Jury urges better training, communication, after inquest into death of Cape Dorset man
A jury in a coroner's inquest has issued several recommendations to RCMP, the Nunavut government and Embrace Life Council after the death of a Nunavut man in police custody three years ago.
A group of six jurors heard testimony last week in Cape Dorset, Nunavut, about the circumstances surrounding the death of Adla Pudlat, 29, who died in an RCMP cell on May 19, 2016.
The jury heard Pudlat had been brought into RCMP custody earlier that evening after his sister reported he bit her on the neck while drunk, and was talking about killing his step-father and himself.
An inquest is required by Nunavut law after the death of anybody in police custody.
After hearing four days of testimony from the medical examiner, RCMP, independent investigators from Ottawa police services and Pudlat's family, the jury released a verdict to confirm that Pudlat died by suicide using an article of clothing. The jury also made recommendations to RCMP and government on how to prevent anything like this from happening again.
The jury found there was a lack of communication between the officer who took the initial call, his partner officer and the cell guard.
The verdict also states "due to no cameras, or audio, and restricted view, the guard had difficulty seeing," which meant he did not have all the information he needed to keep Pudlat safe.
Noise from nearby appliances interfered with the guard's ability to hear what was going on in Pudlat's cell, as well, according to the verdict.
The 26 recommendations largely fall under three umbrellas: improve training, communicate better and improve conditions at the jails to reduce the risk of self-harm.
To improve training, the jury makes several recommendations including:
Any relief RCMP officer who arrives in a Nunavut community should receive Inuit cultural competency training delivered by Inuit instructors where possible.
Police officers should be required to take Embrace Life recommended training: mental health first aid for Inuit, in in-person training sessions.
RCMP staff and civilian guards should receive a Nunavut version of ASIST (Applied Suicide Intervention Skills Training) across the territory.
RCMP should develop a guard training course specific to Nunavut that includes a refresher every six months.
Efforts to hire Inuit as RCMP officers should continue.
The jury also recommends RCMP and the Nunavut government improve communication through a number of actions:
All guards should have a briefing meeting before duties.
The prisoner's intake form should include what the person was wearing when entering cell, as well as a summary of what was said during the emergency call for service.
Log books should be filled out more thoroughly, and if somebody in the cells isn't moving, the guard should try to wake them up.
The recommendations also suggest improvements to the jails themselves:
Make sure any equipment that could interfere with hearing be turned off.
RCMP should improve visibility through cell doors, in order to better monitor prisoners.
There are also three recommendations specific to the government of Nunavut, including one to provide safe rooms for potentially suicidal people at health centres, as an "alternative to RCMP detachment cells."
The jury also recommends the Embrace Life Council continue to raise public awareness about suicide and provide training in Cape Dorset "as soon as possible."
The coroner's counsel encouraged the jury to make these recommendations to Embrace Life Council, to recognize the importance of continuing to fund the council for the good work it's doing
Where to get help:
If you're worried someone you know may be at risk of suicide, you should talk to them about it, says the Canadian Association for Suicide Prevention.
Indian Residential School Resolution Health Support Program, Northern Region — 1-800-464-8106
