Inquest into inmate’s death recommends guards carry ‘911 tools’

PRINCE ALBERT A coroner’s inquest examining the 2017 suicide of an inmate at the Saskatchewan Penitentiary recommends correctional officers working at the facility at night be required to carry “911 tools” — curved blades that can be used to cut through restraints.

Curtis Cozart, 30, was found unresponsive in his cell around 11 p.m. on May 23, 2017. He died in hospital the following day. He had been seven months into a 28-month sentence for assault, theft, obstructing a police officer and failing to comply with a probation order.

A coroner’s inquest in Prince Albert this week heard that a guard doing the 11 p.m. count on the medium-security unit that night saw Cozart in his cell hanging from a noose made of institutional blankets. The guard was not wearing a radio, despite a policy mandating they be carried at all times, and did not have a 911 tool.

The inquest heard that the officer ran down the range to get help and instructed his coworkers to call 911. A call went out about four minutes after Cozart was discovered unresponsive.

Officers converged on his cell, unlocked it, cut Cozart down and began performing CPR. Paramedics arrived 10 minutes after the call was made and continued life-saving efforts. Cozart was taken to hospital, where he later died.

A medical doctor testified that Cozart could have been hanging for 15 to 20 minutes before he was discovered.

The inquest heard Saskatchewan Penitentiary has a policy requiring officers to carry 911 tools after 11:05 p.m., but that the tool is not regularly carried on night shifts and not all officers are aware of the policy. Officers said the devices are kept at patrol posts and available for anyone to use.

The six-person jury recommended that officers “should carry a 911 tool on their person after evening lockup, after inmates retire to their cells” and that policies should be clearly communicated to officers, possibly by having them discussed at meetings.

The correctional officer who discovered Cozart was disciplined for not carrying a radio and all officers were reminded to have radios on them after Cozart’s death, the inquest heard.

“At that time, it was fairly common for not everyone to have (a radio),” an officer testified at the inquest. “Everybody carries radios now,” he said.

Correctional manager Glen Young testified that, if the officer had a radio, it may have allowed Cozart to have been cut down 10 seconds sooner. Even if people were alerted earlier, three officers are needed at a cell to cut someone down and at the time Cozart was discovered unresponsive, all officers were at the far end of the ranges, he said.

The jury recommended that “no less than one” officer remain in a central location while security checks are happening.

The inquest heard that when Cozart was found unresponsive, an officer went to ask a manager to call 911. The manager had stepped away to use the washroom, so the officer asked the main communications and control post to call 911.

The jury recommended that any corrections officer be allowed to call 911 in an emergency.

Coroner’s inquests are not criminal trials and cannot assign blame for a death. Rather, the jury is tasked with determining a cause of death and can make recommendations meant to prevent future deaths in similar situations.