-456-4566), Saskatoon Crisis Intervention Service (306-933-6200), Prince Albert Mobile Crisis Unit (306-764-1011), Regina Mobile Crisis Services (306-525-5333) or the Hope for Wellness Help Line, which provides culturally competent crisis intervention counseling support for Indigenous peoples at (1-855-242-3310).

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Jaryn.Vecchio@pattisonmedia.com

On Twitter: @princealbertnow

by Jaryn Vecchio

Inquest gets details on Pine Grove inmate’s death & ways it may have been avoided

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