Guards not aware of policy mandating 911 tools, inquest hears

Saskatchewan Penitentiary. Herald file photo

Four of the correctional officers working the night Curtis Cozart died were not aware of a national policy mandating that officers carry a 911 tool with them after 11:05 p.m., the inquest into Cozart’s death heard Tuesday.

Cozart was found hanging in his medium-security Saskatchewan Penitentiary cell on May 23, 2017. He was about seven months into his sentence of just over two years for assault with a weapon, theft and obstructing a peace officer.

The second day of the weeklong inquest included testimony from four officers, the correctional manager, a paramedic and a doctor as Blaine Beaven walked the inquest through hours of evidence meant to shed some light on the time before and after Cozart was found hanging from his cell.

Each of the four correctional officers said it was common for officers not to be carrying a radio before the incident. They said that since that night everyone carries one.

None of the officers, though, testified to carrying a 911 tool with them on their midnight shift rounds. A 911 tool consists of a curved metal blade attached to a handle. It’s designed to cut seat belts but can also be used to cut through a noose.

Despite a 2015 policy mandating that the tool be carried after 11:05 p.m., none of the officers said they carry them on nights. Three said no one does, that the devices are kept instead at control posts and are available to anyone on the unit.

The question of training using the tools also came up. None of the officers could remember being trained on what to do if they encounter someone hanging. While officers said they acted the best they could in the scenario — and presiding coroner Tim Hawryluk praised them for their efforts to resuscitate Cozart — they agreed that training for stressful situations gives them something to fall back on “in the heat of the moment.”

Hawryluk compared it to a police officer receiving training on how to use a firearm. It might not be something they ever have to do in practice, but it is within the realm of possibilities.

While each officer was questioned whether training for what to do if you find someone hanging said it might be a good idea, they seemed less sold on the idea that carrying a 911 tool would have sped up response times.

At least two people are needed to be present when a door is opened for officer safety. At least three is ideal in the case of a suicide by hanging so that the victim can be carefully lowered to the floor and not just dropped.

Even if an officer were to be carrying a 911 tool, it was implied, they wouldn’t be able to immediately use it to cut Cozart down.

As the morning progress, the inquest also heard about the 911 call and the defibrillator.

The officer who sent the message to call 911 was Arlene Adam. She attempted to follow procedure — contacting the correctional manager to request that someone call for an ambulance — but the manager wasn’t in his office. She made the decision to call up to the prison’s central management to make that call. They did.

She couldn’t say why the call was delayed by four minutes from the time Cozart was found, though it was suggested that not all the times relayed in the agreed-upon chronology are precise as some of the institutions’ clocks disagree with each other.

She did, though, tell the inquest why the call was so vague. She didn’t know why an ambulance was needed, just that there was an unresponsive inmate.

Adam also helped bring the defibrillator to the scene. The inquest learned that the nearest one was kept at the health care wing. The officers had to pass through several sets of internal doors to reach that wing, though since all the inmates had been locked up, those doors, normally closed, were open. The open doors meant they were able to bring the defibrillator to the scene within about a minute.

In the afternoon, the inquest heard from one of the paramedics who cared for Cozart.

Oliver Jantz said he arrived at the prison at about 11:13 p.m. and got to the inmate’s cell within two minutes.

Jantz said that when he arrived at Cozart’s cell, he found correctional officers performing “good, adequate CPR.” While there were no signs of life and no indications of a pulse, Cozart was still warm. 

To Jantz, that meant there was a chance, even a slim one, that Cozart could survive.

‘If there’s a chance, they can survive this event, we do all we can.”

Jantz rode in the back of the ambulance to the hospital, caring for Cozart. He applied a few doses of epinephrine and continued to monitor his heartbeat.

While Cozart’s heart didn’t begin to beat, Jantz did see irregular electrical signals coming through the monitor.

The ambulance arrived at the hospital shortly before midnight. Dr. Syed Ali was on call that night. He took the inquest through the medical report compiled that night and over the course of the next day.

Despite the state Cozart was found in, with medical intervention, by 12:09 a.m., his heart was beating again.

Cozart’s vital signs weren’t good, though. Over the course of the day, his blood pressure dropped. It took 12 hours to get his blood acidity (caused by high levels of carbon dioxide, or CO2) and C02 levels close to normal. 

Several tests revealed that Cozart had no brain response.

The next day, May 24, at 10:50 p.m., Cozart’s heart stopped. His family had been consulted. He would not be resuscitated. 

Just over 24 hours after Cozart was last seen alive, he was declared dead.

Both Dr. Ali and Jantz talked about what a lack of oxygen does to the brain and to the body. Once the heart stops, every second counts, they said. That’ why CPR is so important. It can continue to provide oxygen to the brain. Each minute the brain is left without oxygen, it loses about 10 per cent of its function. After five minutes, your chances of survival are very low.

After ten minutes without oxygen, you’ll likely be dead, Ali said.

He estimated, based on his state, that Cozart had likely been hanging for 15 or 20 minutes before he was discovered.

The inquest continues today with testimony from the forensic pathologist who conducted Cozart’s autopsy. The jury is tasked with identifying a cause and time of death. It is also given the option of presenting recommendations to prevent future deaths.