REGINA -- A coroner’s inquest into the death of a man at the Regina Correctional Centre in September 2018 has wrapped up.

The inquest revealed multiple failures on the part of the Regina Correctional Centre.

Testimonies revealed that Elton John Heebner – a man with a previous history of suicide attempts – covered his cell window with a sheet shortly after 4 p.m. He was found unresponsive with a braided bedsheet around his neck around 8:25p.m. The six person jury deemed Heebner’s death to be suicide, caused by asphyxiation due to hanging by ligature.

Multiple employees from Regina Correctional Centre testified, stating that the covering of cell windows used to be permitted for short periods of time. Most inmates would use this time to use the washroom in private.

Following Heebner’s death, the jail now prioritizes safety over privacy, with zero-tolerance for covering windows.

Testimony from an investigator for the Ministry of Corrections and Policing also exposed falsified log book entries by a correctional officer working in Heebner’s unit during the estimated time of his death.

Catherine Brooks said according to the book, a range check was completed around 5:30p.m., however video surveillance proved this did not happen.

Brooks further revealed Heebner was on the waitlist for eight programs.

In an attempt to prevent similar deaths in the future, the jury had five recommendations:

  1. Mandatory training and refresher courses. Create better suicide awareness training including a better assessment tool. Training could be online for policies and procedures. If not completed it would be flagged for management attention.
  2. Correction officers should alternate doing the informal and formal checks in a shift. The mealtime check should be formal – a stand in the dining area.
  3. Increase staffing: full-time psychiatrist on staff, three correction officers on a shift (can not allow all off on vacation at same time), another nurse staffed per shift, each inmate has a caseworker (the case worker should be the inmates worker throughout their sentence. The caseworker would not also be a corrections officer.)
  4. More programs and more access to wellness programs for inmates. Attendance to relevant programs would be mandatory.
  5. Better means of communication throughout the facility to inform staff of policy, regulation changes and inmate concerns. Have a bulletin board (electronic or physical) of important updates that employees should sign to acknowledge they have read.

All recommendations have been directed to the Ministry of Corrections and Policing for their consideration.