Inquest hears about Terry Baker’s time in GVI segregation

The segregation range – also known as solitary confinement or “the hole.”

The inquest into Terry Baker’s death at Grand Valley Institution for Women in Kitchener, Ont. heard details Wednesday about her mental health struggles and time in segregation.

Baker, 30, was found unresponsive in a cell with a ligature around her neck on July 4, 2016.

She died two days later.

On Monday, the inquest heard details about Baker’s troubled past before and after her incarceration. She developed substance abuse issues at the age of 13, and was allegedly bullied and sexually assaulted, eventually developing self-harming behaviours. Baker had also left her adoptive family and was living in shelters or with acquaintances.

At the age of 16, she was given a life sentence for the 2002 death of Orangeville teen Robbie McLennan.

Tuesday’s testimony included information on correctional institutions within Canada, mental health supports and inmate suicide.

On Wednesday, the jury heard from Charlene Byfield who held several different positions at GVI.

She was assigned to Baker’s case management team in 2015 and described her as friendly.

“She grew up here as an inmate, as she started here very young,” Byfield told the inquest. “She knew a lot of staff and a lot of staff knew her.”

Mental health struggles

Baker struggled with mental health issues at GVI.

The inquest heard that she had been diagnosed with borderline personality disorder. According to the Centre for Addiction and Mental Health (CAMH), people with BPD may have difficulty regulating their emotions or controlling their impulses. They can experience intense emotions when there are small changes to their environment and may also have other mental health issues, like depression.

Baker had been prescribed multiple medications including anti-depressants, anti-psychotics and mood stabilizers.

She repeatedly tried to kill or harm herself during her incarceration by swallowing batteries, drinking bleach, banging her head against the wall and making ligatures.

The inquest heard that Baker was repeatedly put into isolation under suicide watch, placed in restraints, or had her possessions taken away. Staff were also told that giving her attention would reinforce self-harming behaviours.

Despite her history and lack of improvement, the jury was told that no changes were made to Baker’s management or treatment plan.

Videos inside GVI

Three videos from June 27, 2016 were shown at Wednesday’s inquest. On that day, Baker was found unconscious in a segregation unit cell with a ligature around her neck. All three video had no audio.

Baker would die after another suicide attempt a week later.

The first clip, taken outside Baker’s cell, starts with a guard tapping on the door. When Baker doesn’t answer, he calls for assistance.

More than six people eventually respond.

A report indicates staff performed chest compressions on Baker until she began breathing.

On the video, Baker is seen being led out of the cell with her hands behind her back at 11:42 a.m. An officer handcuffs Baker and a guard searches her before she’s led away.

According to the report, Baker was taken to an interview room with correctional and health care staff. While in the room she began banging her head and staff authorized the use of Pinel restraints.

The second clip shows the inside of a segregation cell with a mattress, metal toilet and sink. At 12:11 p.m., Baker is brought in and led to the bed where, over the next several minutes, she speaks with staff with her hands held behind her back.

One person can be seen holding something on Baker’s head. The video stops at 12:16 p.m.

The report says Baker was strip searched and put in a security gown.

At 12:18 p.m., she can be seen on camera being brought back over to the bed. Baker appears to struggle as staff hold her arms down. More people are then brought into the room and they hold her down on the bed.

The third video shows Baker being strapped to the bed using Pinel restraints. She does not appear to be struggling. Staff then leave the room. Baker struggles briefly but is then still.

When questioned about her reaction to the videos, Byfield explained that when Baker was banging her head she saw the care given by staff. Specifically, staff bringing in a towel to protect Baker’s head and putting a wet cloth on her forehead. She said it demonstrated the care and compassion they had for her.

Dealing with inmates who self-harm

Byfield described some of the actions GVI staff take when an inmate self-harms.

She said they would immediately try to stop the behaviour and keep the person safe. They would then determine the inmate’s level of need after asking them a set list of questions.

Byfield also described to the inquest what happens on suicide watch.

She said the inmate is searched for dangerous objects like sharps, then they change into a security gown and are given a blanket and mattress. During this time an officer sits outside the cell and watches the inmate through a window.

The inquest also heard that inmates are verbally told that they have the right to have an advocate. That can be staff, elders, chaplaincy services, the inmate committee or peer advocate groups. Byfield stated that GVI does not provide a list of potential advocates to inmates as they want to empower them to make their own decisions. If the inmate choses an advocate, they can speak privately in a separate room or among the general population.

Use of restraints

Restraints can also be used in cases of self-harm.

GVI, like many institutions, uses pinel restraints that can be tied around the waist, wrists and ankles.

Byfield explained that inmates would be taken to the cell where the pinel bed was located and officers would secure the restraints if the inmate was kicking or thrashing around. The restraints might be used differently depending on the action, like head banging.

In some cases an inmate might ask to be put in restraints, Byfield testified.

She said, in 2016, other steps or alternatives would be taken and restraints would be the last resort.

Byfield said once an inmate is in restraints they would be monitored by nurses every 15 minutes for the first hour, and then once an hour.

As for reporting, Byfield stated that staff wouldn’t be required to fill out a report on the use of pinel restraints if the inmate asked for the restraints or it was part of their documented treatment plan. She added that requirements have now changed and reporting is always mandatory.

More from the inquest

Byfield was also asked to weigh in on other issues, including staff burnout and the actions taken in the days after Baker’s death.

She said that a debrief meeting was held off-site for staff, officers and first responders. That way they could express their emotions in a safe space as Baker had been at GVI for a long time and many people had a relationship with her.

Asked if something similar was organized for inmates, Byfield said she was not directly involved but staff would have gone door-to-door to let inmates know what had happened to Baker and suggest they seek support from outreach services, chaplaincy services, elders or the committee of inmates.

Byfield is expected to continue testifying as the jury had additional questions at the inquest.