Inmate inquest jury recommends changes to Correctional Service of Canada

The inquest into the death of an inmate at the Saskatchewan Penitentiary ended Friday morning with the jury of six determining facts about the case and presenting several recommendations to prevent similar deaths in the future.

The 27-year-old inmate, Curtis McKenzie, was found unresponsive in his cell after he hanged himself on February 26, 2020. He was declared dead on March 9, 2020, at Victoria Hospital by means of hanging by suicide.

The jury made eight recommendations, seven of which were directed to the Correctional Service of Canada (CSC) and the last one to Victoria Hospital. The recommendations were as follows:

To CSC:

1. To improve policy and best practices regarding diversion of highly valued medication especially with high-risk offenders.
2. To include addictions counsellors, elders, ministers/clergy in their multi-disciplinary team so clients may have the opportunity to access a variety of supports.
3. To work towards lowering caseload numbers for doctors, physicians, parole officers, mental health staff, and health care staff (client-to-service provider ratio) to ensure staff have additional time to adequately assist clients.
4. To provide nursing staff with radios so they can be contacted quickly in order to provide medical assistance as soon as possible.
5. Due to mental health staff challenges, providing additional training regarding mental health issues should be encouraged for all staff.
6. Access/upgrade facilities to include: an interview booth for interviewing observation cell inmates, additional observation cells, and an upgraded elevator.
7. To review the online medical record system in order to provide improved offender medical records and more accurate and detailed notes, especially regarding diversion. This will ensure improved communication among health staff.

To Victoria Hospital:

1. To ensure Victoria Hospital staff who discharge the Penitentiary offender provide immediate notes pertinent to the visit.

Megan Ward, counsel for the family of Curtis McKenzie, said she was happy with the recommendations the jury made and how some addressed mental health issues.

“We knew that a lot of this was going to circle around resources and mental health, so it’s nice to see recommendations that really address those issues,” Ward said.

“I think the family will be happy with what’s in there. I still think there’s still work to be done even past those recommendations, and obviously having the recommendations is one thing, but making sure that those are implemented is a whole other story.”

If given a chance to give a recommendation, she said it would be to ensure inmates have access to mental health resources 24/7 and make sure qualified people are making decisions when it comes to mental health.

Kim Beaudin, National Vice-Chief with the Congress of Aboriginal Peoples, agrees that implementation will be something to watch out for but hopes the inquest will start building momentum for changes in policies.

“I’m fully aware that they (CSC) don’t really follow a lot of the recommendations that come out,” said Beaudin.

“There was no reference to the issue around self-harm in terms of razor blades, and that to me is a huge policy issue. As an organization, as CAP, we’re going to focus on that. I think that’s something that needs to be fully addressed.”

Witnesses at the inquest testified to McKenzie slashing his body approximately 30-40 times using a razor blade. The blade is included in an inmate’s hygiene kit to be used for shaving.

Apart from the recommendations presented, Beaudin says he is happy about how some of the witnesses described McKenzie as a person.

“One thing that at least I was happy about was that they humanized Curtis. They gave him a personality. They talked about what he was like as a person. That was very important because when people go in corrections services and prisons in Canada, ‘out of sight, out of mind’,” said Beaudin.

The jury report containing details about the case and the recommendations will be forwarded to the Chief Coroner’s office in Regina and then to the involved agencies – CSC and Victoria Hospital.