Inquest into Toronto inmate’s 2020 death makes 11 recommendations

Published Oct 12, 2024  •  2 minute read

An inquest jury has made 11 recommendations following the death of an inmate inside a Toronto jail four years ago. Photo by Dave Thomas / Files /Toronto Sun

Four years after an inmate at a Toronto detention centre died while in custody, a coroner’s inquest has made 11 recommendations to the province.

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According to the Office of the Chief Coroner, Abdurazak Mussa was jailed at the Toronto East Detention Centre (TEDC) in Scarborough on July 24, 2020. He was facing criminal charges and was not on bail.

Mussa was informed on Aug. 5 that he would remain incarcerated for two months. He asked for a psychiatric assessment, which an officer processed.

On Aug. 30, shortly after 4 a.m., a night shift officer was performing a security tour when Mussa was observed hanging in his cell with a ligature around his neck. Nursing and correctional staff responded and immediately performed cardiopulmonary resuscitation (CPR). He was transferred to Scarborough General Hospital to receive further treatment.

On Sept. 2, the ventilator that was keeping Mussa alive was removed after doctors determined the 41-year-old was brain dead.

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The inquest, which lasted five days and was required under the Coroners Act, heard from more than a dozen witnesses.

On Friday, the inquest jury issued their recommendations to the Ministry of the Solicitor General.

The first recommendation was that an immediate review should be initiated to determine the potential need at the TEDC for round-the-clock mental health nursing at the site.

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“For greater clarity, immediately assess the possible benefits of having a mental health nurse physically present on-site at the TEDC 24 hours per day, 7 days per week, to ensure adequate coverage during overnight hours and ensure that a minimum of two nurses are on-site at all times,” the jury wrote.

In addition, within the next year, the jury recommended “all correctional officers, sergeants, and supervisors at the TEDC be registered for enhanced or additional training to what is currently in place for suicide prevention training.” A mandatory refresher course to prevent suicides was also suggested on an annual basis.

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The Solicitor General was also asked to review and explore a suicide rating scale at the detention centre to help identify inmates who may be at and “elevated risk of suicide or self-harm.”

Guards working the night shift should continue to follow ministry policies that require them to make “irregular and sporadic” checks to prevent their predictability to inmates, and conduct a quality review of ministry-issued flashlights, the report said.

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Three recommendations involved better record keeping and documentation, as well as the sharing of information with all provincial institutions.

The jury suggested on-duty officers should have cellphones to ensure quicker communication between correctional staff during a medical emergency.

It was also recommended that the ministry conduct a review of “current peer support and other support offered to nursing staff, correctional staff, and witnesses following a critical incident to ensure that it is consistent across the province ….”

The final recommendation suggested an artificial manual breathing unit should be considered where CPR is necessary.

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