Teen hadn’t been deemed high suicide risk

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This article was published 21/12/2016 (3218 days ago), so information in it may no longer be current.

She’d attempted suicide before — and made suicidal comments three weeks prior to being admitted at the Brandon jail — but corrections officers were unaware of that when they declined to override a computer’s decision to deem the young inmate a low suicide risk.

Eight days later, the 16-year-old hanged herself in her cell.

One officer testified that, in six years as a supervisor who reviewed suicide risk reports, he doesn’t recall ever seeing a need to override the computer to bump up an inmate’s risk level, even though he could if the assessing officer expressed concern.

“It’s fair to say then that you’ve never exercised your judgment to question an officer on the recommendation they’ve arrived at?” Prairie Mountain Health lawyer David Swayze asked the corrections officer during an inquest into the girl’s death.

“Fair enough, yes,” Dean English responded, adding that the computer system is still being used three years after the girl’s death.

The inquest into the teen’s hanging on Sept. 28, 2013, and her subsequent death in hospital four days later entered its second day on Tuesday.

On Monday, court heard that the girl climbed onto a desk in her cell and hanged herself with a bedsheet attached to a ceiling vent grate.

The aboriginal girl was a ward of Dakota Ojibway Child and Family Services, and prior to jail she lived with Specialized Foster Homes.

So far, lawyers for DOCFS, Manitoba Corrections, Prairie Mountain Health and Specialized Foster Homes have been questioning jail staff who have taken the stand.

The Brandon Sun is not naming the girl due to restrictions under the Youth Criminal Justice and Child and Family Services acts.

Tuesday’s proceedings focused on a suicide risk assessment completed when the girl was admitted to the Brandon Correctional Centre on Sept. 20, 2013.

The form was filled out by former corrections officer Michael Dixon, who is now a constable with the Brandon Police Service.

Dixon testified that in completing such assessments he relied on the responses from inmates, but also check the Correctional Offender Management computer system (COMS), which notes major incidents involving inmates and contains notes on their behaviour and mental health.

He agreed with inquest counsel Rich Lonstrup’s suggestion that inmates may not be honest about having suicidal thoughts or attempts to kill themselves.

Doing so would make their stay in jail less pleasant. They’d have to wear a smock, for example, might be held in a cell alone and that cell would be relatively empty to prevent self-harm.

Dixon testified that, based on the girl’s responses to his questions, he’d checked “No” under whether the girl displayed or shared feelings of loss or stress. He also marked “No” under symptoms of hopelessness or helplessness and invitations for help, and “No” for any current suicidal thoughts or plan.

Dixon also copied word for word from prior suicide risk assessment done at the Manitoba Youth Centre (MYC) in January 2013, eight months prior to the girl’s final admission to the Brandon jail.

It revealed that a year before that January 2013 entry to MYC, the girl had tried to hang herself with a belt but that effort was thwarted when someone unexpectedly returned home. But at the time she entered MYC, the girl said she no longer saw suicide as an option.

Lonstrup suggested that entry was inaccurate when it was cut and pasted into the September 2013 BCC report, as it referred to the suicide attempt as happening a “year ago,” although Dixon said he would have reviewed that information with the girl for his report.

That piece of information means Dixon marked a “yes” under prior suicidal history, but the explanation under the comments section wouldn’t be considered by the computer program as it would only register yes or no responses on one side of the report.

For her final admission to BCC eight days prior to being discovered hanging in her cell, the computer assessed her as a low suicide risk.

Dixon acknowledged that he could bring any concerns with computer assessments to the attention of a superior, such as English, and that superior could override the machine’s decision and make the inmate a higher suicide risk.

A higher risk level would bring further precautions. Such an inmate would be placed in a cell with another and checked every 30 minutes, or subject to 15-minute checks if she were placed in a cell alone.

Dixon and English both testified that neither of them saw a need to override the computer in this case. Nor would they have consulted outside agencies that had worked with the girl to help in their decision.

During questioning by lawyers, both said they would typically consult COMS and prior suicide assessments.

However, neither recalled reading entries in the COMS computer system highlighted “red flags” for the girl’s suicide risk.

First, the system showed other family members had tried to commit suicide, and her uncle in fact had killed himself. Dixon couldn’t explain why that wasn’t noted on his assessment.

Second, COMS recorded that she’d made suicidal comments when she’d been admitted to jail three weeks before and she’d been assessed as a high suicide risk then. Dixon acknowledged that wasn’t recorded in his report either.

He said the fact the girl was noted to have made suicidal comments during an admission three weeks prior wouldn’t necessarily have brought an override and raised her risk level.

English said the jail doesn’t override the computer assessment based on previous suicide attempts. The girl hadn’t made suicidal comments when she was brought to the jail intoxicated during the previous night.

If the jail considered prior suicide attempts and recent talk of suicide, it would have to override half its assessments, English said.

The girl had also seen a psychiatrist, and was prescribed antidepressant and anti-anxiety medication prior to her entry at the jail, but that didn’t appear on the assessment either.

But English said that also would have been recorded within COMS. That was confirmed in court, but English suggested that was the first time he was aware of the information.

Court also heard that a registered nurse at the jail had referred the girl to a mental health nurse for followup by placing her file on her desk, but that followup appears to have never been done.

That mental health nurse isn’t currently on the list of witnesses for the inquest scheduled for this week, although Lonstrup said she can still be called at a later date.

In asking his questions, DOCFS lawyer Dean Kropp repeatedly noted that the jail has a standing policy that if a suicide risk assessment isn’t completed an inmate should be deemed medium risk until it’s done.

He suggested it would have been wise to follow the policy until all the information about the girl’s mental health history was available.

“Maybe better safe than sorry might have been a better policy?”

English seemed to nod before the lawyer for Manitoba Corrections rose to object to the question, and Judge Shauna Hewitt-Michta disallowed the question.

» ihitchen@brandonsun.com

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