Moses Beaver inquest hears calls for better communications, psychiatric care at Thunder Bay jail

WARNING: This story discusses mental distress and suicide.

Jurors at the inquest into the death of Moses Amik Beaver have been hearing again and again about systemic issues within the corrections system and the strained communications between the people who provided him care. 

Beaver, a Woodlands artist from Nibinamik, an Oji-Cree First Nation in northwestern Ontario, was 56 when he died in custody in Thunder Bay. The inquest — which the Ontario Coroner's Act says is mandatory when a person dies in custody — is in its third week. 

The jury learned this past week that Beaver died by suicide on Feb. 13, 2017. He had been found unresponsive in his cell in the Thunder Bay District Jail and was then brought to the Thunder Bay Regional Health Sciences Centre, where he was pronounced dead.

It took three weeks for Beaver to see a psychiatrist after arriving at the jail from Nibinamik, the jury heard. The psychiatrist who saw him, Dr. Peter Schubert, testified he was not given information about the mental health crisis Beaver experienced in Nibinamik leading up to his incarceration.

He also did not know Dr. Megan Bollinger of Sioux Lookout, who helped facilitate care for Beaver at Nibimanik's nursing station, called the jail with concerns about Beaver's medication and offered to assist with his care/release plan.

Had he known this information and had access to more of Beaver's medical records, Schubert said Beaver's care plan at the jail would have looked much different.

The pattern of missed communication was seen repeatedly in Beaver's case, he said.

Mental health care remains at the forefront of the inquest. Schubert, who provided services at the jail from 2003 to 2018, said he was unable to meet the demand for psychiatric services there; he was given about three hours a week to provide care to about 200 inmates, many with complex mental health and addiction issues.

Mental health nurse Jason Cooper, who saw Beaver before Schubert did, was also unaware of what happened to Beaver in Nibinamik preceding his arrest. He, too, did not know Bollinger had reached out to the jail to offer support.

In 2017, there were only two mental health nurses operating at both the Thunder Bay District Jail and Thunder Bay Correctional Centre, and before his arrival, there was only one, Cooper said. Hiring more mental health nurses and providing them access to electronic charting were his top recommendations for the jury.

Providing mental health care in jail difficult: psychiatrist

Beaver was in the special handling unit of the jail, reserved for inmates who may be injured or under enhanced supervision due to mental health or behavioural concerns.

He was initially placed on suicide watch, where inmates are checked every 10 minutes, and was then downgraded to enhanced supervision, where inmates are checked every 15 minutes. Checks are done every 20 minutes in the special handling unit otherwise, the jury heard.

An inmate on suicide watch may be isolated, lose yard access, have to wear a safety gown, eat with their fingers instead of utensils and have the lights on all the time, Schubert explained.

"In a lot of ways, it's counterintuitive to psychological well-being," he said.

Beaver was not under any special watch at the time of his death. There was a period of minutes between when it appeared Beaver attempted suicide and when correctional officers responded to his cell, the jury observed from video footage within the jail.

Security cameras in the special handling unit do not show the inside of cells. The question was raised as to whether officers would have responded to Beaver sooner had there been video monitoring within his cell.

Schubert told the jury providing mental health care in a jail, particularly to those who have experienced trauma, can be challenging. Comparisons to how mental health patients are treated in hospitals versus jails have been made numerous times during the inquest, with hospitals focused primarily on treatment and jails on security, jurors heard.

They also heard Beaver attended day school, which was similar to residential school except students did not stay there overnight. Schubert spoke of this when discussing the impact of trauma on Indigenous inmates.

"[Beaver] does not know me, and he is in an environment where he's being watched by an officer. He's in a jail cell. He sees me probably as an extension to the institution rather than a therapist he picked to come and see," Schubert said. 

"It is not necessarily going to be the place where he wants to open up at this time and talk about all the trauma and these effects it's had on him in the past, and in fact, I would say that would be the wrong thing to force [him] to do."

Many witnesses referenced the high proportion of Indigenous inmates at the jail — it was estimated at 70 to 75 per cent of the institution's population.

Staff Sgt. Mark Dyrland of jail testified that when his career began 35 years ago, there was no cultural awareness training for correctional officers, but that has changed in recent years. However, he said more training — on the legacy of colonialism, unconscious biases, and how to address systemic racism — would be useful.

Jail staff detail space constraints, staffing challenges

Staff Sgt. Rylan Forrest of the Thunder Bay District Jail spoke of the challenges with overcrowding and resources within the jail in 2017, but said he feels optimistic about improvements coming from the new correctional complex under construction.

The $1.2-billion project will replace the aging jail and correctional centre. The 345-bed facility is expected to be opened in fall 2026.

One promising aspect of the new complex, said Forrest, is there will be no bars or tie-off surfaces within the cells in the special handling unit. He was unsure whether these changes would be made in all cells.

"I think having that type of cellular environment would be important for all inmate safety," he told the jury.

Now-retired correctional officer Brian Billard testified he found Beaver unresponsive in his cell. He recalled attending one suicide awareness course for his job, but said that was the extent of his mental health training. 

"We're not equipped to deal with mental health issues," said Billard.

He also spoke of overcrowding and understaffing at the jail, with a handful correctional officers having to oversee dozens of inmates and shuffle between rooms to provide programming — another reason the new correctional complex is needed, the jury heard.

Billard had dealt with two suicide attempts at the jail prior to Beaver's, he said.

"It accumulates over time when you get involved in those kind of things. They're very stressful, tragic events. They get worse and worse, the feelings. It's not a job for everybody."

More mental health training for correctional officers, along with more support for jail staff following stressful incidents, would be beneficial, he said.

During the inquest's third week, the jury is expected to hear expert analysis on health care in correctional settings, services for Indigenous inmates and responses to acute psychiatric crises in fly-in First Nations.

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.

Support is available for anyone affected by their experience at residential schools:

A national Indian Residential School Crisis Line has been set up to provide support for former students and those affected. People can access emotional and crisis referral services by calling the 24-hour national crisis line: 1-866-925-4419.