The Winnipeg Remand Centre has reconfigured cells to prevent suicides, a change recommended after an inquest into the hanging death of a man who lost an appeal.
Jasbir Brar, 62, was found alone in his cell in the downtown building late on June 4, 2020.
He never regained consciousness, provincial court Judge Keith Eyrikson wrote in an inquest report made public Friday.
RUTH BONNEVILLE / FREE PRESS FILES
The Winnipeg Remand Centre
Eyrikson oversaw a court inquest into Brar’s death in April to examine the circumstances of the death and make recommendations on how to prevent similar incidents.
Eyrikson said there was a small opening on the top bunk in the cell, between the bunk and a small window, where Brar was able to tie a bed sheet around the bunk and then a towel to the sheet to create a noose. The judge recommended space be eliminated from all cells with a similar layout at the remand centre, which jail officials have since done.
Eyrikson, who toured the remand centre along with lawyers during the inquest, confirmed the space had been filled.
“While difficult to predict each and every form of mechanism an individual may use to try to complete suicide, the actions taken by the Winnipeg Remand Centre in this circumstance eliminate at least one avenue of potential suicide,” Eyrikson wrote, saying the recommendation had been “fully implemented.”
Brar appeared before the Manitoba Court of Appeal on the morning of June 4, where his convictions for three counts of sexual assault were upheld. He was to serve another 19 months of custody, along with a subsequent two years of supervised probation.
He was taken into custody by sheriffs, who were to transport him across the street to the remand centre.
One of the sheriff officers told the inquest Brar appeared upset, but she described that as normal behaviour given his appeal was unsuccessful.
Kaur, another sheriff officer and two corrections officers testified he did not appear suicidal and answered no when asked whether he planned to kill himself on different occasions while he was being held at the courts and when being admitted to the jail.
A nurse at the jail did not indicate any suicide or mental health concerns in an assessment of Brar.
Eyrikson said he concluded staff members made adequate efforts to inquire with Brar to conclude he was not a suicide risk.
After he was processed, he was taken to the fifth floor of the jail and locked in a cell that evening.
At the time, policy was to check the well-being of inmates every 30 minutes by looking in cell windows. Brar was last seen alive at about 10:20 p.m., when a corrections officer looked in, but when the officer returned at 11:16 p.m., the officer saw Brar had hanged himself.
Officers responded and cut him down, placing him on the floor to try to revive him. Nurses and other staff arrived to help, while paramedics in an ambulance were also unsuccessful. He was pronounced dead at 12:37 a.m. the next day.
On top of sealing the space from which Brar was able to hang himself, Eyrikson recommended the remand centre make sure every staff member takes a suicide prevention refresher course every two years.
The judge said the mandatory two-year refresher training was delayed for some staff at the time.
Eyrikson further recommended that when possible, video of critical incidents such as Brar’s death should be recorded, something that has become remand centre policy.
The judge also recommended all nurses involved in such incidents author formal reports. Previously, the policy was when two or more nurses were involved, one would write a report on their behalf. Eyrikson said the change has now become policy.
The judge also suggested financial hiring incentives be put in place to recruit nurses to work at the jail to ensure adequate staffing levels.
He also recommends all inmates at the jail be watched on video for 48 hours after their admission, regardless of their assessed suicide risk, that officers be assigned at all times to monitoring pods on cell ranges, and that inmates are checked on every 30 minutes, as is jail policy.
Eyrikson also said the remand centre should continue its efforts to establish peer support and wellness committees.
erik.pindera@freepress.mb.ca
Erik Pindera
Reporter
Erik Pindera is a reporter for the Free Press, mostly focusing on crime and justice. The born-and-bred Winnipegger attended Red River College Polytechnic, wrote for the community newspaper in Kenora, Ont. and reported on television and radio in Winnipeg before joining the Free Press in 2020. Read more about Erik.
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