Four recommendations have been issued to Correctional Service of Canada (CSC) by an inquest examining the death of Curtis Cozart.
Cozart was found unresponsive in his Saskatchewan Penitentiary cell shortly after 11 p.m. on May 23, 2017. He was about seven months into his sentence of two years, four months for assault with a weapon and obstructing a peace officer.
Cozart was given CPR and revived in the hospital. He died at 10:50 p.m. the following day.
Over the past three days the inquest heard from correctional officers, medical doctors and a psychologist about the events before and after Cozart was found in his cell during the 11 p.m. count.
The inquest heard that the officer who found Cozart was not wearing a radio, despite a policy in place mandating them.
That was common at the time, several officers said. Since the incident, they testified, everyone always has one.
Testimony also revealed that the guard who found Cozart wasn’t carrying a 911 tool, a device with a curved blade that can be used to cut through restraints or to cut through noose. While the officer was technically not in breach of a policy that mandated everyone carry the tool after 11:05 p.m., it became clear through officers’ testimony that the tool is not regularly carried on night shifts, and that few were aware of that policy requirement.
The six-person jury recommended that officers “should carry a 911 tool on their person after evening lockup, after inmates retire to their cells.”
The inquest also recommended that policy changes be communicated to officers more formally. Testimony revealed that policy changes are sent in an email. Few of the correctional officers who testified were aware that a 2015 policy mandated midnight shift carry the 911 tool with them after the 11 p.m. count. All of the officers who testified were experienced officers with over ten years of experience at Sask. Pen.
The jury recommended that changes in policy for correctional officers should be confirmed by a signature indicating that each officer has read and understood the changes, or through meetings held about the policy change if possible.
The other two recommendations dealt with calling 911 and with how patrols are conducted.
The jury heard that, at least at the minimum security unit, staff members tend to all get up to conduct their security patrols at the same time. There was the possibility, they heard, that all of the guards would be down near the end of the ranges they’re checking at the same time.
The jury recommended that “no less than one” officer remain in a central location while those security checks are ongoing.
The final recommendation was that any correctional officer should be able to dial 911 in the event of an emergency.
The inquest learned that the 911 call went out about four minutes after Cozart was found in his cell. No one was able to explain the delay, though it was suggested that not all of the institution’s clocks always display the same time.
On Tuesday, the inquest heard from officer Arlene Adam. When she heard an inmate had been found unresponsive, she headed to the correctional manager’s office to inform him so he could call 911. The inquest heard the manager was not available at that moment because he had gone to use the washroom. Adam communicated to the main communications and control post to call for an ambulance.
The manager said that was the right decision.
Speed of response was a topic that came up throughout the inquest. The jury heard multiple times that Cozart could have been without blood flow to the brain — meaning his brain cells had no oxygen — for as much as ten to 15 minutes or more.
Testimony both by paramedic Oliver Jantz and by Dr. Syed Ali indicated that chances of survival after the brain has been without oxygen for ten minutes are very slim.
Ultimately, while health care practitioners were able to restore Cozart’s heart at the hospital, they determined he was likely brain dead as he didn’t respond to external stimuli.
The third day of the inquest was attended by Cozart’s parents. They were unable to make it to the first two days of the hearings. They declined to comment.
The inquest jury also determined the cause and means of Cozart’s death.
The family requested the cause and means of Cozart’s death not be published due to concerns about the well-being of other family members.
Coroner’s inquests are held to determine cause and means of death, as well as to come up with recommendations to prevent future deaths.
The inquest is one of two being held in Prince Albert this year. An inquest into the death of Daniel Tokarchuk is scheduled for April 27. Tokarchuk died in custody on June 7, 2017 at the Saskatchewan Penitentiary. He was the second inmate to die that day. Richard Van Camp died in his cell sometime in the early morning after a scuffle with his cellmate, Tyler Vandewater.
Vandewater argued he acted in self-defence during his trial held earlier this year. A verdict in that case is due on March 5.