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N.L. prisons at 'breaking point,' can't handle increased mental health, addictions issues: review

One of the report's recommendations is that a new provincial correctional facility replace Her Majesty's Penitentiary in St. John's.

Recommends new prison, new mental health units, but all information on inmate deaths blacked out

From left, Samantha Piercey, Chris Sutton, Doug Neary and Skye Martin, all died while incarcerated at provincial correctional institutions between August 2017 and June 2018.

A report into the deaths of two men and two womeninside Newfoundland and Labrador's prison system has found nothing to suggest correctional officers could have saved them, but instead admonished systemic issues inside the prison walls.

A heavily redacted version of the report was given to media on Wednesday, with 17 recommendations to build a new prison, create mental health units in the existing institutionsand cut down on the drug trade inside Her Majesty's Penitentiary.

"The current system cannot adequately address mental health and addictions issues," the report states.

"The corrections system in this province has not been a priority and it has been under-resourced for so long, it has now reached a breaking point."

The four inmates Doug Neary, Skye Martin, Samantha Piercey and Christopher Sutton all died alone in their cells between Aug. 31, 2017 and June 30, 2018.

Justice Minister Andrew Parsons said the provincial government will accept all 17 recommendations and has already begun work to implement some of them.

"What [the families]are going through is unimaginable, and we are going to take steps to make sure this does not happen to any other family again," he said.

A more therapeutic environment with enhanced services cannot wait for construction of a new facility.- Deaths in Custody Review

More than 30 pages were removed from the report provided to the public parts that detail the lives of the deceased inmates, criminal histories and how they died. This is despite the report being titled "Deaths in Custody Review."

Parsons said the details were redacted at the request of the families, but said the report served its purpose for them.

"We had four families that wanted to know what happened, and now they know."

In its conclusion, however, the report says itfound nothing that contradicts investigations by police and the chief medical examiner and states there is no reason to believe the deaths could have been prevented with"action or inaction" by prison staff at Her Majesty's Penitentiary or the Clarenville Correctional Centre For Women.

Prison in shambles

In one section, the report paints a picture of a decrepit and ancient men's prison in the heart of St. John's where inmates are "triple-bunked" in rooms that are meant to handle two people, or contained to makeshift cells in the penitentiary gymnasium.

According to the report, it's a place where mental health and addictions issues are commonplace, and drugs cause "chaos" when they get inside the prison.

To combat the issue, the report recommends a "focused strategy to reduce drug abuse and trafficking within the institution."

Her Majesty's Penitentiary is Newfoundland and Labrador's largest jail. The Victorian-era structure sits on the banks of picturesque Quidi Vidi Lake. (CBC)

While there has been much discussion about building a new prison in the province, the report recommends making some changes in the meantime. It calls for a mental health unit to be constructed out of the existing infrastructure at HMP, as well as the Clarenvillewomen's prison.

"While a new institution will include a space to alleviate the need to use segregation to accommodate inmates experiencing a mental health crisis, a more therapeutic environment with enhanced services cannot wait for construction of a new facility."

Mental health problems rampant: prison staff

According to the report, prison staff stated between 77 and 87 per cent of inmates in the province have some sort of mental health or addictions issue. The review team, led by retired police officer Marlene Jesso, was unable to verify that number.

On Wednesday, Parsons said more mental health resources have been added to the prison system, including Doorways a walk-in mental health service that's been introduced in places like the Burin Peninsula and Labrador to eliminate wait times.

The changes did not go far enough to have a lasting impact.- Deaths in Custody Review

The report states most of its findings were expected they echo much of the same material covered by reviews dating back to the 1990s.

"Most of the issues identified have existed for many years and have been identified by past reviews," it states.

"Even with the implementation of many of these [past] recommendations, the changes did not go far enough to have a lasting impact."

Report calls for increased cell checks

All four inmates died while in their cells. In Martin's case, police say she choked on food while in her cell, days after a she made several self-harm attempts, according to a fellow inmate. The other three inmates died by suicide.

After the deaths, some questioned how they could have been left in dire straits unsupervised. The report said hourly checks are done except for a two-hour window at lunchtime. It recommended making changes to that policy.

"Institutional counts should occur at least hourly and at random intervals and this should be implemented immediately," it said.

The province said it has already taken steps to fix this problem.

"Inmates will return to their cells between 12and 2 p.m. and our department is currently working towards implementinga system where regular and random checks will occur during this time," Parsons said.

Read more from CBC Newfoundland and Labrador