A coroner's inquest will continue hearing testimony Tuesday in connection with the hanging deaths of three inmates at a provincial jail in Lindsay, Ont.
Arun Kumar Rajendiran, Darrel Tavernier and Stephen Kelly were found dead in their cells between 2014 and 2019 at the Central East Correctional Centre (CECC) — a provincial institution with a history of controversy, including the violent death of Soleiman Faqiri in 2016, and a mass inmate hunger strike in 2020.
All three deaths involved the use of a bed sheet and notes indicating an intent to commit suicide were found in each case.
The inquest, which is being held virtually, got underway Monday and is expected to last two weeks. The coroner's jury will hear from approximately 21 witnesses.
Coroner's counsel Jai Dhar told the jurors Monday they will learn more about suicide prevention in correctional centres, including the procedures, policies and training correctional and health staff are given. The jury will also hear how staff assess, treat and manage inmates at risk of suicide.
"One of the questions that you are probably going to ask over the inquest is: are those protections adequate?" Dhar said in his opening statement to the jury and presiding coroner Dr. Bob Reddoch.
The jury will make recommendations aimed at preventing further deaths.
"Nothing that comes out of these procedures is going to bring Stephen back, or the other gentlemen," said Carolyn Moore, Kelly's common-law partner, during the families' remarks.
"But we definitely need to find ways to improve the system so that the other families don't have to experience what these families have had to go through."
Arun Kumar Rajendiran
According to an agreed statement of facts, Arun Kumar Rajendiran, 25, was admitted to the CECC on Oct. 22, 2014 to serve a 730-day sentence after being convicted of conspiracy to commit an indictable offence.
He asked to be transferred to a different facility because he feared for his safety, and went on a hunger strike for five days. Staff responded by placing him in an isolated unit.
On Nov. 12, 2014, the day his transfer was approved, staff found him unresponsive in his cell. They attempted CPR and used a defibrillator until emergency services came, but paramedics were unable to revive him.
Dhar told the jury Rajendiran was not flagged as a suicide risk and never saw a psychiatrist, social worker, or mental-health worker during his time at the CECC..
Tavernier, 42, who was charged with various sexual offences was in custody waiting for trial. He was granted bail, but did not post. A few days after he was admitted on Oct. 14, 2017, he was flagged as a potential suicide risk and moved to an isolated unit, Dhar said.
After seeing a psychologist, he was removed from suicide watch and returned to a shared cell, but was still flagged for "potential suicidality" for the next month and a half.
He was found unresponsive in his cell on Jan. 1, 2018 by his cellmate. Staff used CPR and a defibrillator to no effect. Dhar says a "privacy sheet" was found in his cell and said Tavernier most likely used it to shield his suicide attempt from his cellmate.
Almost 20 notes were found in his cell, some of them indicating "an intent to commit suicide," Dhar told the jurors.
Stephen Kelly, 62, was admitted May 7, 2019. He was charged with first-degree murder, and was placed in custody on remand to wait for his trial, the jury heard.
Health-care staff put him on suicide watch on May 9 but he was eventually removed and placed on his own in a single cell.
Dhar told the jury there was a note in his health-care file ordering daily mental health assessments, which was "not implemented."
One week after being removed from suicide watch, he was found dead by a corrections officer in his cell on May 18..
Jurors heard from two witnesses Monday.
Seena Fazel, a forensic psychiatry professor at Oxford University, told the jury there are several factors that increase the likelihood of suicide among inmates, including:
Conviction on violent and sexual offences,
Being on remand.
Previous suicide attempts.
A history of self harm.
Traumatic life events and diagnosed illnesses.
He said interventions include housing inmates in buildings designed to prohibit harm and tailored cognitive behavioural therapy to treat intense mental illness.
Jarret Merriam, a CECC superintendent, told jurors the centre has about 1,000 inmates, and that province-wide, 76.4 per cent of all people in provincial custody are in remand awaiting further trial and court proceedings.
His testimony continues Tuesday.