Inquest told police did not pass info that inmate who killed himself was suicidal

David Gillan was suicidal and had been arrested by police aware of his mental health, yet that information was not shared with the correctional staff watching him inside the HamiltonWentworth Detention Centre, an inquest into his death has heard.

Instead of being placed on a suicide watch, the 46-year-old, who was arrested by Toronto police, transferred to Hamilton police and then sent to the Barton Street jail on May 18, 2015, was placed in a cell by himself on the 4C Right unit.

By the next morning he was found dead from an overdose of several drugs, including fentanyl.

A note written partly in verse, with paragraphs written in all directions over the page was found in his cell:

“I died alone

I died unwell

I died by myself in an empty cell”

Gillan is among eight inmates whose drug-related deaths are being examined as part of a largescale inquest. His is the only one ruled a suicide by investigators.

On Tuesday, the inquest heard from several correctional officers who said they knew nothing of Gillan being suicidal. Had they known he would have been placed on suicide watch in the segregation unit, they testified.

Gillan had many friends in the jail and was well-liked on the traditionally tough 4C unit. He was very funny and was cracking jokes the night before his death, witnesses said.

Yet friends in neighbouring cells also said he was very upset about his girlfriend leaving him.

According to the agreed statement of facts read by Crown Karen Shea, the coroner’s counsel, Gillan was first admitted to the jail March 4, where it was noted that he had a number of health and mental health issues, including bipolar disorder.

He was released on bail April 29, but his surety — his girlfriend — later revoked his bail.

While being driven to the courthouse May 14 to turn himself in, he jumped from the car and later texted “I (want) to die on my own terms and not in jail.” His girlfriend reported this information to Hamilton police, saying that Gillan “alluded to making suicidal threats.”

On May 16, Gillan called back his girlfriend and said he was lost in Toronto and afraid people were out to get him. She contacted Hamilton police, who contacted Toronto police, who, because of mental health concerns, were authorized to ping Gillan’s cellphone and arrest him.

Yet there was no indication on the Hamilton police booking report about suicidal ideations. And a suicide prevention admission checklist form at the Hamilton-Wentworth Detention Centre was filled out simply with a straight line down the side of the form, striking through all the “no” boxes to questions, including about self-harm.

Lawyer Wade Poziomka, representing Prisoners with HIV/ AIDS Support Action Network (PASAN), which has participatory rights at the inquest, questioned what police communicated to the jail and whether corrections staff took enough time to assess Gillan on admission.

Initially, the inquest was not expected to hear any further evidence about police. However, Shea said she has now asked Hamilton police to respond with a witness to address what was communicated to the jail.

“It’s evident to everybody that the ball was dropped,” Poziomka said, outside the hearing.

“That’s a big blunder, had the correctional facility known that Mr. Gillan was suicidal ... you heard they would have done things different.”

He added that he’d also like to hear from the correctional officer who filled out the suicide checklist.

Correctional officer Trevor Lane was working alone on 4C the morning of May 19 and called for help when Gillan wasn’t answering during breakfast. Deborah O’Donnell, a captain at the jail, responded.

Gillan had jammed the door with material in his cell and another inmate helped by reaching in through the hatch so they could get in.

Gillan looked to be sleeping, lying on his side, with a sheet up to his shoulders and an orange jail shirt over his eyes. But further inspection showed he was already dead, likely hours, as rigor mortis had already set in.

A powder, later identified as fentanyl, was in his cell, along with the note and torn sheets that police believed may have been attempts at a noose.

The inquest also heard about the death of 44-year-old Stephen Neeson, whose nickname was Ocean.

He died from mixed drug toxicity — likely including some of his own medication that he had hoarded — on Feb. 15, 2015, inside his cell on unit 5C Left.

According to the agreed statement of facts in his death, the jail had been on lockdown since Feb. 10, when a pair of nail clippers went missing.

By the morning of his death, the jail was in such disarray that the toilets were backed up and a correctional officer had opened the cell door hatches, which are supposed to only be open for meal delivery, to help air out the cells. However, surveillance video shows inmates “fishing” packages through their hatches.

By the time Neeson was discovered after breakfast rigor mortis had already set in and he was beyond resuscitation.

The inquest continues Wednesday.