Krystal Tavernier is relieved to finally get closure after waiting four years to learn more about the circumstances leading up to her husband's death.
Darrel Tavernier, Arun Kumar Rajendiran and Stephen Kelly died by hanging between 2014 and 2019 at the Central East Correctional Centre (CECC) in Lindsay, Ont. Their suicides were the subject of a two-week joint coroner's inquest that wrapped up Monday, and the crux of 38 recommendations that Tavernier herself helped shape, aimed at helping the Ontario government prevent future suicides.
Tavernier says she believes that if these checks and considerations were put in place before they arrived at the CECC, they could have made it more difficult for the three men to take their own lives.
"I'm not putting the blame on anybody, or on any one thing," said Tavernier, who shares four children with Darrel Tavernier.
"I believe that all of these gentlemen, at the end of the day, they had a plan and would've executed the plan regardless of the circumstances. But it certainly did make it a lot easier to be slipping through the cracks and not being paid attention to."
While Tavernier is hopeful the recommendations will be implemented and help prevent future deaths, an advocate says many of these suggestions have been relayed to the Ontario government in previous inquests, and could be a sign that lessons learned aren't paving the way for change fast enough. According to the Office of the Chief Coroner, from 2016 to 2019, there were 78 deaths at provincial correctional facilities. Of this number, 21 — or 26 per cent —were suicides from hanging.
"I just have the expectation that when we deal with so many of these deaths in similar circumstances — particularly suicides — that the province would have taken enough action up to this point that we wouldn't be having this inquest to begin with," said Sarah Speight, a member of the Criminalization and Punishment Education Project, a research and advocacy group organized by students and professors at Carleton University and the University of Ottawa.
A summary of recommendations include:
Initializing a full audit and review of the quality of health care at the CECC.
Prioritizing staff recruitment and retention.
Implementing an electronic records system to replace the current paper system.
Improving mental health care for inmates, and mental health training for staff.
Scaling back segregation for inmates on suicide watch at the CECC.
All inquests to be done within 24 months of the incident date.
If implemented, not only could they improve inmate health and safety, but also the ability for staff to do their jobs properly, says coroner counsel Jai Dhar.
"There are a lot of people that the jury heard from that really are trying their best," Dhar said."And for reasons that are beyond their control, are not always able to provide the quality of care that they know they should be providing."
Revealed in the inquest, Dhar states Kelly's original health file was misfiled and missing when staff became aware of his death, and Tavernier was scheduled for a psychiatrist appointment weeks before his death. It never actually took place. In Rajendiran's case, he was never flagged as a suicide risk and never saw a psychiatrist, social worker, or mental-health worker during his time at the CECC.
Similarly, Dhar says that CECC staff testified that the facility is operating with only half the number of nurses it can employ and that due to staff shortages and the limitations of the facility's physical space, it can only meet the mandated two hours of social interaction for those on suicide watch and in segregated units up to 50 per cent of the time.
"There needs to be more resources put in place to ensure that the standards that currently exist are actually being met," Dhar said.
Coroner's inquests — which seek to uncover the circumstances that led to specific deaths and prevent future ones — are legally required in custody deaths, but aren't legally binding.
Speight says the recommendations from previous inquests, along with the Ministry of the Solicitor General's official responses, aren't shown to jurors and aren't easily accessible to the public, making it even harder for the public to keep a watchful eye on the province's plans.
In response to the recommendations, the Ministry of the Solicitor General states it takes deaths in custody "very seriously" and is carefully reviewing the jury's recommendations before responding to the Office of the Chief Coroner. It has six months to respond.
"Recommendations from coroner's inquests remain an important resource to the ministry for developing or improving facility operations and inmate safety," reads the statement.
Tavernier says no matter what happens, she hopes other families get spared from having to wait for and sit through coroner's inquests to find out what happened to their loved one.
"There definitely needs to be some urgent reform, and it needs to be done immediately, not toiled around like the last few times."