'Quite horrific': Inquest report into choking death of inmate released

The Women's Correctional Centre in Headingley, Manitoba. (Source: Government of Manitoba)

An inquest report into the death of an inmate at a Manitoba jail found she was unconscious for 34 minutes after choking on her food before guards entered her cell.

The report into the death of Amanda Zygarliski, an inmate at the Women’s Correctional Centre in 2021, was released Tuesday. She died on May 15, 2021, at the age of 40, after accidentally choking on food in her cell.

According to the report, she was trying to alert guards via security camera and a call button, but wasn’t successful.

“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 report, written by Judge Kael McKenzie, reads.

Sandra Wollmann, Amanda’s sister, said Zygarliski was diagnosed with borderline personality disorder and spent 18 years at Selkirk Mental Hospital. She was described as a kind soul to her family.

“She’d give the shirt off of her back if she could,” Wollmann said. “She loved animals, she loved her nephews. She was a great person.”

According to the inquest report, Zygarliski was arrested on May 10, 2021, after becoming violent at her home. She was living in a supportive living program run by Turning Leaf, a support service for people struggling with mental illness.

She was transferred from the Winnipeg Remand Centre to the Women’s Correctional Centre in Headingley due to space. On May 15, she was scheduled to be returned to Turning Leaf. However, representatives did not have proper paperwork and they were turned away, according to the report.

At 4:09 p.m., Zygarliski was brought dinner from a corrections officer. Four minutes later, she started to show signs of choking, the report said, adding she was holding her throat and waving at the security camera for help and pushing a button for assistance.

“Ms. Zygarliski continued to show signs of distress until she ultimately fell to the ground face down and stopped moving at approximately 4:17 p.m.,” McKenzie wrote.

“It was quite horrific, what happened to her in the jail, ” Wollmann said, adding the fact she was not being watched properly was a major issue for the family.

According to the inquest report, corrections officer checked on Zygarliski at 4:30 p.m., and saw her again a few moments later. The officer asked the monitor of the cells if there had been any calls, and did not get a response. A code red was ordered at 4:51 p.m. Three guards entered Zygarliski’s cell two minutes later, and tried to revive her. The report said the guards needed to retrieve a second oxygen tank, as the first one they brought was empty. She was then pronounced dead.

“Ms. Zygarliski was lying motionless on the floor for 34 minutes before a code was called,” McKenzie wrote.

According to the inquest report, the Women’s Correctional Centre has since amended their policies to allow agencies to submit documents electronically when inmates are getting released.

The report found several factors occurring at the time of Zygarliski’s death, including that the officer monitoring inmate cameras did not see her for nearly five minutes when she was in medical distress. It said several officers were going to and from their meal breaks at the time, and meals were being delivered to inmates.

“This meant there was a lot of movement within the institution that required the pod officer to attend to the monitor for the access points rather than the monitor for the cells,” McKenzie wrote.

The inquest recommended a review of the duties of the officer monitoring the inmate cameras be conducted.

“While an officer may have time to complete additional tasks or duties these should be minimal to maintain visual contact with the inmates. It is tempting to use an officer in this role for other staffing assignments, but this should be resisted given that accidents happen in an instant,” McKenzie wrote.

The report also recommends corrections officers be trained to reinforce the safety and well-being of inmates and not hesitate to call a code when needed.

“The inconvenience of attending a code and shutting down the facility is negligible in comparison to a loss of life,” McKenzie wrote.

Wollmann and her family sent an email to Manitoba’s Minister of Justice Matt Wiebe in January 2024, appealing for help and are awaiting a response. CTV News reached out to the minister’s office for comment but have not heard back.