WARNING: this story contains graphic details that some readers may find disturbing.
The jury at a corner's inquest in Regina called for mandatory suicide training and refresher courses for jail staff, so that what happened to Elton John Heebner doesn't happen again.
They determined Heebner died by suicide between 4:09 and 5:00 p.m. CST on Sept. 2, 2018 while in custody at the Regina Correctional Centre.
Witness testimony spanned three days this week and indicated that Heebner hanged himself in his cell using a braid rope made of torn white linen.
On Tuesday, the inquest heard from Ministry of Corrections and Policing independent investigator Catherine Brooks. She filed a report on the death and found that the correctional officer — on duty when Heebner died — falsified log book entries concerning cell checks.
Furthermore, she said the same correctional officer who falsified the entries also did not remove the towel that was obstructing the view into Heebner's cell, although policy said windows were not to be covered on that unit. Brooks also found that no apparent action was taken when Heebner did not show up at dinnertime.
The jurors made several recommendations to the Ministry of Corrections and Policing about how to prevent a death similar to Heebner's.
They said correctional officers on shift should alternate between doing informal and formal checks on the inmates and they said inmate checks at meal times should be made "formal."
They also called for an increase in jail staff and suggested the jail employ a full time psychiatrist. Jurors also suggested increasing the number of correctional officers on shift, as well as having a full time nurse.
The jury said the jail should assign each inmate a personal case worker, who is not a correctional officer, who could work with the inmate for the duration of their sentence.
A history of suicidal tendencies
This week, the jury heard from witnesses that Heebner had historically displayed signs of depression, schizophrenia and suicidal tendencies during previous incarceration periods. Brooks said his file showed he attempted to commit suicide at least six times in 2015.
During the inquest, witnesses said there were no recent "red flags" for Heebner leading up to his death.
Jurors recommended jail staff receive mandatory training or refresher courses on suicide that could be done online. They also recommended the jail implement a "better assessment tool" for suicide.
On Monday, the jurors were told that when inmates are admitted to the RCC they are given an assessment to determine if they are a suicide risk. However, such assessments are seldom done after the initial one despite taking a short amount of time.
Jurors recommended that the Ministry of Corrections and Policing implement more programs in jail and improve access to programming for inmates. They also said an inmate's attendance to relevant programs should be mandatory.
During her investigation, Brooks found that Heebner had been in custody for 684 days and was on the wait list for eight programs.
Lastly, the jurors recommended that there be improved means of communication between staff throughout the facility to relay policy regulations or concerns regarding inmates. The jurors suggested important updates be posted on an electronic bulletin board and suggested that employees must sign off to ensure that they have read the information.
All recommendations will be passed along to the Ministry of Corrections and Policing, which will then have an opportunity to respond.