Suicide prevention policies not properly followed before death of Dauphin inmate, Manitoba judge says

A Manitoba judge says policies meant to prevent suicide at correctional centres weren't properly followed in the death of an inmate who hanged himself at the Dauphin Correctional Centre in 2016. 

Freeman Zong was found dead in a shower area of the correctional centre on July 14, 2016. 

According to the inquest report into his death, authored by Judge Christine Harapiak, Zong was arrested three days prior after his brother called 911 because Zong had fired a gun at his girlfriend and threatened to harm himself.

In the spring before his death, Zong has been diagnosed with post-traumatic stress disorder and had told his assessor he was abusing prescription drugs and alcohol to cope with the death of his mother. 

When he was taken to hospital for a cut on his arm after his arrest, he denied feeling suicidal, but the admitting officer ranked him at a medium risk of harming himself, due to information in the prosecutors' information sheet about the incident for which he was arrested. None of the officers who had direct contact him the day of his death suspected he was at risk of harming himself, the report says. 

But after a series of "upsetting" telephone calls he made from jail, Zong went into his cell, and hanged himself from a vent, behind a blind corner in the washroom as the shower was running, the report says. 

'Multiple gaps' 

Harapiak found that while Manitoba Corrections has developed adequate policies to prevent deaths by suicide in inmates, there were "multiple gaps" in the implementation of these polices with Zong.

She pointed out that part of the suicide policy requires direct, personal observation of how the inmate is doing once every 30 minutes, and that corresponding records are to be made. However, on the day of Zong's death, there was no one designated to complete these observations, she wrote. 

There was also no suicide prevention contact report for Zong, which is defined as a meeting with an inmate to assess their current risk, as per corrections policy. 

Among her recommendations, Harapiak suggested developing a simple checklist with all the components of Manitoba Corrections' suicide prevention policy so that they can be reviewed daily by all staff who interact with an at-risk inmate. 

She also recommended changing vents in the correctional centre to security grade vents, which the report says has already been done, as well as having correctional staff communicate with phone contacts requested by an inmate who is at risk of suicide, and other measures to ensure that suicide prevention policies are thoroughly followed.

If you're experiencing suicidal thoughts or having a mental health crisis, there is help out there. Contact the Manitoba Suicide Prevention and Support Line toll-free at 1-877-435-7170 (1-877-HELP170) or the Kids Help Phone at 1-800-668-6868, or text Kids Help Phone at 686868.