A report into her daughter's suicide took 2 months. She waited more than a year for a copy

For a more than a year,it sat over Lisa Piercey's head like a dark cloud another chapter in the story of her daughter Samantha's untimely death that she was waiting to close.

An Eastern Health employee contacted Piercey in December 2018 to advise her that Dr. Keith Courtney of Alberta Health Services had been contracted to review the health care provided to her daughterand three other people who died while they were in custody in two Newfoundland and Labrador jails.

Samantha Piercey diedin a prisoncell in Clarenvilleon May 26, 2018. A correctional officer found the 28-year-oldhanging from a bedsheet from a vent in the ceiling.

Lisa Piercey said she was told it would take a month to two months for Courtney tocomplete his health-care review. But as weeks and then months went by without any update, she began inquiring when it would be done.

"Nobody knew anything," Piercey said. "They said they didn't know but they'd look into it."

By September 2019, she and other family members of inmates who died while in the care of the Department of Justice were allowed to view the report, but were not given a copy.

Piercey said she was shocked and upset when she received her own copy six months later, in the middle of March.

She saw thatCourtney had dated his report as being finished on Jan. 27, 2019.

"I can't help but feel and wonder, what are you keeping from me?" Piercey said in an interview with CBC News. "There's no respect. It seems like they're not taking mydaughter's death seriously. Transparency is needed so much."

The Department of Health and Community Services said it began redacting reports for the families once it received the final copy from Courtney.

Communication flaws

The medical review was recommendation 17 of a report by retired Royal Newfoundland Constabulary Sgt. Marlene Jesso.

Jesso's review, which was completed in December 2018, looked at the two institutions where the inmates died Her Majesty's Penitentiary, and in Piercey's case, the Correctional Centre for Women in Clarenville.

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Though much of the specific information was redacted, Jesso's report made 17 recommendations on improving a correctional system that it says isat a "breaking point," unable to deal with mental health and addictions issues.

Jesso said her team did not consider the medical treatment provided to the inmates, as it was outside the scope of the review, and instead, recommended that members of the medical community take on their own investigation.

A copy of Courtney's recommendations has been obtained by CBC News.

A psychiatrist with experience in jails and prisons in Canada and the United States, Courtney has lectured and written about suicides in jails and prisons.

In his report, hepointed out significant communication failures between health-care teams, correctional officers and staff at the Waterford psychiatric hospital in St. John's.

"Common themes throughout this review are the lack of transfer information and a lack of documentation," wrote Courtney.

Nearly a month earlier before her death, Samantha Pierceyattempted to end her own life by slashing her wrists with a razor. After receiving treatment, she was sent to the correctional centre, where she later died.

A suicide-risk assessment there on April 26, 2018,identified her as being at risk for self-harm, and she was prohibited from having razors or any othersharp objects.

Staff noted that suicide watches, recent violence, and mental health or medical concerns were often notshared between health care and corrections staff.

4 out of 12recommendations fulfilled

The Department of Health said the government's intention was to release the recommendations in an announcement regarding the transfer of the responsibility for health services for inmates to the Department of Health and Community Services, from the Department of Justice and Public Safety.

"COVID-19 delayed this announcement, but the work to address the recommendations has continued," she wrote.

Eastern Health has since created a steering committee to transfer services from justice to health, and to implement all 12 of Courtney's recommendations.

Four have been implemented thus far, as well asthis work:

• Enhancements to support the transfer of health information between facilities to support continuity of care.
  
• Improved access to health care services and meaningful contact for individuals, particularly those in segregation.
  
• Improved access to mental health and addictions counselling via Doorways counselling and use of Therapy Assistance Onlineto provide virtual care.
  
• Establishment of complex case conferencing with security and health-care staff.
  
• Training opportunities for staff to receive enhanced mental health training.
  
• Establishment of an inmate request form.

A failing grade

Piercey said she'd give the provincial government a failing grade for its handling of her daughter, and says three individuals should lose their jobs over what transpired.

"All it took from the beginning was somebody to say, 'Sorry what happened to your daughter, Ms. Piercey. Let's work together to find out what happened,'" Piercey said.

Piercey is suing the provincial government over her daughter's death. The families of Doug Neary and Skye Martinhave also done so. It's expected that Christopher Sutton's family will file a lawsuit in Supreme Court this year.

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"Her daughter, my granddaughter, she still [does not]understand why they didn't look after Mommy, why they're not telling her they're sorry," said Piercey.

"I try to reassure her, and it's hard when I don't believe it, that they are sorry."

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