Jail guards unaware of 'critical' docs on monitoring inmate mental health issues, Delilah Blair inquest told

WARNING: This story contains references to suicide.

The inquest into the death of Delilah Blair in Windsor, Ont., heard Wednesdayfrom an expert on jail conditions who said care plans are critical, especially for inmates in the mental-health unit.

Kelly Hannah-Moffat testified Wednesday before a coroner's jury examining the May 2017 death of Blair, an Indigenous woman of Cree ancestry who was found without vital signs in her cell and later was pronounced dead inhospital. Earlier in the inquest, twocorrectional officers at the South West Detention Centre (SWDC) who were responsible for Blair's care testified they were unaware of a document that instructed staff to monitor inmatesfor depression and anxiety.

Those documents are "absolutely critical" for people inside jail mental health units, said Hannah-Moffat, who's doneresearchand consultant work on justice issues for both the Ontario and federal governments.

She's also specifically researchedconditions of confinement and prison reform.

In Blair's case, her inmate care plan contained details about watching for signs of depression, anxiety, withdrawaland psychosis, the inquest was told.

While officials already determined Blair died by suicide, the coroner's jury is tasked with investigatingthe circumstances of the death and coming up with anyrecommendations to prevent future deaths. An inquestautomatically may be called when an inmate dies while in custody. The Blair inquest began Monday after two years of pandemic delays.

Blair, a 30-year-old mother of four who had lived in the Northwest Territories and Manitoba before arriving in Windsor, was found in her cell on May 21, 2017. Blair had been charged with robbery. She was awaiting sentencing on a guilty plea at the time of her death.

She had spent time in the women's mental health unit at the jail, which is under indirect supervisionby officers who, at the time, checked on inmates twice every hour.

The inquest was told Blair was found in her locked cell with a bed sheet around her neck 22 minutes after she was last seen in the common area, as depicted in security camera footage shown during the inquest.

During her testimony, Hannah-Moffat was shown photos of both the male and female mental health cell blocks at SWDC.

She describedthe male environment to be more spacious, and as having more light and windows for the inmates to see the outside world. Male inmates also have direct access to a basketball court.

Hannah-Moffat said the Windsor jail's female mental health unit appeared dirty, with no outdoor light orrecreational activities.

"Appalling place to keep somebody if they have mental health problems," shetestified.

"This is more like segregation to me, in terms of the way it's looking" and not a "therapeutic space."

Indigenous inmates face morechallenges:expert

As an Indigenous woman, Blair had a different set of needs and challenges while in jail, said Hannah-Moffat, notingit's difficult to access elders or Indigenous medicine.

"When you're talking about Indigenous women, it's a lot harder for them being in solitary or segregation than it is for other people."

Christa Big Canoe is representing Blair's family at the inquest and is the legal director for Aboriginal Legal Services.

Aspointed out asevidence during the inquest, Big Canoe said the SWDC lackedIndigenous supportsat the time of the Blair'sdeath. For instance, it didn't have an Indigenous inmate liaison officer, and there was noIndigenous programming available in the women's mental health unit oraccess to elders.

"Not having elders would be highly problematic because I think sometimetalking to anelder can really, really help a person. It can really ground a person," said Hannah-Moffat.

"Not having access to that makes you feel more lonely, isolated, more scared," she added.

The two correctional officers and a social worker who previously testified said they didn't know Blair was Indigenous.

A lack of meaningful contact can be harmful,even more so for Indigenous women,said Hannah-Moffat. Speaking with a health-care professional through a meal slot in a jail door isn't meaningful contact, but rather "inhumane," she gave as an example.

"Especially if you're grounded to community and nature. It's equally problematic for them, if not worse," Hannah-Moffatsaid.

The night Blair died, two other women were inside the same mental health unit.

'Yelling and screaming' heard

Krystal Warnock, a former inmate at SWDC,testified she never spoke to Blair face to face because they were under a rotational unlock where only one of the three female inmates were allowed in the common area at once.

One day before Blair died, Warnock recalled,Blair sharedwith her a poem she wrote about her son, by slipping itunder the locked cell.

The night Blair died, Warnock recalledhearing "yelling and screaming" from her cell with a guard. She assumed it was about the TV remote being taken away.

Previous testimony from correctional officer James Wright indicated he heard Blair screaming or yellingwhile with his partner. He testified the remote was returned. Security camera footage showedBlair skipping around the common area within an hour before she was found in her cell.

Warnocktestified Blair "seemed fine" when she saw her,but added she observed Blair feeling agitated, and that she "must have had anxiety" and seemed rowdier than usual.

"She was more hyper, more awake," Warnock said.

Blair's access to call mom called into question

Blair's access to phone her mother has also been a key point of the inquest.

Warnocktestifiedthere was a phone in the common area of the unit. However, to make a long-distance call, a staff member would need to approve a written request and supply a separate telephone.

Selina McIntyre, who lives inHay River, N.W.T., testified Tuesday she hadn't heard from her daughter for four or five weeks. It wasn't until someone from the jail called to say she was dead that she learned Blair was incarcerated.

"She found safety in there. She trusted the system. She knew she had friends in there. She wasn't scared of the system."

The inquest is expected to last nine days.

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If you or someone you know is struggling, here's where to get help:

• Canada Suicide Prevention Service: 1-833-456-4566 (phone) | 45645 (text).

• Canadian Association for Suicide Prevention:Find a 24-hour crisis centre.

This guide from theCentre for Addiction and Mental Healthoutlines how to talk about suicide with someone you're worried about.