Nine recommendations have been made following a nearly week-long inquest into the death of an inmate at the Sarnia Jail.
The inquest, which began March 4, examined the circumstances of Travis Havers' death on December 5, 2020.
The 31-year-old committed suicide while in custody at the Sarnia Jail.
The five person jury made recommendations aimed toward the jail, the Sarnia Police Service and to the Ministry of Solicitor General, including exploring the development of a written protocol between the police and the Sarnia Jail regarding information sharing of inmates coming into custody who may be a risk of harm to themselves or suicide.
The jury also recommended the ministry review the practice at the Sarnia Jail to require the scheduling of medical staff from the Health Care Unit to provide medical coverage 24 hours a day, seven days a week to improve the quality of health care for inmates.
A similar recommendation was made in 2021, following the inquest into the death of Aaron Moffatt in 2018.
The inquest into Havers' death was mandatory under the Coroners Act.
The full list of recommendations is available below:
1. Explore the development of a written protocol between the Sarnia Police Service and the Sarnia Jail regarding information sharing of inmates coming into custody who may be a risk of harm to themselves or suicide.
2. Assess the feasibility of modifying the cells to remove anchor points to assist in prevention of suicide by hanging.
3. Explore the potential of improvements to OTIS Alerts that would allow for Correctional Officers to not be encumbered by excess or outdated information about offenders who have an OTIS history of suicide/self-harm to avoid missing important Alerts.
4. Explore reducing the time within the Policy that it takes for the Mental Health Nurse (“MHN”) to follow up with an inmate after a referral by a Registered Nurse.
5. Any entering inmate with a history of suicide should automatically be placed on an enhanced watch until a physician/competent professional is able to deem them safe to return to normal watch.
6. Review the practice at the Sarnia Jail to require the scheduling of medical staff from the Health Care Unit to provide medical coverage 24 hours a day 7 days a week to improve the quality of health care for inmates.
7. Explore the requirement of implementing live monitoring of video surveillance by a Correctional Officer(s) of all cells at the Sarnia Jail while maintaining the privacy of inmates. This should include the positioning of video surveillance cameras to allow for improved monitoring.
8. Explore whether one mental health nurse (MHN) at the Sarnia Jail is sufficient to provide a reasonable ratio of client to MHN, delivering quality mental health care.
9. Adhere to the policy of no contraband in the cells, specifically the practice of placing items of clothing, towels, bedding, or other items on the cell bars at the Sarnia Jail.