Shannon Sargent’s death at Ottawa Carleton Detention Centre was a homicide, inquest jury finds

The death of Shannon Sargent in a jail cell at the Ottawa Carleton Detention Centre in 2016 was a homicide, an inquest jury has determined.

Sargent, a 34-year-old Mohawk woman from Belleville, had open-heart surgery less than two weeks before she was arrested and remanded to the detention centre on Innes Road.

She was examined in the emergency department of The Ottawa Hospital after a court appearance on July 19, 2016, and a doctor then determined she was stable enough to go to jail.

When Sargent arrived at the Innes Road jail, a jail nurse became alarmed at her condition and said Sargent had to go back to the hospital. Three guards took Sargent to the Civic campus, but she was never seen by a triage nurse. Instead, the guard in charge of the transfer said he was told the visit was just to pick up missing paperwork from Sargent’s earlier hospital visit.

Sargent was back at jail barely an hour later. She died just after midnight on July 20, 2016.

An inquest is mandatory when someone dies in custody in Ontario. The jury can’t find fault, but can make recommendations to prevent similar deaths in the future.

After several days of testimony from jail staff, experts and Sargent’s family, the five-member jury made 37 recommendations. Among them were that all correctional and health-care staff at the jail be formally directed to review new policies, procedures and standing orders and that the province’s Ministry of the Solicitor General consider putting in place “additional initiatives” to improve the way correctional and health-care staff communicate and work with each other at the jail.

Inquest counsel Kate Forget had urged the jurors on Wednesday to “come to an answer that will reflect the conscience of the community in upholding the value of human life.”

The inquest heard multiple arguments surrounding the various classifications of Sargent’s manner of death, and Forget said the question of “by what means” was “the one question the parties could not come to an agreement on.”

Homicide was one of five categories of the manner of death the jurors could have found.

Forget said there were several “indisputable facts” related to Sargent’s death.

“Shannon would have been triaged when she was transported to The Ottawa Hospital, had she been presented as triaged. That is indisputable. This should have happened,” Forget said.

“And arising from that indisputable fact are more questions: What could have happened to Shannon had she been triaged at the hospital during that second transport?”

Forget highlighted expert testimony surrounding Sargent’s health-care consultation forms, which were entered as exhibits at the inquest.

The forms documented that Sargent “looked very unwell,” showed signs of “possible C. difficile,” had “possibly been abusing drugs” and had abnormal blood pressure and heart rate.

That information “would have been provided to the emergency physician had she been triaged again,” Forget said.

Physicians could have interpreted that medical data and found Sargent was at an elevated risk of heart problems, “and this could have resulted in a referral to cardiac surgery,” Forget said.

Forget suggested several recommendations for the jury’s consideration and said that, ultimately, their recommendations will result in “positive, necessary and systemic change.”

The jury recommended that all correctional staff get more training on unconscious bias that includes information on the stigmatization of people who have substance use disorders and that the province should establish a formal process for having Indigenous advisors provide advice on health services to Indigenous people in custody.

Specific to the Ottawa Carleton Detention Centre, the jury suggested that the province should invite representatives of Indigenous and Inuit organizations in the area to put together and present annually community-specific information to staff at the jail that “will ensure all staff are trained in cultural awareness.”

Leo Russomanno, counsel for correctional officer Paul McPherson, asked jurors to consider the evidence “dispassionately” before reaching their verdict.

Russomanno said the jurors’ verdict of homicide “should be reflective of the actual evidence … and whether or not you can safely make that finding: that there was a non-accidental injury that was inflicted on Ms. Sargent that caused her death.

“Ms. Sargent’s trajectory through the health-care system and, ultimately, through the criminal justice system is reflective of an endemic problem in our system that many of us who work in the criminal justice system are painfully aware of.

“It’s an obvious fact that (Indigenous) communities have suffered disproportionately at the hands of the criminal justice and the (correctional) system,” Russomanno said.

Russomanno asked jurors to “consider the various off-ramps that were available to Ms. Sargent along the way.”

He cited the initial arrest that led to Sargent being taken into custody, which is “outside the scope” of the inquest, Russomanno said.

