The security intelligence officer (SIO) who investigated Daniel Tokarchuk’s 2017 suicide in the minimum security wing of the Saskatchewan Penitentiary said he believes corrections officers did everything they could to save the inmate’s life.
Glen Frank, a 10-year veteran of the Sask. Pen’s SIO team, was one of eight witnesses called to testify at day two of the Coroner’s Inquest into Tokarchuk’s death. Frank said he typically deals with investigations in the medium or maximum security wings of the corrections facility, but was on call when Tokarchuk was found hanging on June 7, 2017.
Like other penitentiary employees who testified on Tuesday, Frank said suicide attempts at the prison’s minimum security wing are extremely rare. He conducted an investigation parallel to the RCMP, and said he believed corrections officers made every effort to keep Tokarchuk alive.
“Their response, as far as I’m concerned, was very appropriate,” Frank said when asked about corrections officers Brian MacAuley and Lori Mardell, who both testified on Monday and Zenia Kotelko, who testified on Tuesday.
If there is room for improvement, Frank said officials should look to the tools corrections workers have at their disposal. As with Monday, questions at the Tuesday session frequently turned to the cutting device known as a ‘9-1-1 tool’ that is supposed to help corrections officers free inmates who try to hang themselves.
MacAuley said he was uncomfortable with using the tool, which is why he grabbed a kitchen knife to cut Tokarchuk free. Frank said corrections officers need to have confidence in the cutting devices they’re supplied with, and that may mean more training. In his 33-year career at the Sask. Pen, he said doesn’t recall proper training ever being offered.
Having said that, Frank also told the inquest that inmates who are determined to take their own lives will find a way, despite the best efforts of corrections officers.
“In my opinion, there’s nothing more they could have done to stop this unfortunate situation,” he said.
Much of Tuesday’s testimony focused on Tokarchuk’s mental health prior to his death. Zenia Kotelko, the third corrections officer who was on duty in the early morning hours of June 7, 2017, told the inquest there were no signs he was suicidal the last time she saw him. Like Frank, Kotelko said there’s only so much they can do if an inmate attempts suicide.
“If they want to do it (commit suicide), they’re going to find a way,” she explained. “They’re going to read you.”
Kotelko said overnight checks, which are mandated to occur every two hours, can be very predictable. That makes it’s easier for inmates to anticipate when they’ll be free from surveillance, since the houses used by inmates do not have cameras inside of them.
Kotelko had to leave the duty office unmanned to assist MacAuley and Mardell, which is against policy. Kotelko said she understood what she was doing, and believed it was worth it to try and save Tokarchuk’s life.
“You work with what you get, and you make your best choice,” she said. “In this case, I hope I made the right choice.”
“Life is always more important,” she added. “That was the priority.”
Dr. Robin Finlayson, a penitentiary psychologist with 17 years of experience at the minimum security wing, told the inquest he was “absolutely” surprised when he heard about Tokarchuk’s death. He said the inmate had family problems, but Finlayson believed they were manageable.
He added that Tokarchuk was forthright and open during psychological assessments, and had never engaged in any type of self-harm. However, he also testified that he only learned about the true extent of Tokarchuk’s marriage difficulties afterwards.
“It was totally out of left field,” Finlayson said when asked about Tokarchuk’s death. “There was no indication prior to that.”
Finlayson said Tokarchuk was upset his parole officer revoked some privileges due to concerns about his behavior. However, Finlayson maintained that Tokarchuk seemed to be handling the setback well.
Tokarchuk also suffered from depression, but once again, Finlayson testified that the inmate seemed to have everything under control.
“There is absolutely nothing in hindsight that would have struck me as (signalling) ‘this guy is in crisis,’” he told the inquest.
Finlayson was responsible for writing the psychological assessment that recommended moving Tokarchuk from medium security to minimum security. Finlayson said there were no red flags at that time.
The decision to remove some of Tokarchuk’s privileges came under close scrutiny during the afternoon session.
Tanya Umpherville, the Sask. Pen’s assessment and intervention manager at the time, said there were concerns Tokarchuk was stealing clothing from the Salvation Army during a temporary absence work program in March 2016.
Minimum security inmates are allowed to leave on an escorted or unescorted temporary absence (called an ETA or UTA at the inquest) if they have approval. The trips allow inmates to seek employment opportunities, or access programming options like addictions treatment.
When asked where he got all these extra clothes, Tokarchuk told his parole officer other inmates gave them away after being released. However, Umpherville testified that Tokarchuk wouldn’t tell them which inmate gave away the clothes.
“The concern was that he was stealing, and for us, that was an elevation of risk,” she explained.
There were also concerns about a relationship he established with an unknown woman while working at the Salvation Army. Umpherville said they don’t oppose or prevent those relationships, but expect inmates to be upfront about it.
A three-person panel, which included Umpherville, her supervisor, and Tokarchuk’s parole officer, believed Tokarchuk wasn’t being forthright with them, and revoked his temporary absences. She said he was frustrated with the decision, but seemed to accept it.
Coroner Timothy Hawryluk noted that the decision seemed to have a negative impact on Tokarchuk. Hawryluk was also concerned there was nothing in the report indicating the Salvation Army ever filed a complaint.
Umpherville replied that they always try to do an intervention before revoking an inmate’s ETA or UTA. However, she was not involved in many of the subsequent discussions. Despite working roughly 15 years at the Sask. Pen, she spent less than a year in her role at the minimum security facility, and was not involved in decisions made in the months before Tokarchuk died.
The jury also heard from a number of medical experts, including Dr. Shirwan Kukha-Mohamad, a clinical psychiatry professor with the University of Saskatchewan who also provided psychiatry services to the Saskatchewan Penitentiary for a few months in late-2016.
Kukha-Mohamad said he last saw Tokarchuk in mid-November of that year, but remembered nothing about him. However, Kukha-Mohamad said depression and suicide go together, and he believes there are problems with how Canada treats inmates with mental health problems.
“I would say there is a weakness to providing psychiatric care to incarcerated individuals, and I say that comfortably,” he told the inquest.
Dr. James Brown, an emergency room physician at the Victoria Hospital, also testified. Although Tokarchuk’s official time of death was listed at 4:35 a.m., Brown told the inquest they stopped life-saving measures at 4:24 a.m. He said Tokarchuk probably perished long before that.
“In my professional opinion, the patient was dead before he arrived,” Brown explained.
The Jury also heard from a Parkland Ambulance paramedic who arrived on the scene, along with the family physician who cancelled Tokarchuk’s antidepressant medication.
Paramedic Sherri Morrison testified that Tokarchuk was likely already dead by the time the ambulance arrived. She also said corrections workers seemed to be doing an adequate job of applying CPR.
Dr. Vipul Parekh was the family physician who signed off on the request to stop providing Tokarchuk with the antidepressant Mirtazapine, because Tokarchuk wasn’t taking it. In those cases, Parekh said they cancel the prescription to keep large amounts of medication from piling up in the inmate’s room.
Parekh works at a community clinic in Prince Albert, but started making professional visits to the Sask. Pen in 2010. While he handled Tokarchuk’s medical file, the two never met face-to-face.
The inquest continues at Plaza 88 on Wednesday starting at 9:30 a.m. There are four witnesses scheduled to appear, one of which is forensic pathologist Dr. Shaun Ladham.