Ministry of the
Solicitor General

OCC Inquest - Sawa 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Sawa
Given name(s): Kelvin
Age: 46

Held at: 102 East Main Street, Welland
From: Sept. 24, 2018
To: Oct. 3, 2018
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Kelvin Sawa
Date and time of death: August 17, 2011 at 11:44 p.m.
Place of death: Greater Niagara General Hospital – 5546 Portage Road, Niagara Falls, Ontario L2E6X2
Cause of death: Multiple organ failure due to coerced self-inflicted hanging by ligature
By what means: Homicide

(Original signed by: Foreperson)


The verdict was received on Oct. 3, 2018
Coroner's name: Dr. David Eden
(Original signed by coroner)


We, the jury, wish to make the following recommendations:


Inquest into the death of:

Kelvin Sawa


Jury Recommendations

Admission and Classification Procedures

To the Niagara Detention Centre:
  1. In order to provide protection to inmates who are vulnerable due to the nature of their charges, and where appropriate, place those individuals in the same living unit.
  2. In order to maintain a complete record regarding an inmate, information from third parties raising specific concerns as to the vulnerability of that inmate should form part of the inmate's file.

Inmate Charge Information

To the Ministry of Community Safety and Correctional Services:
  1. In order to reduce the risk associated with the potential for the sharing of an inmate's charge information with other inmates, evaluate the feasibility of restricting access to charge information on OTIS to designated correctional staff and/or removing charge information from the Unit Notification Card.

Inmate and Unit Supervision

To the Niagara Detention Centre:
  1. In order to prevent high risk situations that could lead to serious bodily harm or death of an inmate, evaluate the feasibility of implementing the direct supervision model in protective custody living units.
  2. Evaluate the feasibility of converting the small day room into a module centre with video monitoring for each wing to be manned 24 hours a day.
  3. While the jury endorses the security upgrade project that has been proposed for the Niagara Detention Centre, including the installation of additional video surveillance cameras in the living units, in order to detect high risk situations before they escalate to serious bodily harm or death of an inmate, explore the feasibility of real-time monitoring of all living units with high-resolution cameras with zoom capabilities.
  4. Prior to the installation of the additional surveillance cameras that are contemplated by the security upgrade project, determine the additional resources that will be needed to monitor the cameras, ensure that the necessary staff complement is in place and, at least one month prior to installation, provide the necessary staff training in the use of the technology for optimum results.
  5. In order to maintain safety and security of correctional officers during security rounds and to prevent any distraction of the support officer while performing his or her duties, the sally port door must be kept closed during all security rounds.
  6. When the wing is at its capacity, no more than 50% of the inmates should be allowed out of their cells at one time to prevent potential tension and altercations amongst inmates.
  7. To protect the welfare of the inmates, and prevent physical altercations in areas that are not monitored by surveillance, limit showers to two people at a time, to be regulated by the correctional staff.

Possession and Use of Contraband Ropes/Wraps on Living Units

To the Niagara Detention Centre:
  1. Acknowledging that inmates make ropes and other items used for exercise within living units, examine the feasibility of developing recreational or fitness activities that would permit inmates to exercise either in a designated area outside of the living unit or with sanctioned equipment within the living unit, under the supervision of detention centre staff.
  2. Any ropes or wraps fashioned from torn bed sheets (contraband), should be confiscated if found in the living unit pursuant to policy.
  3. Consider conducting cell checks more frequently than once every two weeks to limit the amount of contraband in the Detention Centre.
  4. Consider making bed sheets out of stronger material to prevent inmates from being able to tear it into strips.

Response to Critical Incidents

To the Ministry of Community Safety and Correctional Services and the Niagara Detention Centre:
  1. In order to maintain safety and security in a living unit, including inmate welfare, and to assist in the investigation after a critical incident involving serious injury or death, current policies and standing orders should be reviewed to ensure that video surveillance footage of the unit is viewed at the earliest possible opportunity after an incident.
  2. In order to maintain safety and security in a living unit, including inmate welfare, and to assist in the investigation after a critical incident involving serious injury or death, current policies and standing orders should be reviewed to ensure that a correctional officer is assigned as a scribe to remain on the unit for a designated period to record and monitor any activity and conversations between inmates.
  3. In order to maintain safety and security in a living unit, including inmate welfare, and to assist in the investigation after a critical incident involving serious injury or death, current policies and standing orders should be reviewed to ensure that once inmates have been interviewed for the purposes of any investigation that has been initiated, they should be provided with the opportunity to receive counselling to address any psychological impact associated with the incident.
To the Ministry of Community Safety and Correctional Services:
  1. In order to preserve evidence or identify issues that may impact on the security of an institution or the safety of correctional staff or inmates, Correctional Services Oversight and Investigation (CSOI) should commence its investigation and take whatever steps are necessary in the early stages, short of conducting any interviews that may adversely affect any police investigation.
  2. In order to ensure that a CSOI investigation takes into account all of the available information relating to a critical incident, including the conduct of correctional officers or staff, develop a policy that CSOI Inspectors should interview inmate witnesses wherever possible and subject to any parallel criminal investigation taking precedence. Where requested, consideration should be given to relocating an inmate witness within the institution or to another institution.
  3. In order to address any potential safety or security concerns, consider issuing another All Chief's Bulletin encouraging police services to share information from their criminal investigation in a timely manner that may be pertinent to Correctional Services.
  4. In order to improve inmate safety and welfare through the existing investigative process, CSOI should continue to conduct its investigations in such a way that safety issues at provincial jails are identified and the appropriate response is initiated in a timely manner.

Raising Correctional Staff Awareness of Issues Raised during this Inquest

To the Ministry of Community Safety and Correctional Services:
  1. InIn an effort to protect the safety and welfare of inmates, training of correctional officers and staff should include emphasis on the importance of maintaining the confidentiality of information regarding an inmate as well as the serious consequences for the inmate that may result from a breach of confidentiality.
To the Niagara Detention Centre:
  1. In order to ensure that correctional staff are aware of the issues identified during this inquest, a memorandum from the superintendent should be issued to all staff that provides a summary of the issues raised as well as the recommendations of this jury

Appointment of Community Advisory Board

To the Ministry of Community Safety and Correctional Services:
  1. In order to strengthen the links between the community and the Niagara Detention Centre as well as raise the awareness of the community regarding current issues at the Niagara Detention Centre, consider the feasibility of establishing a local Community Advisory Board for the Niagara Detention Centre.