SAINT JOHN (GNB) - Recommendations related to the Saint John Regional Correctional Centre were made following a coroner's inquest into the death of Skyler Brent Sappier-Soloman.

The inquest was held May 16-18 in Saint John. Sappier-Soloman died in the early morning hours of Jan. 31, 2022. The 28-year-old was an inmate at the Saint John Regional Correctional Centre and had been transported and admitted to the Saint John Regional Hospital on Jan. 29.

An inquest is a formal court proceeding that allows public presentation of all evidence relating to a death. It does not make any finding of legal responsibility, nor does it assign blame. However, recommendations can be made aimed at preventing deaths under similar circumstances in the future.

Coroners and juries can classify a death as a homicide, suicide, accident, natural causes or cause undetermined. The inquest found Sappier-Soloman’s manner of death was natural.

The five-member jury heard from 23 witnesses during the inquest and made the following recommendations:

  • Develop a standard operating procedure to guide decision-making based on risk level and clarify the roles and responsibilities of Corrections Health Services nursing personnel and Justice and Public Safety correctional officers when a patient requires transfer from a correctional facility to a hospital. Procedures to determine the method of transportation to a hospital facility should be developed. These should be based on a medical assessment of a patient’s risk levels and distinguish between non-urgent and urgent risk levels, and whether an ambulance or correctional services van are appropriate for transportation.
  • Investigate the possibility of using the Epoc Blood Analysis System. This medical equipment would provide quick access to basic bloodwork results. Further, the Saint John Regional Correctional Centre should consider the use of electrocardiograms within Corrections Health Services. Electrocardiograms can help inform decisions related to client care, including the necessity of transfers to the hospital. Further, the Saint John Regional Correctional Centre should examine the feasibility of these tools, especially in relation to human resources, scopes of practice, and training needs.
  • Explore the potential addition of a paramedic to the Corrections Health Services staffing model. A review of the use of paramedics in Corrections Health Services in other facilities across Canada will provide valuable information about the feasibility and effectiveness of adding such a role to the service. The associated skill set could potentially enhance the care team, contributing to positive care outcomes for urgent health needs.
  • Improve policies and procedures regarding transport and when to call an ambulance.
  • Improve policies and procedures regarding when to seek hospital care.
  • Improve record-keeping. Correctional officers should document if an inmate requested painkillers, saw a nurse, or made a medical complaint. This should be noted to monitor shift turnover.
  • Have the inmate’s vitals charted every time they are checked, even if they are unremarkable.
  • Provide medical attention and mental health services when they are needed.
  • Update contact information once an inmate arrives at the facility.
  • Have a nurse on an overnight shift from 11 p.m. to 7 a.m.
  • Install video and audio devices in the medical unit cells for nurses and/or correctional officers.
  • Nurses should be able to enter as well as verbally and physically check on an inmate while they are in a medical unit cell.
  • Create a policy or procedure to enter any medically related interaction and information regarding an inmate on a computer where specific user identifications are used.
  • Conduct monthly follow-ups regarding note taking. Once a month, shift supervisors should conduct an audit, review, and sign every correctional officer’s notebook.
  • Ensure an inmate is checked every fifteen minutes and that they have been asked how they are doing when they are placed in a medical unit cell, which would include a visual check. Any changes in the inmate’s condition should be immediately reported to the medical staff.
  • Establish policies and procedures to provide effective communications between the Saint John Regional Hospital and the Saint John Regional Correctional Centre to ensure the status of inmates is relayed to the institutions when they are admitted.
  • Ensure that all the contact numbers of next of kin are verified during inmate admissions and that the list is updated.
  • Develop a more efficient process for providing temporary absences to hospitals versus providing a hard copy.
  • Ensure all video surveillance timestamps are synchronized and accurate.
  • Ensure the Saint John Regional Correctional Centre has all-wheel-drive or 4-wheel-drive vehicles for the winter months.
  • Conduct a review of the policy on plowing contracts. Driveways, parking lots, and pathways must be kept clear during storms, not only after they end. Ease of access for transportation or ambulances must be maintained.

The chief coroner will forward these recommendations to the appropriate agencies or organizations for consideration and response. The responses will be included in the chief coroner’s annual report for 2023.