Cell guard, Ottawa police testify on 2nd day of inquest into death of man in RCMP cell

The second day of a coroner's inquest into the death of Adla Pudlat heard emotional testimony from the cell guard present when the man was found dead in an RCMP cell in Cape Dorset, Nunavut.

Pudlat was found dead early in the morning of May 20, 2016, having killed himself, according to police testimony heard on day one. Nunavut law requires an inquest in cases where someone dies in police custody. The inquest is looking into the circumstances around his death and how similar deaths can be prevented in the future.

Six jurors are listening to testimony this week in Cape Dorset. It will be up to them to confirm how Pudlat died and provide recommendations to the RCMP and government on how policies can be improved.

Pudlat's sister, Shekulia Pudlat, hugged Allen Morrison, the on duty cell guard on the night of Pudlat's death, before he started testifying Tuesday.

Morrison said he had been called in to guard last minute, arriving just before 8 p.m. on May 19. He testified that he was not told that Pudlat's sister had reported that he was having suicidal thoughts.

On Monday, an RCMP officer, Const. James Dibert, said he had been informed Pudlat was talking about suicide on the day of his detainment, but didn't pass it on to the other officer on duty because he didn't see any signs of mental distress from Pudlat and often, nothing comes of it.

Morrison also said Pudlat exhibited no warning signs for suicidal behaviour — signs he, as a social worker with 15 years of experience, said he was trained to recognize.

He'd been a guard in the community for about half a year, and previously worked in the same capacity in Baker Lake, in 2011.

To get that job, he was required to do a three-hour in-class training on what to do in the case of fire or other emergencies and had shadowed other guards, but he had significantly more relevant experience than that.

He'd previously worked at Nunavut's Department of Family Services and logged what he estimated was more than 100 hours of online training through the department's RELIAS online training platform in Nunavut-specific training with modules on culture, history and violence.

Procedures for prisoners with suicide risk

Guards are required to check on prisoners in cells every 15 minutes, Morrison testified. RCMP officers and Morrison said that it's standard to vary that time by a few minutes — checking on the prisoner after 12 or 16 minutes, for example — so there's no identifiable pattern.

In cases where the prisoner may be a threat to themselves, those checks are increased to every 5 minutes.

When confined to cells, prisoners are stripped down to one layer of clothing, but what they are wearing is not logged on the prisoner intake form — only what personal effects are kept by the officers.

If there are mental health concerns about a prisoner, they don't get to keep their own clothes but are put in an un-rippable gown called a babydoll, police testified.

The increased checks and gown were not used that night, as Dibert, who picked up and assessed Pudlat, said Pudlat told him he was not thinking of suicide.  

Cell guards are not permitted to enter the cells except in cases of emergency, so Morrison was checking on Pudlat through the cell door window and through the meal tray slot in the door, which is around knee height.

Early on in the evening, Morrison had a discussion with Pudlat, but around 8:30 p.m. from the window Morrison could only see Pudlat's legs and assumed he was sleeping on the floor with his head near the door.

Morrison testified he thought he could hear Pudlat breathing, so he let him sleep. When he didn't move for several hours, Morrison began knocking on the cell door and asking Pudlat questions, but didn't get a response.

It was around 1 a.m. when he called Dibert, the officer on duty, to come to the detachment, open the door and check on Pudlat.

Once the door was open, Morrison and Dibert testified that it was clear Pudlat had died by suicide using an article of clothing.

This finding was confirmed by the medical examiner and the external investigation team that was called in, members of which also testified for the inquest on Tuesday.

Ottawa police investigation

On the morning of Pudlat's death, the Ottawa police were called to investigate because Pudlat died under police supervision.

Nunavut's RCMP has a memorandum of understanding with the Ottawa police. An investigation team from Ottawa looks into police-involved deaths so the Nunavut RCMP aren't investigating themselves.

The investigation began that evening around 6:30 p.m. Sgt. Eustace "Sam" Roberts conducted a forensic scene investigation. He'd been told it was a suicide, but said he was looking for any possibility when he entered the cells.

The investigation team leader, Sgt. Nicole McGetrick began conducting interviews with those involved.

She interviewed any officers who had dealings with Pudlat, finding out that police were investigating him for an assault on his stepfather two days earlier.

In Pudlat's medical records, she found that he had expressed that he was thinking about suicide to a nurse in Cape Dorset and the nurse had encouraged him to come in for follow-up appointments.

Both Roberts and McGetrick testified that the results of their investigation confirmed the in-custody death was a suicide.

The inquest is scheduled to continue through Thursday.

Where to get help:

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.

First Nations and Inuit Watch helpline at 1-855-242-3310.

Canada Suicide Prevention Service

Toll-free 1-833-456-4566

Text: 45645

Chat: crisisservicescanada.ca

In French: Association québécoise de prévention du suicide: 1-866-APPELLE (1-866-277-3553)

Kids Help Phone:  1-800-668-6868 (Phone), Live Chat counselling at www.kidshelpphone.ca

Canadian Association for Suicide Prevention: Find a 24-hour crisis centre

Indian Residential School Resolution Health Support Program 
Northern Region 1-800-464-8106