Inquest recommends more mental health services after inmate's death in Manitoba jail

WARNING: This story contains discussion of suicide. If you or someone you know needs help, please see the end of this story for resources.

An inquest into the death of a 26-year-old man who killed himself while incarcerated in segregation in 2020 is recommending more mental health services for inmates at the Manitoba jail where he died.

Jordan Timothy Sutherland was transferred to the Milner Ridge Correctional Centre, near Beausejour in southeastern Manitoba, from the Brandon Correctional Centre in the province's southwestin April 2020, after exhibiting self-harming behaviour. That includedhitting his head against a wall during his pre-trial detention, the inquest report into his death released Thursday said.

When he got to Milner Ridge, Sutherland asked to be put in the segregation unit because he didn't feel comfortable going into a regular unit with other inmates. In the following days, Sutherland was assessed as a low suicide risk and seen over video by a psychiatrist who said he was doing well and decreased the amount of medication he was taking.

Sutherland stayed in segregation for about a month, and during that time didn't attempt self-harm or express suicidal thoughts. He moved back into a regular unit for two weeks before asking to move back into segregation in June 2020, saying he wasn't having thoughts of self-harm, but wanted to have his own cell and area to work out.

About eight hours after Sutherland moved back into segregation, an officer found him dead in his cell during a routine check.

The report described him as a polite, respectful person but said he "appeared to have been struggling with addictions and homelessness for some time."

"It was clear that his death and the entire incident had an impact on many staff at Milner Ridge, some of whom went on leave following the tragic event," the report said.

"Mr. Sutherland's death is no doubt painful for his family and friends."

Lack of psychiatric nurses

The inquest heard from a number of witnesses, including a longtime psychiatric nurse at the institution who testified that Milner Ridge is now home to more inmates with mental illnesses than ever before,and that those mental health issues are now more severe.

"She felt that many of the inmates in segregation should be in the psychiatric hospitals," the report by provincial court Judge Dave Mann said.

The inquest earlier this year also heard from several people, including the psychiatrist who assessed Sutherland, who said Milner Ridge should have a psychiatrist available at least one full day every week instead of the current half-day, which the mental health worker said forces him to see 10 or 11 people for short visits in a single afternoon and sign off on medication for another 14 or 15 he doesn't see personally.

That was one of the eight recommendations in the report, which also recommended increasing the number of psychiatric nurses working at the facility to at least five full-time equivalent positions. The inquest heard the institution's lack of psychiatric nurses was evident in the fact that after Sutherland's medication was reduced, no psychiatric professional followed up with him within a few days, which is considered best practice.

That failure to follow up "appears to have been largely a resource issue," said the report, which noted that because psychiatric nursing staff are only available during the day at Milner Ridge, anything that happens after 4:30 p.m. gets dealt with by corrections officers.

The report also recommended hiring an in-house psychologist at the facility, at least on a part-time basis, and exploring the introduction ofmental health group programming facilitated by either mental health nurses or a psychologist.

It noted when Sutherland was in segregation for over a month, amandatory 30-day assessment wasn't done,and recommended adding a reminder into the jail'ssystem to ensure those checks aren't missed.

Other recommendations in the report included ensuring staff are up to date on suicide intervention training, looking into adding air bags to help withCPR to all units' code red bags for medical emergencies, and adding a second computer to the facility'sstaff lounges to keep workers better informed about policy changes.

The report also noted there were internal investigations and reports completed before the inquest that addressed some of the other issues preceding Sutherland's death, including a small gap between the cell's concrete bunk bed and the window on the wall it was attached to, whichallowed him to tie two bedsheets together to hang himself.

Following an internal review, the jail welded a metal plate to close that gap in all the cells that had a similar design to the one Sutherland was in, which the report said should prevent the same thing from happening again.

If you or someone you know is struggling, here's where to get help:

• Canada's Suicide Crisis Helpline: Call or text 988.
• Kids Help Phone: 1-800-668-6868. Text 686868. Live chat counselling on the website.
• Canadian Association for Suicide Prevention: Find a 24-hour crisis centre.
• This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.

If you're worried someone you know may be at risk of suicide, you should talk to them about it, says the Canadian Association for Suicide Prevention. Here are some warning signs:

• Suicidal thoughts.
• Substance abuse.
• Purposelessness.
• Anxiety.
• Feeling trapped.
• Hopelessness and helplessness.
• Withdrawal.
• Anger.
• Recklessness.
• Mood changes.