Inquest into 2020 Winnipeg Remand Centre death calls for video monitoring of new inmates

WARNING: This story contains discussion of suicide. If you or someone you know needs help, pleasesee the end of this story for resources.

An inquest into the death of a man who killed himself the night he was brought into the Winnipeg Remand Centre in 2020 recommends that everyone held there be monitored via video in their cell for their first 48 hours in custody.

Jasbir Brar, 62, died by suicide in the late evening hours of June 4, 2020, when he was taken toremand afterhis appeal on three counts of sexual assault was denied earlier that day. He was expected to serve another 19 months in custody, followed by two years of supervised probation, an inquest report by provincial court Judge Keith Eyrikson released Friday said.

Brar was locked alone in his cell that evening and was last seen alive around 10:20 p.m. Just under an hour later, he was found unresponsive in his cell and taken to hospital, where he was pronounced dead.

The report said none of the officers who interacted with Brar as he was brought into custody noticed anything unusual about him, telling the inquest that while his mood appeared typical for someone who had just lost anappeal, Brar repeatedly said when asked that he had no thoughts of suicide.

One officer who did Brar's intake process at the remand centre said when they asked Brar if he had thoughts of suicide, Brar "shrugged his shoulders and didn't say anything." When pressed for an answer, he said no, the report said.

Another who spoke with Brar said he indicated his plan was to stay safe in remand, and that he had the option of talking to his wife, who was supportive of him.

In recommending the change to video monitoring practices, the inquest report said the current policy at the remand centre is to put people with suicide concerns in a special unit where they're monitored via video until there are no concerns for their safety. People considered a low risk are placed in a regular cell, with no video monitoring.

While "not foolproof," the report said the recommendation would "provide Winnipeg Remand Centre staff the ability to monitor those individuals for the first 48 hours where they may have difficulty acclimatizing to a stressful living situation."

"This may act to allow Winnipeg Remand Centre staff to more closely monitor individuals and their health and safety in the initial phases of the integration process who show no signs of concern for suicide or self harm," the report said.

Offer remand nurses 'substantial financial incentives'

The report also recommended having someone assigned to monitor the centre's "pods,"which are small observation areas overlooking the cells, around the clock to allow officers "to monitor to a great extent what is occurring" in real time.

That couldmake it possible to spot "something out of the ordinary, such as what tragically occurred here more readily," and allowhelp to beprovided "on a more timely basis," the report said.

The night Brar died, there was no one working in the pod. However, the report said once Brar was discovered in his cell, staff "acted as expeditiously as possible and without delay."

The report also recommended continuing a policy requiring every inmate be checked on every 30 minutes after lockdown in the evening.

The inquest heard thatBrar was left unseen for 56 minutes before being found unresponsive in his cell "owing to manpower shortages" that were worsened by the COVID-19 pandemic, but the system has since been revamped to provide"strong protections so that each and every inmate will be visually viewed at least once every half hour."

It also recommended ensuring all staff get a refresher course on suicide prevention every two years as required something the inquest heard doesn't always happen because of difficulty accessing the program and a backlog that developed during the pandemic.

The report also recommended "substantial financial incentives" be offered to recruit and retain nurses at the remand centre, where the inquest heard "staffing numbers remain problematic" and "recruitment is a very present issue."

There were"luckily" twoovernight nurses on duty on June 4, 2020, the report said, but evidence at the inquest indicated thatowing to staff shortages, there was a one-hour periodbetween the day and night shift when there was no nurse on duty at all.

"This is unacceptable, and a significant issue," the report said.

A number of the report's recommendations have already been implemented since Brar's death, including sealing the opening near the bunk bed that allowed Brar to hang himself in all cells that had such an opening, providing cameras to record similar critical incidents in order to clarify issues and provide learning opportunities, and requiring individual nurses involved in critical incidents to each complete a report, instead of one nurse writing it for the whole group.

It also recommended the remand centre continue its efforts to provide peer support and wellness committees, noting the number of people there affected by Brar's death.

If you or someone you know is struggling, here's where to get help:

• Canada'sSuicide Crisis Helpline: Call or text 988.
• Kids Help Phone: 1-800-668-6868. Text 686868. Live chat counselling onthe website.
• Canadian Association for Suicide Prevention:Find a 24-hour crisis centre.
• This guide from theCentre for Addiction and Mental Healthoutlines how to talk about suicide with someone you're worried about.

If you're worried someone you know may be at risk of suicide, you should talk to them about it, says the Canadian Association for Suicide Prevention. Here are some warning signs:

• Suicidal thoughts.
• Substance abuse.
• Purposelessness.
• Anxiety.
• Feeling trapped.
• Hopelessness and helplessness.
• Withdrawal.
• Anger.
• Recklessness.
• Mood changes.