Stony Mountain suicide couldn't be prevented, inquest finds

There is nothing Stony Mountain Institution can do better to prevent suicides, says the Winnipeg judge who heard an inquest into the 2013 death of Gilbert Moise.

Moise, 21, killed himself April 7, 2013, in his cell in segregation.

Health professionals told the inquest Moise was distressed about being kept in segregation, but he showed no signs of suicidal thoughts during daily health check-ins or meetings with mental health professionals and had plans for the future, the inquest report noted.

"Short of stripping a cell down to the bare walls, and creating inhumane living conditions, I do not know what else could be done to prevent someone bent on taking their own life from doing just that," wrote Judge K. Dale Harvey in a 15-page report on the spring 2016 inquest.

"I make no recommendations for changes in policy or procedure that have not previously been considered, recommended, or made that would be likely to prevent similar deaths from occurring in the future," he added.

Just over a month into the equivalent of a five-year sentence, a correctional officer saw Moise's cell door blocked by a towel during a routine checkand opened the cell to find Moise dead. A suicide note was found in the cell.

The last person to see Moise alive, corrections officer David Olmstead, told the inquest he had felt something was wrong.

He testified that he asked Mr. Moise if everything was OK.When Moise replied "yes," the officer told him to press his call button if he needed "any help or anything."

On his next check about 30 minutes later, Olmstead made the discovery.

There was a two-minute delay while correctional officers gathered to check on Moise, as per protocol.Harvey was satisifed the delay was needed for officers' safety.

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Laura Kirby, the prison's manager in charge of segregation, testified that Moise was unhappy with his placement in the segregation unit but was there for other inmates' safety, as he had been in fights while on remand.

"Kirby confirmed that Mr. Moise twice was offered the option of a move out of segregation but declined," the report noted.

"However, he had indicated a desire to be transferred to an institution in British Columbia as he had family supports there, something that was being considered as a part of the 70-day intake process."

Moise had met with a nurse and the unit psychologist, who indicated that Moise denied any current suicidal ideation or plan.

Two days before his death, Moise met with the unit psychiatrist, who also reported no cause to suspect suicide.

"Clearly the results suggested that [psychiatrist]Dr. Yaren had no cause to suspect an imminent suicide; in fact, they suggested Mr. Moise had plans for the future, consistent with his request for a transfer to the Pacific Region to be closer to family supports," Harvey's report noted.