Coroner's jury recommends cell checks every 30 minutes

Walter Short says he had hoped for more to come out of the inquest into the death of his son, James Leo Short, at the Regional Psychiatric Centre in Saskatoon in 2017, but he feels the jurors did a good job with the information they had.

“The disappointment I think comes from there was a lot more information there that may have changed things a little bit … that wasn't able to be brought forward,” Walter said on Wednesday.

James, 33, who was from Alberta, was found unresponsive in his cell in the Clearwater unit at the RPC on Aug. 30, 2017. He had been transferred to RPC from Drumheller Institution for mental health assessment and treatment in 2016 while serving a 40-month sentence for charges including robbery.

The six-person jury deemed the cause and means of Short's death to be undetermined.

An autopsy performed the day after Short died did not determine a cause of death, but found fluid in his lungs. The doctor who performed Short's intake exam in 2016 said no “red flags” were identified. James was known to have asthma and schizophrenia, but had not been examined by a physician since that intake exam.

Among the recommendations to the Correctional Service of Canada, jurors called for cell checks to be completed every 30 minutes rather than every hour, that correctional officers confirm “proof of life” and verify the inmate can be roused, and that staff are required to use their hand-held radios in an emergency.

The jurors also called for staff working in an area to be instructed on where emergency devices and supplies are located, and that their certification and training be up to date and current for their position.

They also called for “reasonable steps” to be taken to secure the necessary records if any issues of concern are identified during intake to RPC.

Walter Short said the jurors made good recommendations but there could have been more meaningful changes if they were presented with all the information. During the testimony of James's primary-care nurse, she held up a partially redacted copy of nurses' notes she said was provided by the CSC'S lawyer.

James, who was adopted, had acute fetal alcohol spectrum disorder. Walter said he and his wife tried different avenues to find help for him, but no resources were available.

James went to live on his own, ended up on the streets and began to steal; Walter said the stealing was part of his son's FASD, which can cause a person to see something and believe it's theirs. Punishing someone with FASD for theft doesn't help them learn, since they can't make the connection, he said.

He wants his son to be remembered as a quiet, talented artist. James was “caught up in a bad place, there was no help for him,” he said.

“He was always a gentle, polite, smiling, just a nice kid.”

The CSC did not respond to a request for comment by press time.