Inquest makes recommendations to prevent Indigenous deaths in federal custody

Brennan Nicholas was 24 when he died by suicide at Millhaven Institution. This collage of photos, showing him in happier times, was presented to the jury by his mother, Denise Desormeaux. Photo courtesy of the Ministry of the Solicitor General.

The jury tasked with investigating the suicide of Brennan Nicholas came back from deliberations Friday, Mar. 11, 2023, with 33 recommendations for the prevention of deaths of inmates in federal custody, especially Indigenous persons. Nicholas died on June 15, 2018, while residing in the Regional Treatment Centre, a psychiatric facility within the walls of Millhaven Institution.

Early in the inquest proceedings, inquest counsel explained that Brennan Nicholas was a band member of Rama First Nation and a community member of Oneida who identified as Haudenosaunee. His mother, Denise Desormeaux, provided insight, in counsel’s words, into “who Nicholas was, where he came from, his connection to his community, and the challenges they have faced.”

Dr. Robert Reddoch presided over the inquest, at the outset of which he set the scope of the inquiry: first, to examine Nicholas’s death; and second, to examine the prevention of deaths “of Indigenous persons in federal custody… through the exploration of the provision of health care to people experiencing mental health issues and/or trauma.”

The Office of the Correctional Investigator’s Annual Report 2021-2022 found 55 per cent of self-injuries in prisons involved Indigenous people, and 83 per cent of all incarcerated people who died by suicide in 2020-2021 were Indigenous.

After concluding that Nicholas did indeed die June 15, 2018, at 7:25 p.m., from a self-inflicted “incised wound of the neck” which he inflicted with a razor, the jury made 30 recommendations to the Correctional Services of Canada (CSC) and three to the Ontario Ministry of the Solicitor General (SOLGEN).

With regards to Millhaven Institution-Regional Treatment Centre (MI-RTC) itself, CSC should ensure there is “sufficient space… to provide Indigenous ceremonies, cultural practices, and correctional programs, including dedicated sacred grounds.” As well, CSC “should prioritize and expedite establishing a permanent and more purpose-built therapeutic psychiatric facility…. [and as] an interim measure… make modifications to create a more therapeutic psychiatric facility” while the new facility is built.

The jury called on CSC to prioritize the improvement of Indigenous services, staffing, and engagement. These include ensuring that Indigenous patients have sufficient and timely access to Indigenous-specific services in federal custody. As well, CSC should revise Commissioner’s Directive 702 to recognize the role of Indigenous elders and Indigenous liaison officers as “central to the delivery of Indigenous spiritual and cultural access for health care and wellness.”

These goals could be accomplished through the jury’s further recommendations that CSC train frontline staff to recognize and understand the importance of Indigenous elders and liaison officers; that CSC specifically target the recruitment of Indigenous staff, especially medical personnel; and that Indigenous services be supported with adequate funding. 

Further, the jury recommended that CSC ensure any improvements or evaluations to CSC’s Clinical Framework for Identification, Management and Intervention for Individuals with Suicide and Self-Injury Vulnerabilities include Indigenous community and Indigenous medical professional input about how the framework applies to Indigenous persons in custody.  

One tragic aspect of the case of Brennan Nicholas was that his nearly 250-page provincial health care record was not uploaded to the CSC system or reviewed by CSC when he was transferred to Millhaven Institution in February 2018 to serve a life sentence for second-degree murder. Had this happened, the jury found, CSC staff would have known that Nicholas was banned from having access to razors because he had tried to take his life twice while incarcerated at the Elgin-Middlesex Detention Centre (EMDC).

The jury therefore recommended that a patient’s provincial health care transfer record be promptly uploaded onto the Electronic Medical Record – Open Source Clinical Application Resource (OSCAR) upon their admission” to MI-RTC. Staff should “review incoming individuals’ health care transfer packages as part of their referral and admissions process,” and “the interdisciplinary health care team will meet to discuss the individual’s relevant healthcare information and previous health care management.”  

Further, while the razor protocol at MI-RTC has since been updated to ensure only electric razors are given to inmates, the jury recommended that CSC “make electric shavers available at a reasonable cost to persons in custody at all of its correctional institutions.”  

To the Ontario Ministry of the Solicitor General, the Jury recommended a review of the Health Care Transfer Summary “to enhance information-sharing when an individual is being transferred from provincial custody to federal custody based on evidence heard in the inquest into the death of Brennan Nicholas or with input from the Correctional Services of Canada.” 

In particular, the jury recommended, the review of the Health Care Transfer Summary should focus on including additional information about previous self-injurious behaviour or suicide attempts, including but not limited to the number of attempts, and the date of the attempts, the means involved, the level of severity and treatment required, known triggers, any preventive measures that may have been in place while in custody (for example, restrictions or bans), and, specifically, whether the patient is being followed by a psychologist and/or psychiatrist. The results of the review should be entered into the Electronic Medical Record (EMR) system once it is implemented. 

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