Inquest recommends review of Manitoba solitary confinement after man kills himself in custody

An inquest into the death of a man who killed himself after more than three weeks in solitary confinement has recommended a full review of the use of segregation in Manitoba's correctional institutions.

Jeffrey Tait was found unresponsive on the floor of his cell at the Headingley Correctional Centre on Jan. 29, 2019, with a piece of fabric wrapped around his neck, a report on the inquest by Manitoba provincial court Judge Stacy Cawley released Friday said.

A day earlier, the 31-year-old man was released from a weeks-long stint in segregation because staff noticed his mental health declining. During a review, Tait said he was not doing well.

He was also emotional and was seen rocking back and forth in his cell, but was never assessed as more than a low risk for suicide, the report said.

While he was prescribed medication for symptoms of mild psychosis, he refused to take it later on the night of Jan. 28. The next morning, Tait asked staff if he could smudge, the report said, noting he was meeting with an elder who helped him develop a spiritual care plan.

Because of a policy forbidding outdoor access when the temperature is below –32 C, his request was denied. Tait became argumentative and threatening toward staff, the report said.

He also refused to return to his cell and asked to go back to segregation — a request the report said staff complied with to de-escalate the situation.

Out of view

Within two minutes of entering the cell where he would later be found dead, Tait covered its camera with wet toilet paper, obstructing its view.

By the afternoon, the toilet paper started to dry and peel away enough to show Tait sitting against a cell wall with a blanket over his head, the report said.

He got up just before 3:30 p.m. for his meal delivery and joked with staff.

After receiving the tray, he was seen sitting on the floor against the wall with a piece of white fabric tied around his neck.

Within minutes, he fell to the right, out of the camera's view. Correctional staff did security checks twice in the next hour, but didn't notice Tait was unresponsive — though senior management said those rounds should confirm inmates are alive and safe.

He wasn't discovered until 4:48 p.m. After failed resuscitation attempts, he was pronounced dead less than a half hour later.

Tait, a father of four, also left behind his partner and both his parents, the report said.

23 days in segregation

The report said Tait spent 23 days in segregation before he died, including time in solitary confinement at the Dauphin Correctional Centre immediately before being moved to Headingley.

The bulk of that was 15 days of punitive segregation he got from a discipline board at Headingley, after an earlier incident at the Dauphin jail where he smashed his cell window with a chair.

That's the maximum disciplinary segregation sentence an inmate can be given for a single incident, the report said.

He was also placed in segregation while in the Winnipeg Remand Centre before Dauphin, "due to his gang status and incompatibility with other inmates."

The use of solitary confinement has been the subject of a number of lawsuits across Canada, including one certified as a class-action case last year in Manitoba and another in Alberta. 

Another lawsuit in Newfoundland and Labrador was certified as a class action case in 2021, while Ontario lost its bid to quash a $30-million class-action award for its mistreatment of inmates in solitary confinement the same year.

Report recommendations

The report on Tait's death recommends the province get an independent third-party agency to do a review of the use of segregation in Manitoba jails. 

Specifically, it recommends the agency review whether segregation is actually being used as a last resort, determine how to reduce the amount of time inmates spend in segregation and how to protect their mental health while they're in it, and recommend alternatives to segregation.

It also recommends the government create additional specialized housing placements for inmates with mental health concerns like Tait, since one of the reasons he spent so much time in segregation was because of limited specialized housing options.

The report recommends Manitoba Correctional Services do more training for staff around what to do if an inmate tampers with a cell camera, that senior management at Headingley do a review of their monitoring operations and that the facility create a space accessible year-round for cultural and spiritual practices like smudging.

It also recommends the province spend more to improve cell designs and make it harder for inmates to tamper with the cameras, and to improve suicide-risk training at Headingley — including specialized training on how segregation can affect mental health.

The province said Friday it is reviewing the recommendations.

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

• Talk Suicide Canada: 1-833-456-4566 (phone) | 45645 (text between 4 p.m. and midnight ET).
• Kids Help Phone: 1-800-668-6868 (phone), 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.

If you're worried someone you know may be at risk of suicide, you should talk to them about it, says the Canadian Association for Suicide Prevention. Here are some warning signs: 

• Suicidal thoughts.
• Substance abuse.
• Purposelessness.
• Anxiety.
• Feeling trapped.
• Hopelessness and helplessness.
• Withdrawal.
• Anger.
• Recklessness.
• Mood changes.