Inquest recommendations include more timely access to elders, suicide prevention training
- Kaitlynn Nordal | July 29, 2019
The inquest into the death of Waylon Starr wrapped up on July 25 at Court of Queen's Bench in Regina.
During the morning’s proceedings, Coroner Brent Gough, who presided over the inquest, reminded the jury that their recommendations and findings were to be based solely on the testimony heard from the witnesses and exhibits that had been seen since the 22nd.
When instructing the jury, Gough said the evidence seen pointed to intentional, self-inflicted wounds and were intended to cause self-harm or death. He also noted that there was no evidence that anyone had any physical contact with Starr between 7 p.m. and 10:27 p.m., when he was found by correctional worker Justin Amyotte.
Gough also reminded the jury that Starr did not have a roommate and his door had remained closed, according to the security footage.
During the proceedings Gough gave some suggestions for recommendations.
He said the Regina Provincial Correctional Centre (RPCC) should establish a clear policy on window coverings in the jail as one witness said they should be taken down immediately, another said there should be a balance between an inmate's dignity and safety, and a third said they could be left up for about 20 minutes.
Since Starr was unable to see an elder, Gough recommended there should maybe be faster access to elders and chaplains at RPCC.
In one of his final suggestions for recommendations, he suggested suicide prevention training and re-certification for all staff and there should be staff briefings during shift changes.
At this time, he reminded the jury these were only his thoughts and their findings and recommendations should not be swayed by them.
After deliberating for roughly four hours, the jury came back with their findings and recommendations.
The six jurors agreed that Starr died on August 24, 2017 at 23:23 at the Regina Provincial Correctional and his cause of death was asphyxiation by hanging, which resulted in suicide.
Their recommendations were:
1. Provide timely access to elders. The meetings should be offered on intake forms and during every medical visit. This could require more elders on staff at RPCC.
2. Require mandatory suicide prevention training for all staff, with re-certification every three years.
3. Review cultural awareness training offered to staff with consultation from First Nations elders.
4. Require staff briefing at every shift change. Audit all log books regularly to ensure correct record keeping and legibility of records.
5. Create a policy for in-cell privacy and inmates blocking their windows. Do not allow subjective interpretations of the policy.
6. Determine if there are times when incidents are more likely to occur and increase staffing and checks.
7. Develop a more formal method for the inmate’s family to alert staff and leave messages if there are any issues.
8. Conduct mock rescue drills with staff.
After the inquest, Gough thanked the family for attending and asking questions during the proceedings.
"I cannot tell you how important it is for the operation of the system for people to participate," Gough said. Gough also said their input was reflected in the recommendations and could prevent deaths in the future.
The jury also expressed their condolences and said some have also lost family members to suicide.
Starr's mother, Verna, said she was happy about the recommendations for elders and a new system for families to contact workers. She had harsh words for staff at the correctional centre.
"I was very happy because maybe they'll lift their phones up and get off their asses and stand up and listen to some people that need help,” said Verna. She hopes these changes prevent other suicides in the future. "It is my hope, because I have a lot of relatives that are in the same situation and some of them did try and commit suicide but they were there for them right away," said Verna.
However, she still wants to see someone held responsible for her son's death through the justice system.
“My confidence level is kind of low right now because it seems so unreal,” said Verna. “I want to see someone held accountable, because somebody shouldn’t be pleading to talk to an elder. They [prison officials] are not taking them seriously enough. They should take them seriously when they admit they tried to commit suicide the day before.”