Policy changes were made when it comes to correctional officers checking on inmates after two-time murderer Traigo Andretti died in his cell from an apparent suicide, according to the now acting warden of the Regional Psychiatric Centre.
Now, a manager does random checks of camera footage of correctional officers doing their rounds – when they check on inmates and confirm they are alive and breathing, Lesia Sorokan said during day two of the inquest into Andretti’s death.
She confirmed Andretti’s death “contributed” to the change in policy after a correctional officer failed to confirm Andretti was alive during hourly checks on the night of July 1, 2016. Jeff Salyn testified Monday that it appeared Andretti was sleeping with the light on. At some point Andretti died.
“It was done too quickly,” Sorokan said of Salyn’s checks on Adretti. “It was walk-by.”
Salyn was put on administrative leave while a review was being conducted but he resigned before it was completed. He now works at the Saskatoon Correctional Centre, he testified.
Andretti was found dead by a different correctional officer when he did his first round of checks around 7 a.m. July 2. Andretti was found with his left wrist sliced and the blood had drained into a makeshift basin made of blankets and plastic garbage bags found under his bed. A Saskatoon police officer testified all evidence points to a suicide.
A handful of suicide notes and a cross with RIP in it was drawn on the cell wall. Several RPC staff members testified nothing appeared out of the ordinary from looking through the window of the cell and that all items were discovered after staff went inside.
Andretti was serving two life sentences for the killing and dismembering of two women. He was transferred to RPC through a psychiatrist referral on Apr. 26, 2016 and placed on the maximum security unit which has the most mental health treatment.
During his time at RPC he met with a psychiatrist 13 times and a psychologist six times. Sorokan went over notes from those meetings and said his suicide ideations “continued” throughout his time at the facility. He self-harmed and told staff he had suicidal thoughts and a plan, but did not disclose it. He also told staff he didn’t believe he’d be forgiven for his crimes until he killed himself and that he had too much blood in his system, which was making him sick.
Some days he told staff he was doing well and staff wrote there are no indications of psychosis or mood concerns. At one point he was put on additional mental health monitoring for suicide and self-harm concerns, but was taken off that three days before he died.
A weapon was never found in Andretti’s cell or after an X-ray was done on Andretti’s body. Chief forensic pathologist Shaun Ladham testified the cause of death was blood loss from a cut and explained the incisions are consistent with a sharp object.
Police officers and RPC staff testified they believe Andretti flushed the weapon down his cell toilet. Towels saturated with blood and what appeared to be water were found in Andretti’s sink, which could explain why no blood spatter was found anywhere in the cell, except a small area on the door.
Ladham told the inquest jury Andretti could have held something to the cut to stop blood flow and points to the paper towel rolls found in the makeshift basin.
An inquest doesn’t find criminal blame but establishes facts surrounding the death. The jury can make recommendations to prevent similar deaths.
An inquest into the death of a person who dies in custody is mandatory in Saskatchewan, unless the coroner believes the death was due to natural causes and not preventable.
The final witness is expected to testify Wednesday.
