Inmate’s death inquest jury mulling potential suggestions for changes at the Sarnia Jail

A coroner’s inquest jury was mulling Friday more than a dozen potential recommendations about how the Sarnia Jail is run in response to an inmate’s death by suicide more than three years ago.

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Travis Havers, 31, was not placed on suicide watch when he was held in custody at the jail on Dec. 3, 2020. He died two days later of asphyxia by hanging and a correctional officer found a suicide letter on the bed in Havers’ cell, according to a statement of agreed facts heard Monday as the five-day inquest got underway.

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This week’s inquest, mandatory under the Coroners Act, has been examining the circumstances surrounding Havers’ death. The jury may make recommendations – while not placing blame – aimed at preventing further deaths, which the Ministry of the Solicitor General could implement.

After hearing from the final witness Friday, four potential recommendations were offered to the jury on behalf of the coroner’s counsel, the Ministry of the Solicitor General’s counsel, and Havers’ family. They included:

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• Explore the development of a written protocol between Sarnia police and the Sarnia Jail on sharing information about inmates coming into custody who may be at risk of self-harm or suicide.
• Explore potential improvements of the offender tracking information system (OTIS) to ensure correctional officers don’t miss important alerts.
• Review the jail’s practice that requires the scheduling of medical staff from the health care unit to work 24 hours a day, seven days a week.
• Adhere to the policy of no contraband in the cells, specifically the practice of clothing and bedding items being placed on the cell bars.

The coroner’s counsel and Havers’ family suggested 10 more potential recommendations, but the Ministry of the Solicitor General’s counsel opposed them. They included:

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• Have the ministry assess the feasibility of modifying the cells in the Sarnia Jail to remove anchor points to help prevent suicide by hanging.
• Implement a policy that all cells have tear-resistant bedding to avoid suicide by hanging or self-harm.
• Explore current policies and procedures regarding the initial admission process of inmates and consider a peer or supervisor review to avoid missing alerts.
• Explore reducing the time it takes for the mental health nurse to follow up with an inmate after a referral by a registered nurse.
• Implement the requirement for peer review of any referrals by the registered nurse to the mental health nurse to ensure an inmate has been seen in the required time.
• All inmates should have access to 24-hour mental health care either in person or by telephone.
• Any incoming inmates with a history of suicide should automatically be placed on enhanced watch until a doctor is able to deem them safe to return to normal watch.
• Explore implementing live monitoring of video surveillance by a corrections officer of all cells while maintaining the privacy of inmates.
• Install automated external defibrillators in each area of ​​the jail so they are closer and easier to access.
• Increase the amount of mental health training correctional officers receive and require yearly updates.

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“You’re not obliged to accept any or all of these recommendations, but we know that you’ll give them careful consideration,” coroner counsel attorney Aniko Coughlan told the jury after presenting the 14 points.

The jury also has to answer five mandatory questions based on the evidence they heard this week: who died, how they died, where they died, when they died, and manner of death.

It wasn’t clear by press time Friday when the jury will come back with its verdict and decision on any potential recommendations. Although scheduled to take only five days, the presiding officer said Friday they may have to come back on a different date.

By jury suggested a dozen changes following a November 2021 inquest into the death of Sarnia Jail inmate Aaron Moffatt.

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@ObserverTerry

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