Inmate suicide at Manitoba prison 'tragic but unpreventable,' inquest finds

WARNING: This story contains details of suicide.

A man's death by suicide at a federal prison in Manitoba was "tragic but not preventable," says an inquest report into the 2019 death.

Timothy Koltusky, 34, was a convicted dangerous sexual offender who was serving a sentence of two years and 11 months for breaching a long-term supervision order when a correctional officer found him hanging from a ceiling pipe in his cell at Stony Mountain Institution on March 12, 2019.

"It is impossible to know what prompted Timothy Koltusky to take his own life," provincial court Senior Judge Donald Slough wrote in an inquest report issued Thursday.

Evidence was presented during the inquest that Koltusky had been bullied leading up to his death but did not present any acute mental health concerns at the time.

A "self governing" code among inmates meant Koltusky was a target because as a sexual offender, he was at the bottom of the hierarchy.

"As such he would be a target for violence and bullying," Slough wrote.

Despite reports of Koltusky experiencing bullying in his unit in prison, fellow inmates and correctional officers testified at the inquest that he was "forward thinking, engaged in institutional programming and work, moving forward with his life" in the time leading up to his death, the report said.

Regardless, he had expressed to a psychologist two months before his death that some inmates in his unit had been making his life "a living hell," and he had feelings of anxiety over being threatened by other inmates.

"When asked by Crown counsel if this disclosure would trigger a transfer to another unit or institution the witness indicated such a transfer would only come about if it was requested by the inmate," Slough said.

"Timothy Koltusky made no such request."

History of depression

Koltusky had been diagnosed with a "long-standing history of depression" and had made suicide attempts, one as a youth.

He suffered physical and sexual abuse during his childhood and was incarcerated for repeated sexual violence toward sex workers, the report said.

While in provincial custody in 2008, he attempted suicide "but changed his mind and was saved by the intervention of correctional officers," Slough said.

Despite Koltusky's history, Brice Beirnes, his parole officer, testified he "expressed shock" when learning of the death and that he saw no signs to suggest suicidal ideation or a plan to end his life.

The Correctional Services of Canada board of inquiry into the death examined any pre-incident indicators, precipitating events, security classification of the inmate, mental health care provided, staff presence and staff response to the incident, including medical interventions. Its report was filed as evidence in the inquest.

"Having carefully reviewed that report I am satisfied the steps taken by correctional officers on March 12, 2019, were appropriate, to try to save Timothy Koltusky," Slough said.

"There is nothing in the evidence to suggest that inadequate care or supervision contributed to Timothy Koltusky's death."

If you or someone you know is struggling, here's where to get help:

• Canada's Suicide Crisis Helpline: Call or text 988.
• Kids Help Phone: 1-800-668-6868. Text 686868. Live chat counselling on the website.
• Canadian Association for Suicide Prevention: Find a 24-hour crisis centre.
• This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.