A coroner’s inquest jury has recommended making nine changes to how the Sarnia Jail operates after hearing five days of evidence surrounding the death three years ago of an inmate.
A coroner’s inquest jury has recommended making nine changes to how the Sarnia Jail operates after hearing five days of evidence surrounding the death three years ago of an inmate.
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Travis Havers, 31, was not placed on suicide watch when he was held in custody at the Sarnia 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 an agreed statement of facts heard March 4 as the weeklong inquest got underway.
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The inquest, mandatory under the Coroners Act, examined the circumstances surrounding Havers’ death. The jury was given the chance to make recommendations – while not placing blame – the Ministry of the Solicitor General could implement aimed at preventing further deaths.
After deliberating Friday, they came back with nine recommendations, including three aimed at the Sarnia Jail. They include:
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- Explore the development of a written protocol between Sarnia police and the jail on sharing information about inmates coming into custody who may be at risk of self-harm or suicide.
- Explore whether one mental health nurse is sufficient to provide a reasonable ratio and quality of care.
- Adhere to the policy of no contraband in the cells, specifically the practice of placing clothing and bedding items, on the cell bars.
The jury included six additional recommendations for the ministry, with most of them focused on the Sarnia Jail:
- Assess the feasibility of modifying the cells to remove anchor points to assist in prevention of suicide by hanging.
- Explore the potential of improvements to the offender tracking information system (OTIS) to help correctional officers avoid missing important 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.
- Any entering inmate with a history of suicide should automatically be placed on an enhanced watch until a physician or competent professional is able to deem them safe to return to normal watch.
- Review the practice to require the scheduling of medical staff from the health care unit to provide medical coverage 24 hours a day, seven days a week.
- Explore the requirement of implementing live monitoring of video surveillance by a correctional officer while maintaining the privacy of inmates.
Many of the recommendations were offered to them on behalf of the coroner’s counsel and Havers’ family, but they didn’t have to accept any of them. The ministry’s counsel opposed some of the coroner’s counsel’s and Havers’ family’s suggestions, but any recommendations brought forward by a jury following a coroner’s inquest are seriously considered.
By jury suggested a dozen changes following a November 2021 inquest into the 2018 death of Sarnia Jail inmate Aaron Moffatt.
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