Ministry of the
Solicitor General

OCC Inquest - St. Amour 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: St. Amour
Given name(s): Justin
Age: 31

Held at: Ottawa City Hall – Keefer Room
From: April 8, 2019
To: April 18, 2019
By: Dr. Michael B. Wilson
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Justin Joseph St. Amour
Date and time of death:  Dec. 8, 2016 at 5:00 p.m.
Place of death: The Ottawa Hospital, 501 Smyth Rd., Ottawa, Ontario
Cause of death: Complications of hanging
By what means: Suicide

(Original signed by: Foreperson)


The verdict was received on April 18, 2019
Coroner's name: Dr. Michael B. Wilson
(Original signed by coroner)


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


Inquest into the death of:

Justin Joseph St. Amour


Jury Recommendations

To the Ottawa Carleton Detention Centre and the Ministry of the Solicitor General:

  1. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should ensure that there are no suspension or hanging points in any prisoner area. These efforts should include conducting an “annual suspension point audit” of the Ottawa Carleton Detention Centre with the results provided to senior managers.
  2. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should ensure that medical records at the Ottawa Carleton Detention Centre are in electronic form and easily accessible to all medical staff. These efforts should include exploring the use of voice dictation software for charting. In the interim, the Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should develop a tracking system for medical charts which facilitates locating and access to the charts by health care staff at the jail.
  3. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should increase the complement of health care staff, in particular nurses, mental health nurses, psychologists and physicians. Mental health staffing should be available to inmates and correctional officers during the week, evenings, nights and weekends.
  4. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should explore the possibility of including nursing and other medical staff as part of the regular formal debriefing (“muster”) sessions for the Stabilization / Segregation and Health Care units.
  5. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should use best efforts to ensure that a mental health nurse is present when admitting inmates to the jail. When possible, suicide screening conducted at admission and discharge should be completed in a private area.
  6. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should use best efforts to ensure that correctional officers do not have to continue their shifts after witnessing highly traumatic events. The institution will continue to consult the Critical Incident Stress Management program after a major incident.
  7. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should liaise with psychological experts and mental health resources to explore options and potential models for delivering treatment based on dialectical behaviour therapy to inmates diagnosed with borderline personality disorder.
  8. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should make best efforts to ensure only seasoned Correctional Officers staff inmates housed in the segregation area or the Health Care Unit. Correctional officers assigned to the segregation area or Health Care Unit should be required to review the Inmate Care Plans for all inmates in those areas and encouraged to develop a rapport with and provide companionship to the inmates based on guidance from those plans.
  9. The Ottawa Carleton Detention Centre should make best efforts to provide additional mental health training. This additional mental health training should be delivered by experts as well as experienced correctional officers who could speak about scenarios that occurred at the Ottawa Carleton Detention Centre.
  10. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should consider authorizing access to supervisory staff to view the live feed video and audio monitoring equipment in cells in the Health Care Unit and Segregation Units along with provision of video and audio monitoring of current management offices.
  11. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should consider designating a family emergency response liaison, who would be responsible for facilitating communications from family members of inmates who have reported self-harming behaviour or threats of self-harm or suicide.
  12. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should take steps to ensure that any discharge planning done to prepare inmates with borderline personality disorder for community re-entry include efforts to ensure continuity of care for those suffering from this chronic and debilitating disorder.
  13. Suicide prevention refresher training of all correctional officers, sergeants and supervisors by the Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should be mandatory and annually monitored for compliance with non-compliance reported to supervisors for immediate follow-up. This training should apply to everyone and incorporate examples and scenarios from recent suicides and /or serious suicide attempts within the facility.
  14. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should enhance the mentoring program and develop an incentive plan for the continuation of this successful program to ensure adequate staffing.
  15. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre, in order to break up the cycle of “revolving doors” and reduce the “silo effect” after numerous suicide attempts, an inmate should be automatically considered for admission to a long-term facility to provide a stable environment for treatment.
  16. The Ministry of the Solicitor General and the Ottawa Carleton Detention Centre should direct that during inmate rounds, at the scheduled inspection times, all guards will rotate their inspections to provide “another set of eyes” and perspective on the inmates’ behaviour.

To the Ottawa Carleton Detention Centre:

  1. The Ottawa Carleton Detention Centre should prepare, with the help of psychologists, social workers and community agencies, discharge plans designed to reduce and prevent the “revolving door” experiences of many mentally ill persons. This includes persons with borderline personality disorder, in an effort to secure proper housing and care for inmates with mental health problems once they are returned to the community.
  2. The Ottawa Carleton Detention Centre should ensure that every correctional officer working in an area with inmates is equipped with a two-way radio.
  3. The superintendent at the Ottawa Carleton Detention Centre should issue a memo to reinforce that correctional officers are expected to familiarize themselves with any inmate care plans that exist for the inmates they are supervising, as required by existing policy.

To the Ministry of the Solicitor General:

  1. The Ministry of the Solicitor General should continue to revise and expand on its mental health training both at the Correctional Officer Training and Assessment program (COTA) and in refresher training.

To the COTA program and the Ministry of the Solicitor General:

  1. When the COTA program and the Ministry of the Solicitor General consider new correctional officer and refresher correctional officer training, they should continue to use scenarios based on real events, including coroner’s inquests and their recommendations. This should re-enforce, with real stories (including using the specific facts of this inquest) the importance of the learning taking place.

To the Ministry of the Solicitor General, the Ottawa Carleton Detention Centre and the COTA Program:

  1. The Ministry of the Solicitor General, the Ottawa Carleton Detention Centre, and the COTA program should ensure that correctional officers receive initial and ongoing training in the modalities of suicide, suicide response, borderline personality disorder and inmate care plans.

To the Ministry of the Solicitor General, the Ottawa Carleton Detention Centre and the Ottawa Hospital:

  1. The Ministry of the Solicitor General, The Ottawa Hospital and the Ottawa Carleton Detention Centre should liaise in order to ensure that critical mental health information is shared with the Ottawa Carleton Detention Centre. This information sharing shall be in accordance with privacy legislation.

To the Ontario Ministry of Health and Long-Term Care:

  1. The Ontario Ministry of Health and Long-Term Care should take steps to increase awareness of borderline personality disorders among people suffering from this disorder, their families, mental health professionals and the general public by promoting education, research, funding, early detection, and effective treatments.