An inquest into the death of a Manitoba inmate in 2011 concluded that there was little staff could have done to prevent it.
Judge Dale Schille wrote in his final report on the death of Tyler St. Paul at Milner Ridge Correctional Centre that most of the potential issues at the time, which might have been considerations for recommendations, have already been addressed.
Schille also said that although St. Paul’s death was “tragic”, it “also represents a highly isolated event,” since it was the first homicide of an inmate inside a provincial institution in Manitoba.
Prison beating led to death: investigation
St. Paul died from a punctured lung following beatings he received over two days in May 2011.
St. Paul was a member of one gang and wanted to switch over to another gang. Gang rules dictated that anyone leaving the gang had to receive a beating, the report said.
When investigators later listened to recorded phone conversations St. Paul had made, he said he was aware of the beating and intended to take it “like a man”.
On May 15, while the lone staff member on the range was distracted by inmates in the staff office, security footage showed a group of St. Paul’s fellow gang members entering his cell. The investigation later learned that St. Paul was beaten, but the security camera showed him leaving his cell with his shirt off, with no visible injuries.
The next day, a group inmates entered St. Paul’s cell again and beat him. This time, St. Paul called for help. Staff found him conscious in his cell, saying he had been “jumped”.
Shortly after, he went unconscious and could not be revived.
Eight people were convicted of manslaughter in his death.
Review into death
A corrections review of the incident listed 25 recommendations, most of which have been implemented, Schille said.
Since the death, the institution has implemented policies that mandates staff physically patrol the unity using a wand system that records the identity of the person using it, as well as the time that specific person inspected a specific cell.
Now, only the inmates assigned to a specific cell are allowed in that cell.
Also, where previously inmates on both tiers of the unit were allowed out of their cells at the same time, now inmates from only one tier are allowed out at a time.
Conclusion of inquest
The inquest concluded that there were no changes necessary to staff levels or responsibilities. It did recommend that a wand system be implemented in all units of the institution.
Schille said that although the death happened in 2011, it took until now for the inquest to conclude because the criminal cases stemming from the incident were being conducted.
Schille also concluded that due to the length of time that had elapsed since the incident, and given the fact that the inquest followed a Corrections Division of Manitoba Justice, police investigation and criminal prosecutions, there were little additional recommendations that the inquest could make.
Currently, inquests are mandatory any time an inmate dies in custody. Schille suggested that in the future, the Chief Medical Office be given the authority to decline to conduct an inquest in certain circumstances, such as this case.
