Inquest recommends changes after inmate's 'tragic' choking death at Manitoba jail

An inquest into the death of a woman who fatally choked in a Manitoba jail without anyone noticing as she waved for help has recommended changes to training for supervisors at the facility and how inmates there are monitored.

Amanda Zygarliski, 40, died in her secure cell at the Women's Correctional Centrein Headingley, just west of Winnipeg, after choking on a chicken wrap she was given for dinner on May 15, 2021, an inquest report written by provincial court Judge Kael McKenzie this month said.

Video from her cell taken a few minutes after she was given her tray of food showed Zygarliski appearing to try to throw up or cough, holding her throat and waving at a security camera for help but no one came by her cell and saw her on the floor until more than 10 minutes after she stopped moving. It was more than 20 minutes after that before anyoneactually opened the door to her cell and called a code red for medical help, the report said.

"While the cause of this tragic death was accidental and may not have been preventable, had Ms. Zygarliski's gestures for help been noticed and acted upon immediately, at a minimum there may have been a chance to save her life," the inquest report said.

It also noted that when an oxygen tank was finally brought to Zygarliski's cell, it was empty and another had to be retrieved.

The inquest heard Zygarliski, who struggled with mental illness, was arrested days earlier after assaulting police officers as they tried to take her into custody under the Mental Health Act because she was cutting herself and had become violent.

The report said because she hadviolent charges pending anda related criminal record,she was taken into custody at the Winnipeg Remand Centre and later transferred to the Women's Correctional Centre because of overcrowding.

Because of her mental health issues, Zygarliski was given "red flag" status meaning she was in segregation for the safety of herself, other inmates and correctional staff.

The day she died, Zygarliski was supposed to have been released to Turning Leaf Support Services, which runs the supportive living program where she was staying before her arrest.

But when people from that group showed up to get her, they were told they didn't have the proper paperwork and were turned away, the inquest heard.

Zygarliski's family told the inquest, which was delayed because of the COVID-19 pandemic, they remembered her as "a kind, loving and fun person" who "in return was loved despite her mental health struggles," and is missed by her siblings and nephews.

No monitoring for 5 minutes during medical distress

Video from the cell Zygarliski was in was supposed to be monitored from a secure area known as a "pod" by a correctional officer, with whom inmates can communicate over an intercom.

But the video from that day showed Zygarliski appeared to have pushed the intercom button as she choked and stayed there for about 20 seconds before collapsing face down on the floor.

"This is not an assignment of fault, but rather an acknowledgment that [it] appeared from the evidence that the officer monitoring the pod did not observe Ms. Zygarliski for nearly five minutes while she was in medical distress," the inquest report said.

The report said duties and distractions in the control centre could distract an officer from viewing the inmates "long enough for a tragic accident to happen."

At the time of Zygarliski's death, officers were coming and going from meal breaks and meals were being delivered to inmates. Thatmeant there was a lot of movement, requiring the officer to monitor the access points into the unit instead of the cells themselves.

The inquest recommended a review of the duties of the officer responsible for monitoring inmates' cells, and said while it's "tempting" to have that officer also assigned to other duties, "this should be resisted given that accidents happen in an instant."

It also recommended training to influence the jail's workplace culture, noting there was reluctance shown in Zygarliski's case for male officers to check on a female inmate because of the jail's "cross-gender" policy, to believe she needed help and was not "acting," and to call a code red for medical help, which would have set off actions such as deploying a response team.

"The inconvenience of attending a code and shutting down the facility is negligible in comparison to a loss of life," the report said.

"Senior officers and supervisors should be trained to influence the culture by demonstrating tolerance for codes, respectfulbut necessary interactions between male officers and inmates, and providing feedback on negative attitudes towards inmate behaviours."

The report also noted the jail has already made internal changes of its own, including reviewing the placement of oxygen tanks. It has also adjustedits policies to allow outside agencies to submit documents electronically when they don't have proper documentation with them and are picking up inmates who have been granted release, like Zygarliski had been.

Zygarliski, who was from Selkirk, was the first person to die while in custody at the Headingley women's facility, which opened in 2012.