Sawa inquest jury weighs in on jail death
After eight days of hearing from more than a dozen witnesses, the jury in the coroner’s inquest into the death of a Port Colborne man has had its say.
The six-member panel issued a list of 23 recommendations aimed at either Niagara Detention Centre or the Ministry of Community Safety and Correctional Services.
The inquest was held at the courthouse in Welland. Dr. David Eden presided with Karen Shea acting as counsel to the coroner.
“We were very pleased,” said Lisa Quesnelle, Sawa’s sister. “We made some recommendations to the jury. They were submitted between Karen and us. The jury came back with everything we asked for and more.”
Sawa, 46, a Port Colborne cab driver, hanged himself at the Thorold detention centre on
Aug. 15, 2011, after he was terrorized and beaten by inmates on the protective custody range.
After a severe beating in the shower, video of the activity on the range showed Sawa was spat on, kicked and hit in the common area. There were also reports an inmate forced a stick of deodorant down his throat. The torture ended when Sawa was driven back into his cell, given a noose made of torn bed sheets wound together, and told to use it.
Two of the inmates, Jeremy Hall and his lieutenant Cale Rose, pleaded guilty to manslaughter in Sawa’s death.
There was also evidence presented that a corrections officer sparked the attack by telling an inmate that Sawa was charged with sexual assault of a minor.
“I was disappointed that the ministry didn’t want to make any
recommendations,” Quesnelle said. “They were there for a week and a half. It is like they didn’t learn anything.
“We weren’t blaming them. We were information gathering. After all that happened, I guess they don’t think there is a problem.
“The correctional officers, Brooke Storm and Don Shaver, made some suggestions. I was pleased with that.”
Any combination of 10 of the first 13 recommendations directed to the detention centre may have saved Sawa’s life.
• The jury recommended access to the Offender Tracking Information System (OTIS) be restricted to designated correctional staff and the charge information be removed from the Unit Notification Card.
• The jury asked for a feasibility study to look at a direct supervision model in protective custody living units. Along those lines, the panel asked about the possibility of converting a small day room into a module centre with video monitoring for each wing to be staffed 24 hours a day.
• The jury endorsed a security upgrade project proposed for Niagara Detention Centre which would include installation of more video surveillance cameras in the living units which would help staff detect high-risk situations before they escalate.
• The next recommendation asked for a study to determine what additional resources are necessary to monitor the cameras and would like to see the staff complement in place at least one month before installation for training.
• The jury proposed that no more than 50 per cent of inmates be allowed out of their cells at one time when a unit is at capacity, and having correctional staff regulate, and limit, showers to two people at a time.
• Acknowledging that inmates make ropes and other items for exercise on the units, the jury asked the detention centre consider the possibility of developing recreational or fitness activities either in an area outside of the range or with sanctioned equipment on the range, all under the supervision of detention centre staff.
• The jury said staff should follow existing policy and confiscate any ropes or wraps fashioned from torn bedsheets as contraband.
• The jury also believes staff should conduct cell checks more frequently than once every two weeks for contraband and consider making bed sheets out of stronger material to prevent inmates from being able to tear it into strips.
• The ministry was asked to review its policies to ensure video surveillance footage is viewed as early as possible after an incident.
• The ministry’s Correctional Services Oversight and Investigation team should start its work and take whatever steps necessary as quickly as possible short of conducting any interviews that would adversely affect any police investigation.
• CSOI Inspectors should also interview inmate witnesses wherever possible and consider relocating them within the institution or to another institution for their safety.
• To ensure correctional staff are aware of the issues identified during the inquest, a memorandum from the superintendent should be issued to all staff to provide a summary of the issues raised as well as the recommendations of this jury.
• The jury also urged establishment of a local community advisory board for Niagara Detention Centre.