How a troubled Nunavut teen escaped police custody and took his own life

This story was originally posted on May17.

After complaining for hours about a problem with the heat in his RCMP cell, Tommy Anguilianuk a troubled young man with a history of suicidal thoughts convinced a detachment guard to not only release him, but also lend him his shoes and a parka.

The circumstances leading to Anguilianuk's death early on the morning of Jan. 21, 2013, were laid bare for members of a coroner's jury that met May 2 to May 6,in Hall Beach, Nunavut.

Exhibits from theinquest, which range from police reports and photos to treatment requests and guard logbook entries, paint a grim picture of the events that led up to the 18-year-old eventually stealing a rifle and ending his life.

Hours after Anguilianuk died, officers with the Ottawa Police Service's major crimes unit flew to Hall Beachto conduct an external review of the circumstances surrounding the young man's death.A coroner's inquest is automatically called when a person dies while in police custody in Nunavut.

'It's like I'm being cooked'

The detachment in Hall Beach, population 730, has two RCMP constables who work day shifts Monday to Friday.Cell guards at the detachment are advised to check on prisoners at least once every15 minutes and log their observations in a book.

These brief descriptions show Anguilianuk's growing agitation in the hours before his escape and death.

An entry from Jan. 20says the "prisoner is weeping [panicking] he feels that [it's] too hot in here."

According to evidence presented at the inquest, there was a problem with the heating in the detachment.

The logbook shows that at one point Anguilianuk told a guard, "It's like I'm being cooked." Later, he complained he was numb, saying "I can't feel my body anymore."

Over the course of his detainment, Anguilianuk repeatedly asked for water, banged on the walls of his cell, pulled at the door and cursed.

With the help of an Inuktitut translator, the guard who eventually let Anguilianuk out of his cell told Ottawa police the 18-year-old "was kind of panicked" that night.

Anguilianuk escapes with guard's shoes

According to the Ottawa police findings, Anguilianuk asked his guard, who was a casual employee of the detachment, "if he could go outside for a cigarette and to get some fresh air."

In the early morning of Jan. 21, 2013, that guard opened the teen's cell.

It was cold ( 34 C, but with a windchill of 46), so the guard let Anguilianuk borrow his parka and a black pair of running shoes.

As soon as the door to the detachment was open, Anguilianuk ran away into thedark.

In a panic and without any shoes or coat, the guard searched the detachment for something to wear before giving up and calling one of the RCMP constables at his home to tell him what happened.

The cell must have been unlocked, the guard told the constable, adding that he was in the bathroom when it happened.

While he "immediately knew [the guard]was lying," the constable told Ottawa investigators, hecalled the other local RCMP officer and rushed to the detachment to begin a search.

At some point, the guard remembered the logbook and wrote two final entries.

The first, in a time slot for 12:45, said only "ESCAPE!"

Then, in the line for the next 15-minute slot he wrote, "No show gone to escape!"

His final hours

A rough map entered as an exhibit at the inquest shows the path Anguilianuk likely took during his last few hoursrushing through most of the hamlet's streets.

In the course of their two-hour search, Hall Beach's two RCMP constables and local bylaw officers followed footprints in the fresh snow and items apparently thrown aside by Anguilianuk as he moved through town.

By the time they found the lost prisoner it was too late to save him his body was curled in the fetal position and resting on a rifle.

The final report from Ottawa police describes what likely happened in those lost hours.

Anguilianuk pried open his cousin's door and stole a rifle. He knew where to find it, because the two had been hunting together.

He walked to a home he knew on the edge of town and walked to a back porch, obscured from view by a snow drift, a pick-up truck and a small shed.

At around 2:30 a.m., a man and a woman in the home heard the shot that ended Anguilianuk's life.

They assumed it was a passing snowmobile.

A troubled life

To those closest to Anguilianuk, his last act did not come as a surprise.

Several of the people interviewed by police recounted how the 18-year-old was suicidal.

Treatment reports show Anguilianuk said he would hurt himself. The handwritten notes go on to describe how the young man had feelings of anger because of his "bad thoughts." Anguilianuk also said he had been physically abused during his childhood.

The guard who let Anguilianuk escape called the young man a former friend, but told Ottawa investigators he stopped hanging out with the teenager "due to the fact Anguilianuk was always talking about suicide."

Ottawa police wrote in their final report, "Anguilianuk's own family had refused him entry into their homes. He was living wherever he could find a place to sleep."

A cousin ofAnguilianuk'stold investigators the teen did not want to be sentto theBaffin Correctional Centre theIqaluitjail Canada's auditor general has called the country's worst.

2 hours of training; no security check

Ottawa police later discovered the man tasked with guarding Anguilianak had only received two hours of training.

Guards at RCMP detachments across Nunavut's remote communitiesare more likely to be local residents, with little security experience, rather than veterans or retired police officers.

Guards are given "brief training, teaching them their responsibilities as guards," the Ottawa police report found.

According to rules set out for guards, an RCMP officer "must be present before a prisoner is taken out of his/her cell."

The guard's job is to check the prisoners "frequently and at irregular intervals" to ensure they are safe. Prisoners with suicidal tendencies are to be "constantly" monitored.

Anguilianuk's guard was given no significant training in Hall Beach. The guard was given a "two hour cell block training course" in Pond Inlet, where he had previously worked.

"Recently the RCMP commenced security background checks on their guards," Ottawa police investigators wrote.

"In this particular case the RCMP had yet to complete their security check on the guard in question."

Changes coming to training

Cpl. David Lawson, a spokesperson for Nunavut RCMP, says the organization is reviewing its policies in light of recommendations from the coroner's inquest.

Regarding the jury's recommendation for longer training hours for guards, Lawson told CBC, "There's already something in place, but I believe it was just one-day training.

"We're looking at making it two-day training."

Photos of the Hall Beach detachment show the rules for guards were kept in a binder, but were available in English only.

Some were written on Post-it notes.

"TO ALL GUARDS," one of these notes reads, "Never give a pris a stuff other [than] food & drink. Never answer a phone.Never let prisout."

The jury at the inquest recommended rules for the guards be shown more prominently and translated into Inuktitut.

"That's something we've accepted," said Lawson. "We are in the process of translating all of our instructions right now."

Nunavut's Chief Coroner Padma Suramala says her office will follow up with the RCMP and other organizations named in the recommendations in six to 12 months.

She said the emotional inquest, while challenging at times, has provided closure to Anguilianuk's family.

But she's quick to say it did not lay the blame for his death at anyone's feet.

"Coroner's inquests are fact-finding exercises, not fault finding," she said. "No one is on trial."