Coroner's inquests a 'toothless tiger,' say critics, as inmates continue to die behind bars

When Debra Taylor heard another inmate hanged themselves in a Windsor, Ont. jail she almost broke out in tears. Her brother died the same way more than a decade before, leaving her wondering if his death and the painful inquest that followed were all in vain.

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The Ministry of Community Safety and Correctional Services still does not supply all inmates with tear-resistant sheets, despite Coroner's Inquest recommendations spanning decades that say the simple change could stop people from hanging themselves and save lives.

"The inquest tore all of us apart and to not take any of those recommendations to heart, and for it to happen senselessly again, is just unfathomable to me," said Taylor. Her brother Jamie Farmer took his own life using bed sheets in 2003. 

How many people have to die until it's looked at? If it's a safety hazard ... then do something about it.- Selina McIntyre, mother of Delilah Blair

An inquest completed a year after his death recommended the ministry "obtain acceptable, non-tearable sheets and pillow cases for all inmates." 

In the past 20 years at least five people in Windsor jails have turned sheets meant for comfort into a noose used to end their lives.

Ministry says inmates prefer comfortable sheets

Inquests into Farmer's death and the death of Michael Henderson in 2001 both make recommendations that tear-proof bedding be given to all inmates, but a spokesperson for the ministry said that direction has not been followed.

"Inmates prefer more comfortable standard bedding than the tear-resistant bedding, which is only used in exceptional circumstances," said Brent Ross. "Retaining standard bedding is a good way to engender a positive and cooperative atmosphere in our institutions."

But family members mourning loved ones say discomfort is better than death.

"My brother's death was in vain then," said Taylor. "This is a human life, even if the person was in jail."

On May 21, Delilah Blair took her own life at the South West Detention Centre. Government officials have not said how she died or if there will be an inquest. Selina McIntyre told CBC a coroner confirmed her daughter hanged herself in her cell using bed sheets.

For Taylor, the details brought back a "deep sadness" and memories of her brother, who she was so close with he was "halfway between her sibling and child."

"What makes me really relive it is the pain that I know other people are going through when this happens," she explained. "I could cry just thinking about it because I wouldn't wish that pain on anyone."

Inquests a 'toothless tiger'

Bed sheets may be the biggest killers in Ontario detention centres, according to Kevin Egan, a lawyer with McKenzie Lake law firm in London, Ont, who is representing hundreds of inmates in lawsuits over jail conditions. 

• VIDEO: Tour the South West Detention Centre

"It [hanging] seems a fairly common thing to do," he said, adding that jails are not motivated to improve the lives of inmates because of a lack of funding and training, combined with a "general attitude that the lives of inmates don't matter." 

Egan has represented the families of several inmates who took their own lives in prison. Despite having an "incredible amount of time" to make corrections to sheets and several other dangers to inmates, the government has largely ignored inquest recommendations, he explained.

"I refer to inquests as a toothless tiger. It looks good, they're investigating, but often nothing comes of it," Egan said. "They know these dangers exist and they're basically turning a blind eye to it and allowing the deaths to continue."

Simone Rickerby has wrestled with that tiger. As Farmer's stepmother she represented the family through the difficult days of the inquest and firmly believes Delilah Blair would still be alive, if the ministry had followed its recommendations.

"I was told that every inquest, nobody follows through with it," she said. "It's awful, it's just awful. It keeps happening."

Where's the change?

McIntyre is worried her daughter will become just another number for the ministry to ignore.

Inquests are mandatory following any unnatural death in custody, but the grieving mother said she hasn't heard if the coroner will be investigating Blair's death further. Even if they do, she said, she's not optimistic she'll get the answers she so desperately needs.

"If I'm going to suspect the same answer … what's the change?" she asked. "If it's been done before, then my daughter will be just another statistic in this inquest."

For the families who have lost loved ones to suicide using bed sheets behind bars the solution is simple if only the ministry would act on inquest recommendations.

"How many people have to die until it's looked at?" said McIntyre. "If it's a safety hazard ... then do something about it."