A total of 11 recommendations have been made following an inquest into the death of a Sarnia Jail inmate five years ago.
The nearly week-long inquest, which started on September 22, examined the circumstances surrounding the death of Brent Moore on August 30, 2020.
The jury heard the 40-year-old died in hospital two days after being transferred from the Sarnia Jail, where he was found in his cell with a bedsheet around his neck and no vital signs.
The five person jury made two recommendations toward the Sarnia Jail, including providing refresher training every two years for health care staff regarding documenting a person in custody's medical care to ensure consistency and completeness.
The jury also provided eight recommendations to the Ministry of the Solicitor General, including evaluating the feasibility of persons in custody seeing a mental health nurse within 48 hours of referral.
The inquest into Moore's death was mandatory under the Coroner's Act.
The full list of recommendations can be found below:
To the Ministry of the Solicitor General - Sarnia Jail:
1. Provide refresher training every two years for health care staff at the Sarnia Jail regarding documenting a person in custody's medical care in Health Care Record - Part D, to ensure consistency and completeness.
2. Evaluate the feasibility of:
a. Increasing the hours of a primary care provider to visit the Sarnia Jail, in person, on a regular basis, to provide health care for persons in custody.
b. Having a psychiatrist visit the Sarnia Jail, in person, periodically, to provide mental health care for persons in custody upon referral.
To the Ministry of the Solicitor General:
3. Consider having a Designated Medical Request Form with the following recommendations:
a. Using unique identifier (e.g. coloured paper) for medical Request Notes for staff to differentiate and prioritize medical requests.
b. In order to ensure the continuity of medical Request Notes, the following must be documented on the note:
i. The person in custody's name and the date it was written. If the person in custody does not include this information, the receiving staff member must include it.
ii. The name of the staff member who receives the Request Note and the date and time it is received.
iii. The name of the health care staff member who first receives the Request Note and the date and time it is received.
iv. The name of the health care staff member who acts on the Request Note and the date and time.
c. The action taken by health care staff should be documented in the Medical Record.
d. Develop training, including appropriate response times, on the above for all correctional and health care staff.
e. Ensure all inmates are aware of specialized medical request form upon arrival.
4. Wherever possible, considering operational limitations, interactions between health care staff and a person in custody should be conducted in a private space, not in an area where conversations can be overheard by other persons.
5. Evaluate the feasibility of persons in custody seeing a mental health nurse within 48 hours of referral.
6. Include a prompt on the Health Care Record - Part A to ensure persons in custody who indicate opioid substance use are being referred to a health care provider to discuss options for opioid agonist treatment.
7. Consider formalizing a process for ongoing mental health follow-up with persons in custody who have requested mental health assistance, including after the request has been addressed.
8. Consider creating Ministry-authored mental health screening tools to replace the Brief Jail Mental Health Screen and Jail Screening Assessment Tool, that can be updated to meet the needs of the Ministry.
These new screening tools should:
a. Use current and plain language that would be accessible to both health care staff and persons in custody. (i.e. avoid words like anhedonia, neologisms)
b. Avoid language that has a religious connotation (i.e. sinful)
c. Include the risk factors and warning signs identified in section 6.2 Suicidal Screening and Identification, Suicide Prevention Policy.
9. Send out a reminder email to all health care staff to advise of the availability of the Jail Screening Assessment Tool's resource booklet and e-learning module. Ensure that staff stay up to date on the accurate completion of this tool.
10. Consider using the circumstances of Brent Moore's death in training for both health care and correctional staff as a case study in identifying those who have some risk factors for suicide and request mental health support, but may not be forthright about their feelings, thoughts or suicidal ideation.
To the Office of the Chief Coroner
11. When conducting a death investigation at a correctional facility, the investigating coroner or Regional Supervising Coroner with carriage of the matter should speak with the physician at the facility in order to more fully inform their investigation
