Inquest into 2017 Sask. Pen death begins

Curtis Cozart was found hanging in his cell shortly after 11 p.m. the inquest heard Monday

(Herald file photo)

More than two years after Curtis Cozart was found dead in his Saskatchewan Penitentiary cell, the public finally has some answers into his death.

Cozart was found dead shortly after the 11 p.m. count on May 23, 2017. He was only seven months into his two-year and four-month sentence for assault with a weapon, theft under $5,000, obstructing a police officer and failing to comply with a probation order. He was arrested in 2016 in Moose Jaw after pulling a knife on police officers, being hit with a taser twice and fleeing to rooftops before being talked down.

A coroner’s inquest into the circumstances surrounding his death is being held this week at the Coronet Hotel.

On Monday the inquest heard evidence suggesting Cozart may have died by suicide. That was the determination of Const. Troy Antal of the RCMP’s General Investigative Section, who was assigned the case.

A note was found inside the cell. It appeared to have been written by Cozart.

The inquest also heard from the correctional officer who found Cozart that night. He testified that while conducting the 11 p.m. count, he came upon Cozart’s cell. He could see Cozart pressed up against the bars, but couldn’t see what he was doing.

“You see some strange things at night,” the guard, a 15-year veteran of CSC, said.

He kicked the cell door and shouted at Cozart to startle him. It was at that point that he could see Cozart hanging from a noose made up of blue institutional blankets.

“It takes your brain a second or two to realize what’s happening,” he explained.

He immediately ran for help, and to get keys and a 911 tool — a device with a curved blade designed to cut through restraints — to cut Cozart down

It’s required that officers working the night shift carry a 911 tool, but only after 11:05 p.m.

Many of the questions posed to prison staff by the jury and by presiding coroner Tim Hawyrluk surrounded whether officers carry 911 tools during their security patrols and counts. When the officer found Cozart in his cell the nearest 911 tool was in a lockbox located down the range near a control panel.

Video evidence shown at the inquest shows the guard kick the cell before almost immediately running down the range to get assistance at about 11:02 p.m.

While guards are required to carry a radio at all times, the inquest heard that the correctional officer was not carrying one. He was disciplined, and briefing notes for the next two weeks included a reminder that all officers are to carry a radio at all times.

“At that time it was fairly common for not everyone to have one,” the officer said. Since then, that’s changed. “Everybody carries radios now,” he said.

As the officer ran through the prison, he alerted other guards and instructed his coworkers to call 911.

Four minutes later, the call went out.

Audio from that exchange was played at the inquest.

“You have to call 911, we’ve got an inmate who is not breathing,” a voice is heard on the recording, which was made at about 11:06 p.m.

The call to paramedics itself detailed an “unresponsive male … not breathing in his cell.” It contained no other information.

A jury member asked why it took four minutes to make that call. The officer said he didn’t know.

After the officer ran to get help, others began to converge on the cell, located on the end of the top level of the medium-security unit’s ‘b’ range.

Correctional Manager Glen Young, who was working that night, said that while using a radio may have sped up the process, it would only have saved about ten seconds. That’s because, he said, at the time of the count, officers would have been at the far end of the ranges. It takes a minimum of two officers before you can open a cell door. It takes three to cut someone down who is hanging. Two are required to support the body while the third used the 911 tool to cut the inmate down.

When the first three officers arrived at the cell, after cutting Cozart down, they immediately began CPR. When they got tired, the guard who found Cozart and another took over.

“It felt like an hour …. It could have been ten minutes,” he said.

 About six minutes after Cozart was first discovered, an officer arrived with an automated external defibrillator (AED), as well as a naloxone kit to treat overdoses.

While the AED was hooked up, it didn’t apply a shock as there was no pulse. Instead, it instructed officers to continue CPR.

At 11:16, 14 minutes after Cozart was discovered, paramedics arrived on the scene.

They hooked Cozart up to a LUCAS device, used by first responders and medical personnel to automatically perform chest compressions.

Four minutes later, they worked with correctional officers to strap Cozart onto a backboard, carry him onto a stretcher and rush him to the ambulance.

Cozart was taken to the hospital, where he was later declared deceased.

Investigators at the hospital found a letter in Cozart’s pocket. The letter’s significance is not currently known, however, it was implied that it relates to a phone call Cozart made shortly before 10:30 p.m., one of Cozart’s last known actions before he was found dead.

The video showed Cozart’s final hours. He was seen wandering the range and conversing with other inmates, activity a correctional intelligence officer described as normal. At about 10:15 he was on the phone. Just before locking up for the 10:30 p.m. stand to count, he walked up to a windowsill, climbed onto it to look outside, and then entered his cell and closed the door. He came to the door for the 10:30 p.m. standing count.

It was the last time he would be seen alive.

The inquest continues today at 9:30 a.m. with testimony from more officers and the paramedic who attended to the scene. Wednesday’s testimony will include the external autopsy report from forensic pathologist Dr. Shaun Ladham. After the testimony has been entered, the six-person jury will deliberate and come to conclusions regarding cause of death and future recommendations. That’s the purpose of an inquest — not to make criminal findings but to issue recommendations as to how to prevent future deaths. All in-custody deaths not from natural causes are subject to a coroner’s inquest.

This is the first of two inquests into deaths at Saskatchewan Penitentiary scheduled for this year. The inquest into the death of Daniel Tokarchuk is set to begin on April 27 in Prince Albert. He died on June 7, 2017, just hours after Chris Van Camp was stabbed to death by his cellmate, Tyler Vandewater. Vandewater pleaded not guilty and argued self-defence. The verdict in that case is due on March 5.