OCC Inquest - Laface 2019
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given name(s): Dextin Robert
Held at: Sudbury
From: April 8, 2019
To: April 9, 2019
By: Dr. S. C. Bodley
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Dextin Robert Laface
Date and time of death: August 6, 2017
Place of death: Health Sciences North, Sudbury
Cause of death: Self-inflicted hanging injury
By what means: Suicide
(Original signed by: Foreperson)
The verdict was received on April 9, 2019
Coroner's name: Dr. S. C. Bodley
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
Dextin Robert Laface
To the Sudbury District Jail:
- That the Sudbury District Jail employ the necessary expertise to assess the cells for access to materials and tie off points that allow self-strangulation. Such assessment should include a comparison between the current cell configurations at the Sudbury District Jail and information as to the best practices for cell configurations. Cells used for single occupancy or for inmates requiring special housing, such as segregated housing should be given priority in this assessment process. Additionally the bedding be replaced with security blankets or linens of similar material.
- Suicide risk in the segregated prison populations should be regularly and directly assessed by mental health care professionals. Such risk assessments should be discussed and specifically documented at the segregation review meetings at the Sudbury District Jail. Information and observations gathered by all participants should be shared openly within the continuum of care.
- Where an inmate had disclosed a recent significant life trauma, such as a sexual assault, in addition to the offering of initial treatment options, there should be additional follow-up by a mental health nurse or social worker within 72 hours. This follow up should involve engaging directly and privately with the inmate and continuing to make them aware of the available resources for treatment.
- If an inmate has indicated previous suicide attempt(s) at the time of admission that there be a system in place to flag this to the team to raise their awareness and identify risk.