Jury at Timi Gusak inquest delivers recommendations

The jury at an inquest into the death of an inmate at a Milton jail has returned 28 recommendations for the government and the correctional facility.

Accused child predator Timi Gusak died on Oct. 8, 2019 after being found in medical distress his cell. During the inquest it was revealed the bedsheet loop Gusak used to kill himself was already inside the cell when he was moved there after being taken off suicide watch.

The 32-year-old was facing three counts of sexual assault against young girls in Waterloo Region, as well as child pornography charges.

Gusak was awaiting trial when he died.

Kevin Emery, an officer who worked in the Maplehurst unit where Gusak was found, testified on day three of the inquest.

He was the officer who moved Gusak into the cell in unit 11 where the bedsheet ligature was already present.

The inquest saw video and photos from Maplehurst that showed multiple corrections officers had a clear view of the bedding loop throughout the day before Gusak was placed in the cell. It was tied around a bedpost, and appeared to be the only item in the room besides the furniture.

Emery testified that because Gusak was being placed in a makeshift stepdown or protective custody cell – a cell one level below segregation or suicide watch – it wasn’t cleaned as thoroughly as it would have been if it was a segregation or suicide watch cell.

Emery said he did not know Gusak was coming off of suicide watch and said he was not familiar with Gusak’s charges. Had he known he was coming off of suicide watch, Emery said he would have removed the ligature.

He said from a policy perspective, the loop should have been removed.

Earlier in the inquest, the jury heard from the psychiatrist who made the decision to remove Gusak from suicide watch. Dr. Robert McMaster said being on suicide watch is “very uncomfortable” and can lead to a worsening of someone’s mental health.

McMaster also said he knew Gusak felt unsafe around other inmates and guards because of his sexual assault charges.

Maplehurst Correctional Complex in Milton, Ont. is seen in a file photo. (Corey Baird/CTV News Toronto)

Jury recommendations

Among the recommendations, the jury said the province should develop a plan to house inmates charged with sexual offences separately from the general prison population.

“This plan should include adequate and appropriate staffing and infrastructure to prevent bullying and intimidation of these inmates by other inmates and/or correctional staff,” the jury said in their verdict.

They also recommended the province complete a staffing level audit at the Maplehurst Correctional Complex and create an action plan to increase the number of correctional staff working there.

The jury said Maplehurst Correctional Complex should change logbook procedures to include the name of the specific officer completing a task in entries, increase the number of mental healthcare staff working at the jail, and explore ways inmates can meet with healthcare professional without correctional officers present.

The jury’s full recommendations are below:

To the Government of Ontario:

1. Conduct a comprehensive audit to determine the correctional staffing levels needed at the Maplehurst Correctional Complex. This audit should include consultation with the Maplehurst Correctional Health Care Unit and the Solicitor General’s Corporate Health Care Unit to recognize the increasing pressures that mental health needs of inmates are placing on operational staff.
2. Analyze the causes of correctional staff absenteeism and attrition at Maplehurst Correctional Complex and take appropriate action to encourage retention of staff.
3. Create an Action Plan based upon the results of the audit and the staff absenteeism / attrition analysis to increase the number of correctional staff at Maplehurst Correctional Complex to an appropriate complement and to maintain adequate correctional staffing levels.
4. Develop, implement, and maintain a long-term provincial plan to establish adequate and safe housing for inmates charged with sexual offences. This plan should prioritize the need to house and transfer these inmates with each other and keep them separate and apart from the rest of the inmate population. This plan should include adequate and appropriate staffing and infrastructure to prevent bullying and intimidation of these inmates by other inmates and / or correctional staff.
5. Develop educational programs for correctional officers who work with inmates charged with sexual offences to make them aware of the vulnerabilities of that population including (but not limited to): the likelihood of existing untreated childhood trauma, the possibility of increased levels of suicidality and the increased risk of bullying, intimidation, and physical violence due to the nature of their charges.
6. Develop a practice to ensure that correctional officers scheduled to work on units housing inmates charged with sexual offences recognize the need for and are willing to provide a safe and compassionate environment for these inmates.
7. Develop a training program that would assist correctional officers to understand the importance that a positive staff – inmate relationship has on inmate health, security, life promotion, future willingness to engage in treatment and reduction in recidivism.
8. Seek and allocate adequate funding and resources to implement these recommendations.
9. Advise inmates upon admission that a Code of Conduct exists for correctional officers and that inmates may request to review the publicly available summary of that Code of Conduct. Facilitate any requests made by inmates to review.
10. Implement an annual acknowledgment of the Code of Conduct by correctional staff.