“We have someone who is an addict, who is arrested for simple possession and breach of a condition, and that is what ultimately brought her into custody and to the hospital, then back to OCDC.”

When she was brought to the jail from the hospital, the police officer overseeing her case did not bring hospital discharge papers.

Sargent was assessed by an officer superior to McPherson — before McPherson had started his shift — and had been determined to be “fit for jail,” Russomanno said.

“She sat there for over two and a half hours before she was taken on that escort by Mr. McPherson and his two colleagues. And then, ultimately, she comes back from the hospital escort and doesn’t return to hospital.

“There was an opportunity for anyone who had assessed her at that point in time, that, if she had needed medical attention, to send her right back to hospital, and, obviously, that didn’t happen.”

Russomanno urged jurors not to place any weight on expert opinion evidence from Dr. Aikta Verma, who testified there could have been a “different outcome” if Sargent had been assessed further in hospital and received appropriate treatment.

“You’re being asked to speculate whether the medical attention Ms. Sargent would have received would have saved her, or whether she would have received appropriate medical attention,” Russomanno said.

Much of the focus of the inquest was on that hospital escort and “what McPherson did and what he did not do,” Russomanno said.

He countered earlier arguments that his client had been angry or deceitful over the hospital escort or that McPherson knew Sargent was in distress.

Phone records indicate that McPherson called his superior officer on the way back to OCDC, he said.

“Are these the actions of somebody who was seeking to inflict injury on Ms. Sargent and thereby causing her death?” Russomanno said, asking jurors to find her manner of death was “undetermined.”

“The state of the evidence is woefully inadequate (for) any finding of homicide,” he said. “Mr. McPherson was a cog in the wheel. He is a part of a system that tragically failed Ms. Sargent, but that does not mean that her death was a homicide.”

All of the jury’s recommendations to the Ministry of the Solicitor General

1. The Ministry shall ensure that all correctional staff involved in medical escorts are provided initial training and annual refresher training that covers the following topics:
a. Health care staff’s authority to determine whether or not a person in custody requires care at a hospital;
b. A procedure for assigning staff to a medical escort;
c. The roles and responsibilities of staff assigned to a medical escort;
d. The roles and responsibilities of staff overseeing a medical escort;
e. The roles and responsibilities of staff upon returning to the correctional facility with the person in custody; and
f. A procedure for addressing issues relating to a medical escort.

2. The Ministry should consider revising its Correctional Services Code of Conduct and Professionalism to expressly state: the vital role of correctional officers in preserving life.

3. The Ministry shall ensure that all correctional and health care staff at the OCDC are formally directed to review new policies, procedures, and standing orders.

4. The Ministry should secure and retain all available security footage immediately following an incident that occurs at a correctional facility.

5. The Ministry shall direct correctional staff at the OCDC to report any suspected breaches of the Statement of Ethical Principles and/or the Ontario Correctional Services Code of Conduct and Professionalism to their appropriate supervisor.

6. The Ministry shall consider implementing additional initiatives to improve correctional and health care staff communication and collaboration at the OCDC.

7. The Ministry shall ensure that persons in custody are assessed for any health issues promptly after being admitted into the OCDC.

8. The Ministry shall review all operational policies and procedures to advance the principle of equivalency (entitling people in detention to have access to a standard of health care equivalent to that available outside prison and conforming to professionally accepted standards).

9. The Ministry should establish a patient-centred model of care that promotes consistent, integrated, and team-based care and that enhances the continuity of care and successful transitions to and from the community.

10. The Ministry shall explore ways to increase addictions-specific supports for persons in custody at the OCDC.

11. The Ministry shall ensure that a person in custody’s medical record at a correctional facility has up-todate information on the person in custody’s primary health care providers.

12. The Ministry should provide health services relating to the provision of methadone or suboxone to persons in custody at the same time every day so that persons in custody receiving opioid agonist therapy receive it at consistent and regularly scheduled times.

13. The Ministry shall pursue health accreditation with Accreditation Canada, or another comparable body. The Ministry should support the development of standards focused on ensuring culturally safe care for Indigenous individuals housed at correctional facilities.

14. The Ministry should conduct a comprehensive and ongoing process of engagement with persons in
custody at the OCDC in the development of health care strategy, policy, and delivery.

