Inquest into death of mentally ill prisoner finds staff unaware of schizophrenia diagnosis

An independent review into how mentally ill prisoners are treated in Canadian prisons has been recommended after an inquest concluded "very few staff members" were aware of the severe psychiatric concerns of an inmate who died at Manitoba's Stony Mountain Institution by suicide in 2013.

Judge Brian Corrin wrote the inquest report, released publicly on Thursday, but deferred to recommendations from the John Howard Society of Manitoba and the local chapter of the Canadian Mental Health Association, organizations granted intervenor status in the inquest into the death of Devon Sampson, 34.

In their joint submission, the advocacy groups concluded an independent review into the prison's reliance on solitary confinement and its treatment of mentally ill prisoners is necessary.

Corrin wrote their recommendations "deserve serious consideration."

The recommendations also included better training for staff, and external accreditation for mental health services at Stony Mountain.

"Devon's incarceration was characterized by repeated reference to significant mental health concerns that did not appear to inform correctional planning," the joint briefing from the John Howard Society and the Canadian Mental Health Association read.

"A consequence of a lack of co-ordination is that CSC [Correctional Service of Canada] staff responsible for the care of an inmate do not have all of the necessary information to review or assess all of the potential concerns that may arise."

An inquest is mandatory in Manitoba in cases where someone dies in custody. Its purpose is to examine what, if anything, can be done to prevent similar deaths in the future.

Neglect of mental health

The John Howard Society and the Canadian Mental Health Association found inattention to Sampson's mental health deficiencies, gaps in information sharing between staff who were inadequately qualified to deal with mentally ill prisoners, and an overreliance on inmates reporting their own mental illness to determine security measures.

Sampson was in a federal correctional facility for his third time when he died on Nov. 23, 2013.

He became entangled in the criminal justice system as an adult, while grappling with schizophrenia that brought recurrent depressive episodes.

He was also noncompliant with treatment, the inquest heard. At times, he traded in his psychotropic medications for illegal substances that fuelled his crack cocaine addiction. 

During his final stint at Stony Mountain, where he was routinely moved from custody with other inmates to solitary confinement, several staff members were never made aware of his schizophrenia, previous suicidal ideations or his need for medication.

Simpson was placed in segregation for the final time following his assault of a nurse on Nov. 10, 2013.

The individuals tasked with regularly monitoring Devon in the days leading up to his death were operating with an incomplete understanding of Devon's mental health needs.- Joint briefing from the John Howard Society of Manitoba and Canadian Mental Health Association

The staff member completing a mandated assessment relied entirely on Sampson's own admission that he had never experienced a mental health problem, when that was not true. 

Two days after the assault against the nurse, a psychiatrist ruled that Sampson had suffered a psychotic break and required additional medications to control his behaviour.

But that information was never relayed to other staff members.

"The individuals tasked with regularly monitoring Devon in the days leading up to his death were operating with an incomplete understanding of Devon's mental health needs," the joint briefing read.

"Some professionals acknowledged had they had more information, they would have altered their approach to dealing with Devon at the time."

He died from an apparent suicide nearly two weeks after the assault. 

The inquest report speculated Sampson's failure to self-report or express concern for his emotional state showed a resignation or frustration over his isolation and lack of human contact.

Placed under watch

The inquest, which began in September 2017, also investigated the suicide of Stony Mountain inmate Dwayne Flett, who died on April 15, 2015, at the age of 32, after apparently hanging himself.

In the months preceding his death, Flett, who was diagnosed with schizoaffective disorder, was placed on suicide watch multiple times. 

Staff members were reluctant to take his threats of self-harm seriously due to his contradictory statements, and suspicions that he made the threat to remove himself from stressful situations with other inmates.

However, staff took precautionary steps each time, witnesses told the inquest.

Concerned by his behaviour on the night he later killed himself, he was visited by staff every half-hour and spoke with a correctional officer an hour before his suicide, who said Flett showed no indication that he was about to kill himself.

The inquest report concluded that staff, who normally followed proper protocols, failed to place Flett on high suicide watch at that time of his death, instead opting for frequent check-ins. 

Stony Mountain Institution decided to institute full suicide observation immediately after an inmate threatens self-harm — a more stringent approach than required by federal standards and one applauded by Corrin in his report.

Since the inmates' deaths, the jail no longer segregates prisoners with "serious mental illnesses with significant impairment," Corrin wrote.

If you're experiencing suicidal thoughts or having a mental health crisis, there is help. Contact the Manitoba Suicide Line toll-free at 1-877-435-7170 (1-877-HELP170) or the Kids Help Phone at 1-800-688-6868.

With files from Dean Pritchard