A coroner’s inquest jury looking into the death of a mentally ill man at the Ottawa jail has called for sweeping changes in how corrections officers monitor suicidal inmates — but has stopped short of declaring his death a homicide.
The inquest, which wrapped up Thursday, was examining the death of 31-year-old Justin St. Amour, who hanged himself in his cell at the Ottawa Carleton Detention Centre (OCDC) on Nov. 30, 2016.
He died in hospital eight days later.
St. Amour had a long history of petty crime, and during his many incarcerations had made multiple threats and attempts at taking his life.
St. Amour had been diagnosed with borderline personalty disorder and was struggling with an opioid addiction before his death.
He had also been sleeping in a cemetery prior to his final arrest.
2 dozen recommendations
On Thursday, the jury of three men and one woman handed down 24 recommendations, the majority of which were directed at OCDC and Ontario’s ministry of the solicitor general, which oversees the facility.
The recommendations include:
- That the number of health care staff at OCDC — particularly nurses, mental health nurses, psychologists and physicians — be increased.
- That OCDC provide additional mental health training to its staff, and that mental health professionals be at the jail nights and weekends.
- That the ministry and OCDC prepare discharge plans for inmates returning to the community that involve housing and mental health care, in order to reduce the « revolving door » phenomenon.
- That inmates, particularly ones who have been suicidal, automatically be considered for admission to a stable long-term facility for treatment.
- That there be video and audio monitoring of management’s offices at OCDC.
- That there be no « suspension or hanging points » in any prisoner area at OCDC, and that a « suspension point audit » be carried out at the facility.
Tom Schneider, counsel to the coroner, lauded the « intelligent jury » for issuing recommendations that would improve prisoners’ safety at OCDC.
« Justice was served. They came back with a verdict of suicide, which I think most closely reflects the evidence, » Schneider told CBC News following the inquest.
« And I think they also came back with a series of recommendations that may prevent further deaths like this in the future. »
The jury also suggested there be live feeds of the 24-7 cameras operating in the health care and segregation units at OCDC — a recommendation Schneider especially agreed with.
« If that camera was being monitored, we might not be standing here today, » Schneider said. « We might have been able to prevent this death. »
‘I could look at it both ways’
St. Amour’s mother, Laureen, said that « for the most part » the inquiry answered her questions about her son’s death, but she would have preferred it had been ruled a homicide — or at least declared it indeterminate.
« I could look at it both ways. But I respect the jury and the decision they came [up] with, » she said.
« Personally, I think they should have come with a homicide verdict, but I can see where that would have been hard, given Justin’s history. »
Nothing is going to bring my son back.– Laureen St. Amour
If St. Amour’s death was deemed a homicide, it would have been a purely factual finding and no blame would have been assigned.
As for the recommendations, Laureen St. Amour said the need for mental health staff to be on duty outside working hours was particularly pressing.
« There would [have been] someone there to help my son, whether it’s to de-escalate or put him on suicide watch, » she said.
« But nothing is going to bring my son back. »
Paul Champ, the lawyer for St. Amour’s family and the one calling for the homicide finding, said he understood why the jury didn’t end up making that decision.
« They probably had a lot of sympathy — and properly so — for those guards, » Champ said.
« It was clear that they are working in very difficult circumstances, and really trying to do their best, I guess, to care for someone who was seriously mentally ill and probably shouldn’t have been there in the first place. »
Need help? Here are some mental health resources in the National Capital Region:
Association québécoise de prévention du suicide: 1-866-APPELLE (1-866-277-3553).
Ottawa Suicide Prevention: 613-238-3311