15. The Ministry should consider providing an independent advocate to protect the interests of inmates.

16. The Ministry should implement an enhanced admission screening form for persons in custody who disclose the use of street drugs during the admission process. This form should require an admissions nurse to identify: type(s) of drugs used, frequency of use, dosage, means of administration, number of consecutive days used prior to incarceration, and any other relevant information.

17. The Ministry shall ensure that all correctional staff receive additional training related to unconscious bias that includes the stigmatization of persons who have substance use disorders.

18. The Ministry should invite representatives from Indigenous and Inuit organizations in the Ottawa Carleton region to create and annually present regional and community specific information to all frontline staff in the OCDC. This will ensure all staff are trained in cultural awareness.

19. The Ministry shall provide correctional officers who work on ranges designated for women with specialized training in gender, mental health, and Indigenous realities.

20. The Ministry should establish a formal process to engage Indigenous advisors to provide advice on the provision of health services to Indigenous persons in custody.

21. The Ministry shall support the National Inquiry into Missing and Murdered Indigenous Women and Girls’ Call to Justice 14.6 as it applies to provincial correctional services. Section 14.6 states the following: We call upon Correctional Service Canada and provincial and territorial services to provide intensive and comprehensive mental health, addictions and trauma services for incarcerated Indigenous women, girls, and 2SLGBYQQIA people, ensuring that the term of care is needsbased and not tied to the duration of incarceration. These plans and services must follow the individuals as they reintegrate into the community.

22. The Ministry shall conduct a quality-of-care review when critical incidents occur at a correctional facility, such as a death, with all involved staff participating. The quality-of-care review should account for any privacy or legal privileges.

23. The Ministry should conduct a workforce assessment to determine the appropriate staffing levels for health professionals and program staff for the OCDC and its population.

24. The Ministry should develop wellness initiatives to support existing correctional and health care employees.

25. The Ministry shall ensure that a person in custody’s institutional record at a correctional facility has up-todate information on the person in custody’s next of kin.

26. When admitting a person that has previously been in the custody of the OCDC and information from any prior admittance is relied on to complete admission forms, care should be taken to proactively update or confirm their contact list.

27. The Ministry shall implement a process requiring the inclusion of a letter describing what is contained in the return of property of an individual that has died in custody.

28. TOH will continue to revise its interdepartmental consultation and referral guideline as needed to ensure that it reflects clinical scenarios for patients presenting to the emergency department within a specific timeframe following a procedure or surgery.

29. TOH will continue to leverage EPIC’s existing functionalities with respect to the ability to flag a patient’s Plan of Care and continue to provide education to staff on this feature.

30. TOH will provide training to physicians, nurses, and allied health practitioners on providing safe care to Indigenous patients.

31. The Ministry and TOH shall collaborate to establish a joint protocol to govern medical escorts from the OCDC to TOH. The parties should consult with all appropriate stakeholders and partners in establishing the protocol.

32. The Ministry shall ensure that all staff involved in medical escorts are informed of the details of the protocol once it is established. TOH shall ensure that all staff in the emergency department who may interact with medical escorts are informed of the details of the protocol once it is established.

33. The Ministry and TOH should streamline delivery of Health Care Consultation Forms between the Hospital and OCDC by way of electronic transmission.

34. The OPS shall ensure that officers comply with the Prisoner Transportation Policy 6.09 and the Transporting Prisoners to Hospital Procedures 6.09-1.

35. The OPS should provide additional training to relevant staff on the Prisoner Transportation Policy 6.09 and the Transporting Prisoners to Hospital Procedures 6.09-1.

36. The OPS shall explore how to improve procedure to determine how to efficiently locate a person in custody’s next of kin when their next of kin is unknown.

37. A public health campaign should be created by Indigenous and Inuit urban organizations, in consultation with, and funded by the MOH, to reduce stigma surrounding mental illness and substance use disorder, and to enhance understanding people living with opioid use disorders, especially those who receive opioid agonist or substitution treatment (e.g., methadone). The campaign should address mistrust of the colonial health care system amongst Indigenous people.

With files from Blair Crawford