To Maplehurst Correctional Complex:

1. Where possible and operationally feasible, continue to assign casual staff (fixed term) to those units that they are familiar with and where they have worked before.
2. Amend logbook policy and procedure to require logbook officers to identify, in writing, the specific officer who engaged in the actions recorded in the logbook. Require that all entries are legible and that the officer’s name is fully recorded and prohibit the use of initials or illegible signatures.
3. Issue a Standing Order that requires a physical and visual cell inspection to be completed by a correctional officer once an inmate has vacated a cell and the removal of all items (except the mattress) prior to a new inmate being housed in that cell. The officer’s name and the date and time that the cell inspection was completed should be documented.
4. Maintain and enforce policies relating to the removal of ligatures from cells and continue to encourage correctional officers to remove from all cells any loops, ligatures, and / or lines made from clothing or bedding or any other fabricated item that could pose a risk to an inmate.
5. Develop a policy or protocol that would require any corrections or health care staff member to immediately report (unless prohibited by confidentiality pursuant to PHIPA) any allegations of threatening or assaultive behaviour by another inmate or a staff member against an inmate. This policy should further require an immediate response to the allegations and immediate re-housing (if necessary) to ensure inmate safety and security.
6. Immediately discourage and discontinue any internal practices or procedures that encourage the completion of documentation that certifies that a cell inspection or unit tour was completed when it has not, in fact, been done.
7. Modify the existing daily cell inspection report to record the officer’s name, the date and time and the method of inspection (physical versus visual).
8. Increase the complement of psychologists, psychiatrists and social workers and actively engage in efforts to hire additional members of these professionals.
9. Implement a system that requires a multidisciplinary recovery care plan for inmates who are coming off suicide watch. This plan should be patient-centred and include health care professionals, social workers, the inmate and those correctional staff who will be interacting with the inmate. In the event that the multidisciplinary recovery care plan cannot be executed, it should be reevaluated with the inmate and the healthcare team prior to taking further action.
10. Implement a system that encourages correctional officers to provide written observations to the health care team of behaviour from inmates coming off suicide watch that raise mental health concerns.
11. Explore creative use of existing spaces within the Maplehurst Correctional Complex that, while still maintaining the safety of health care professionals, permits inmates to meet with health care professionals without correctional officers present (such as the family or professional visit areas).
12. Continue training for correctional staff who are present for health (including mental health) meetings regarding maintaining the privacy of inmate’s health information.
13. Develop a policy or protocol to inform the inmate of their confidentiality rights in relation to their personal health information when interacting with a member of the healthcare team.
14. In conjunction with any related province-wide mandates, develop, and implement a long-term internal plan to establish adequate and safe housing for inmates charged with sexual offences. This plan should prioritize the need to house these inmates with each other and separate and apart from the rest of the inmate population. This plan should include adequate and appropriate staffing and infrastructure to prevent bullying and intimidation of these inmates by other inmates and / or correctional staff.
15. Ensure that all correctional officers are aware of the special needs of inmates charged with sexual offences including (but not limited to): the likelihood of existing childhood trauma, the possibility of increased levels of suicidality and the increased risk of bullying, intimidation, and physical violence due to the nature of their charges.
16. Include in any suicide awareness programs images and measurements of the bedding loop that Mr. Gusak used to take his life, to permit correctional officers to better understand how such an object can be utilized as a tool of suicide and the importance of removing such items from cells.
17. Increase the hours of mental health nurses such that a mental health nurse is available to provide in-person health care to inmates twenty-four hours a day, seven days a week.
18. Upon admission, inform inmates of their right to have health care services delivered in the absence of anyone who is not within the inmate’s circle of care and document the delivery of this information in the inmate’s health care file.

With files from CTV's Stefanie Davis