An inquest is examining the deaths of two inmates at the Stony Mountain Institution.
Sheldon Anthony Mckay was murdered on March 21, 2005.
Court heard he had been dead for several hours before being discovered.
"It just kind of dawned on me that, thinking, where's this guy been?" testified corrections officer Kirk McIntosh. "I haven't seen him all morning."
The other inmate, Durval David Tavares, was killed by gang members on May 3, 2006 in the recreation hall area.
Correctional officer Vincent Laroche testified that he performed a sweep of the area, but when he returned less than an hour later, it was clear something was very wrong.
"Right away, we noticed bloody drag marks," said Laroche. "And at that point we followed the drag marks to the gymnasium. And that's where we noticed there was an inmate lying on the ground, his head in a pool of blood."
What can be done to prevent future deaths such as these?
A Stony Mountain Intelligence officer testified some changes have already been made.
Video cameras, which at the time were of very poor resolution, have now been replaced with high-definition surveillance cameras. These cameras have been placed in areas with fewer blind spots.
But staff at the facility say little can be done to eliminate 100 per cent of all risk to inmates’ safety.
"Fact of the matter is, if a group of four or five converge on one inmate, a lot of damage can be done in a short time," said Laroche.
Inquest council is recommending more standing head counts, to better know if an inmate is OK or in trouble, and having staff members in the recreation hall at all times.
