WARNING: This story contains details some may find disturbing.
A jury has made 32 recommendations following an inquest into the death of an Indigenous man at the Millhaven Institution near Kingston, Ont.
The recommendations into the 2018 suicide of Brennan Nicholas include that staff should promptly review provincial medical records after a transfer and that Correctional Services Canada (CSC) should expedite a purpose-built therapeutic facility at the federal prison.
The 24-year-old Nicholas, who was originally from the Oneida Nation of the Thames, died at Millhaven's regional treatment centre on June 15, 2018.
The inquest, which began in late February, heard from CSC health-care staff and Nicholas's family and was shown surveillance video from the day of his death.
Jurors found that Nicholas died by suicide. The cause of death was a cut to his neck.
'We wish you strength' says jury foreperson
Thirty of their recommendations were aimed at CSC, including ensuring Indigenous inmates have access to both elders and space at Millhaven for ceremonies, including dedicated sacred grounds.
The jury also called for staff at CSC to review medical records when an inmate is transferred and ensure those files are easily accessible and quickly uploaded to the federal online system.
"There are many who will forever feel the loss .. to each of you we wish you strength," the jury foreperson said in a brief address to his family.
Nicholas spent time under suicide watch, was banned from having razors and had tried to take his own life on two separate occasions while incarcerated at the Elgin-Middlesex Detention Centre (EMDC), according to an agreed statement of facts.
He was transferred to Millhaven in February 2018 to serve a life sentence for second-degree murder, but the jury was told that his nearly 250-page provincial health-care record — which detailed his history, triggers and razor bans — was not uploaded to the CSC system or reviewed by employees.
Despite that, CSC medical staff testified even if they had reviewed the record it would not have changed their own assessment of Nicholas, his care and whether or not to provide him with a razor.
Christa Big Canoe, the lawyer representing his family, said they'd contemplated arguing that his death was a homicide as Nicholas used a razor to take his own life and it "blatantly obvious" he shouldn't have had one.
She said his mother, Denise Desormeaux, felt it was "no different than giving someone who was struggling a gun, rope, knife or weapon — the means to end life — when he was not in the best mind or ability to resist."
In her closing statement, Big Canoe added the family was "mind-boggled" that his provincial file wasn't reviewed and that Nicholas's death showed systemic failures.
She pointed to a "dire picture" shown in statistics from the most recent annual report from the Office of the Correctional Investigator, which found 55 per cent of self-injuries in prisons involved Indigenous people and 83 per cent of all incarcerated people who died by suicide in 2020-2021 were Indigenous.
"CSC is not improving correctional service or rehabilitation to Indigenous people despite alarm-ringing about the problems for literally decades," she said.
Mathew Johnson, the lawyer representing CSC, said Nicholas's death was a tragedy.
He referenced testimony from regional treatment centre staff who said 80 to 90 per cent of inmates there have a history of suicide or self-harm and described treating patients with such complex needs in a prison as "incredibly challenging."
While simply not giving Nicholas a razor may seem like an easy solution, the lawyer said he believed it wasn't that simple.
"I would suggest to you that CSC was being cautious," he told the jury.
"Rather than putting Mr. Nicholas on a restriction that they did not believe they could enforce, they decided that the best approach is to acknowledge the reality of their environment and try to build coping skills."
Prison has changed razor protocol
Razors had previously been handed out by the inmates themselves, but Johnson said that protocol had changed and that staff were now issuing electric razors instead.
The jury recommended CSC continue to ensure only staff hand out the electric razors and said they should be available at all correctional institutions.
Inquest counsel Kate Forget stressed that the situation showed a communication breakdown between EMDC and CSC.
"One of the most difficult facts that we've had to face throughout this inquest is that Mr. Nicholas did communicate," she said. "He communicated on multiple occasions, to multiple people, that razors were a trigger or that razors were not a good idea for him to have."
Forget went on to recall a moment Desormeaux had shared from her son's time at EMDC, where they sang songs and drummed together through the glass at the provincial jail.
"We all felt that moment and we can relate in the same way, universally, when we think about a mother's love for her child," she said, fighting tears.
Jury members were provided with a list of 40 proposed recommendations, 18 of which were supported by both CSC and the family.
Family members suggested another 18 of their own — some of which were reflected in the themes of the jury's recommendations — including that staff should undergo suicide-prevention training and increased Indigenous-specific training and that elders and knowledge keepers are adequately funded.
On the inquest's first day, Desormeaux shared how her son loved sports and animals as a child, but had endured abuse and suffered trauma.
She remembered him as an amazing brother, friend and uncle who had "such good medicine" in his laughter and referred to anything he really liked with a catchphrase — "classic."
Nicholas lived with addiction and mental health struggles before being convicted and spending time behind bars.
His death "destroyed" the family, Desormeaux said, describing the effects as "enormous grief that does not seem to be going fully away."
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