Inquest into woman’s death at Kitchener, Ont. prison begins

The inquest into the death of an inmate at Kitchener's Grand Valley Institution for Women has begun.

Terry Baker, 30, was found unresponsive in her cell in July 2016 and died two days later.

A coroner's inquest was first announced at the end of 2017 but was postponed twice because of the pandemic and delays in getting documents from Corrections Canada.

Life before prison

On Monday, the inquest heard that Baker began having substance abuse issues at the age of 13. She had also allegedly been bullied, sexually assaulted and turned to self-harm. Before her incarceration, she had left her adoptive family and was living with acquaintances or in shelters.

Baker was given a life sentence for first-degree murder in the 2002 death of Orangeville teen Robbie McLennan. She was 16-years-old at the time and had been in a relationship with one of the other two males involved in the crime.

Behind bars

On Monday, the inquest counsel walked through the mental health issues Baker was dealing with, particularly in the days leading up to her death.

The inquest heard that she continued to self-harm at GVI.

Baker also reportedly felt remorse for McLennan’s murder and was sent for psychiatric evaluations.

She was then prescribed medications including anti-depressants, anti-psychotics and mood stabilizers.

GVI employed “administrative segregation” at the time of Baker’s death. According to Monday’s testimony, it was typically used to “protect the safety of the institution,” for the well-being of an inmate, or if an inmate was interfering with an investigation.

Self-harming or suicidal behaviours, like the ones exhibited by Baker, were generally treated as a security issue.

The inquest heard that Baker repeatedly tried to kill or seriously hurt herself, including by swallowing batteries, drinking bleach, banging her head and tying ligatures.

Baker was repeatedly put into isolation under suicide watch, placed in restraints, and had her possessions limited or even taken away. Staff were also told not give her additional attention so her self-harming behaviours “wouldn’t be reinforced,” the inquest heard.

Despite concerns from GVI staff that Baker wasn’t improving, the inquest heard that no changes were made to her management or treatment plan.

Before Baker’s death

Baker had spent more than a decade at Grand Valley Institution for Women.

The inquest was told that about 10 days before her death, she became upset after a visit with her mother. When she made threats to kill a staff member, Baker was put in a segregation cell.

On June 27, she was found unresponsive on the floor of her cell with a ligature tied around her neck. Staff performed life-saving measures and Baker began breathing again. The inquest heard that she was moved to an interview room where she tried to bang her head against the wall. Baker was then moved again. This time she was put on high suicide watch and kept in restraints for approximately 20 hours. According to Monday’s testimony, Baker continued to bang her head during this time.

On June 29, she was switched from high to moderate suicide watch but was still under constant observation through the weekend.

The following Monday, July 4, staff met to discuss if Baker should stay in segregation. It was ultimately decided to release her the next day. She was also moved from suicide watch to mental health monitoring, with staff checking in every 30 minutes. She was no longer being actively observed on camera but cameras were recording her activity.

The inquest learned that at 8:37 p.m., an officer saw her lying on her back on the cell floor. Baker had a ligature, from a piece of her sweatshirt, around her neck and she wasn’t breathing.

Two officers went into her cell, removed the ligature and started CPR.

She died two days later, on July 6, after being removed from life support.

Parallels with Ashley Smith

Baker’s death happened nine years after another inmate, Ashley Smith, strangled herself while in GVI custody.

Prison guards were told not to intervene and videotaped the 19-year-old as she died.

Smith had spent the last three years of her life in solitary confinement, exhibiting increasing self-harming behaviour.

Baker was also in segregation at the time of Smith’s death.

Inquest continues

Inquests are mandatory whenever a prisoner dies in custody. A jury examines the events around a death and they may issue recommendations to help prevent similar events in the future.

Testimony is expected to continue Tuesday.

-- With reporting from CTV's Heather Senoran and Stefanie Davis