Judge makes no recommendations in suicide at Edmonton Remand Centre

Donald Kushniruk was the first inmate to die at the new Edmonton Remand Centre.

The 49-year-old killed himselfinside a cell on the mental health unit three years ago, shortly after the facility opened.

A fatality inquiry report into his death was released Monday, but made no recommendations to prevent similar deaths.

Judge Kirk MacDonald determined staff followed all the rules and policies in place at the time.

"Mr. Kushniruk's suicide was sudden, unexpected and executed in secret," MacDonaldwrote in his six-page report."No one could have foreseen Mr. Kushniruk's actions; and absent that foresight, no one could have prevented them."

Kushniruk was no stranger to the remand centre or staff on the mental health unit. He had previously spent 31 months in the old remand centre on minor charges that ultimately resulted in a seven-day sentence.

The final report made no reference to Kushniruk's former brush with the justice system, which the chief judge of the Albertaprovincial courtcalled one of the "worst" and "saddest"he'd ever seen.

• "Miscarriage of justice:" the trial of Donald Kushniruk

The father of two was sent to the new remand centre with symptoms "consistent with paranoid schizophrenia"after allegedly threatening his probation officer in May 2013. But staff did not believe Kushnirukexhibited any suicidal tendencies and noted he had never threatened self-harm in the past.

He was in custody for two weeks before he killed himself.Staff said he caused no problems and his behavior did not raise concerns.On the last night of his life, staff checked on him hourly and didn't notice anything out of the ordinary until 4:09 a.m.

During the last check, a correctional officer thought Kushniruk's head was at an odd angle,so he entered the cell and found a ligature around the inmate's neck.

Actions "deliberate" and hidden

The fatality inquiry found Kushniruk fastened a strip of cloth from his bedsheet around his neck, then used a book to make a tourniquet to tighten the sheet. A securityvideo showed Kushniruk got up from his bed at 1:07 a.m. to get a book from his table.Then he was seen "doing something under the sheet".

"Plainly, Mr.Kushniruk'sactions were deliberate and calculated to frustrate observation or discovery," MacDonald'sinquiry report noted."The reasons for Mr. Kushniruk's suicide, and their origin and duration, are as hidden from us now as his actions were in that dark cell."

After thedeath, SheilaHallett told CBC News herex-husbandwas mentally ill and the justice system was no place for him.

"He was not a criminal,"Hallett said. "And you know in the end, I think he was just tired of fighting."