Gang-related attack led to death of man at Beausejour jail in 2011, inquest finds

An inquest has found the 2011 death of a man at a Manitoba jail was the product of a co-ordinated gang-related attack that wasn't stopped, in part, due to a lack of adequate supervision.

Tyler St. Paul, 21, was attacked by fellow gang members on the morning ofMay 16, 2011, at Milner Ridge Correctional Centre, outside Beausejour, Man. St. Paulcalled for help, but within an hour of staff arriving, he lost consciousness and died.

• Inquest into killing of 21-year-old Beausejour inmate begins Oct. 2

An inquest led by provincial court Judge Dale Schillestartedin spring and his findings were released Friday,about 5 years after St. Paul's death. The provincial review was postponed until after inmates involved in the homicide could be prosecuted, Schillewrites in the inquest report.There were eight inmates convicted of manslaughter.

Footage from May 15 and 16, 2011, revealed "a series of abnormal events" in the Birch Unit where St. Paul was housed in a cell, Schille found.

There were five units, including Birch, at Milner Ridge, which could hold more than 500 inmates altogether. The two-tiered Birch Unit had eight cells on each floor and 64 inmates.

St. Paul was a member of one gang but trying tojoin another, the inquest report states.

"Gang rules dictate that a person wishing to leave the gang receive a beating administered by other members. Mr. St. Paul had declared an intention to stay on the range and receive the anticipated beating," the inquest states.

Surveillance footage from the evening of May 15 was reviewed after St. Paul's deathand showed several inmates entering and leaving hiscell. While the camera did not record what happened inside the cell, investigators later learned St. Paul "received a beating from other members of his gang" that night, and then emerged shirtless from his cell "in anact of defiance towards the gang to demonstrate that he was unscathed despite the beating."

There was a "significant expectation" that at least one of the two Birch Unit staffkeep an eye on inmates in the shared common area, either on the ground or from a vantage point where they could see everyone.

That didn't happen the day after the initial attack. Theinquestfound on May 16, 2011,inmates conspired to distract the loneguard in the staff office of the unit while gang members again entered St. Paul's cell and assaulted him.

He pressed an emergency button in his cell and when staff arrived, St. Paul said he had been "jumped." He became unconscious shortly after and an autopsy later confirmed he suffered a punctured lung.

Gang segregation

Two staff were on duty inside the Birch Unit "at all times," and another two working in an observation "pod" that providesecondary observation resources across the five units, the inquest report states. Pod staffcan control the opening and closing of cell doors.

The Birch Unit was a designated "gang unit" when St. Paul was killed,where members from two different gangs were segregated from the general jail population and held.

The inquest said it's clear that since St. Paul was killed by members of his own gang that isolating gang members from the general population "obviously merits scrutiny" because it may strengthen gangs.

Current policy allows the institution to spreadgang members around the jail as needed; forming firm rules around segregatinginmates would likely be "counterproductive," the inquest report states.

There hasn't been an increase in staffing or guard responsibilities since St. Paul's death, although guards must now physically patrol each unit and regularly check inside cells, the inquest report says.

"Inmates cannot be kept isolated from each other. Recognizing that inmates, especially gang inmates, may act in concert to perpetrate an attack on another inmate requiring mere seconds to cause serious injury or death, serves to put the problem in proper context," the report states.

"Several witnesses expressed the view that no measures are available to ensure a similar death does not occur in the future. No changes appear necessary from the inquest perspective."

Recommendations

Some, but not all, of the units at MilnerRidge contain "punch wand" stations at key points that record officer presence "to ensure mandated patrols are being conducted." Spots that don't have these systems in place currently operate on a sign-in sheet system.

The inquest recommends implementing wand units in every unit.

At the time of St. Paul's death, inmates fromboth floors of the Birch Unit were allowed to roam the common area freely at certain times. That has since changed so that now only one floor of inmates is let out at once, which is meant to improve supervision.

Inmates are also now restricted from going inside any cells but their own.

Schille also echoed a recommendation from an earlier inquest into the deaths of inmates David Durval Tavares and Sheldon Anthony McKay. In that inquest, Judge Brent Stewart proposed that the office of the chief medical examiner be allowed to decline to conduct an inquest when an inmate death has already been thoroughly examined through other means.

• Sheldon McKay, David Tavares inquest report highlights gang power in prisons

"This inquest was conducted several years after the death of Mr. St. Paul and follows both a thorough review conducted by the Corrections Division of Manitoba Justice, a police investigation and ensuing criminal prosecution," Schille wrote.

"This inquest expended valuable public resources which might have been conserved had such discretion existed to decline to direct an inquest into this death."