CONTENT WARNING: some details in the following story may be distressing

Randal Nicotine, of Red Pheasant First Nation, died while at the Saskatoon Provincial Correctional Centre in May 2019.

An inquest into his death is taking place this week at the Saskatoon Inn and Convention Centre.

The inquest is being presided by Bill Davern on behalf of Saskatchewan’s Office of the Chief Coroner.

Monday saw the selection of 6 jurors, 3 Indigenous and 3 non-Indigenous, who will hear from ten witnesses on the circumstances around Nicotine’s death. At the end of the inquest, the jury will have an opportunity to make recommendations to prevent similar deaths in the future.

Early evidence indicated Nicotine died by suicide in the early morning hours of May 14th, 2019 in his cell.

First witness was corrections officer who found Nicotine in distress

According to testimony from Robert Blain, the corrections officer who discovered Nicotine in distress during his hourly check, Nicotine used a ligature made from bedsheets around a metal grate over the cell’s intercom system.

Blain testified he immediately informed the other officer on staff in the unit of the emergency, grabbed the 911 knife on the unit, and with the help of another officer cut Nicotine down. CPR was then performed on Nicotine until EMT and EMS arrived, however, Nicotine was pronounced dead at the scene.

When Blain was asked by lawyer Robin Ritter if he had any recommendations for the jury he had four to offer. He believes any safety concerns around ligature points in inmate cells should be addressed and units should have three officers on staff during night shifts to conduct hourly checks. He also believes officers should have more easily attainable access to previous inquest recommendations and should be more informed about previous suicidal tendencies of inmates.

At the recent inquest into the death of Benjamin Toutsaint, who died in a simlar manner, the jury recommended officers carry the 911 knife on person. During Monday’s testimony, Blain spoke on the safety concerns around having the knife on them during a volatile situation. He also says even if he had the knife on him he would not have entered Nicotine’s cell alone because it takes two officers to succesfuly use the knife to help someone in distress, and he also says there is a risk of any situation becoming too dangerous for a lone officer. Hence, Blain offered the recommendation to have a total of three staff during night shifts; two to do the hourly checks and the other to stay behind at the unit’s main office. Currently two staff are on duty during the night shift.

A question to Blaine from Randal Nicotine’s sister Ashley Nicotine indicated Nicotine had previously been on a suicide watch. Blain says he was unaware that had been the case, but believes that information would have been helpful.

Other corrections officers testify

Another witness was corrections officer Kurtis Bamberger who was the responding officer on another unit – this means he was responsible to attend to any emergency on another unit. He responded to the “code blue” (medical emergency) on Nicotine’s unit.

Robert Blain had indicated on average the correctional centre would experience around 2-3 code blues a week and Bamberger testified the centre undertook three code blue’s on the night Nicotine died.

Both corrections officers indicated no AED was brought to Nicotine’s cell by staff from the correctional centre and the first AED to arrive at the scene was brought when EMS/EMT professionals arrived. However, Bamberger said officers have received increased training on AEDs and responding to medical emergencies since Nicotine’s death in 2019.

Bamberger said it is policy for corrections officers to be informed of suicidal ideations of inmates. He said it would be “irregular” for staff to not be informed of any past suicidal ideation from Nicotine.

The inquest also heard from the corrections officer who cut the ligature from Nicotine who testified she did not find any sign of life of Nicotine when she cut him free. The officer believes the AED may not have been helpful in reviving Nicotine, but believes because of recent training since Nicotine’s death an AED would be brought if a similar situation were to arise now.

Another officer testified to completing a suicidal assessment screen on Nicotine around one month before his death. He said Nicotine scored 1 out of a possible 17 points on the assessment, which indicated a very low score on suicidal ideation. However, the officer did admit the success of the assessment is determined by the honesty of the inmate.

The officer said he does not believe it is possible for an inmate cell to be entirely free from ligature points and said the suicide observation rooms for inmates who score high on a suicidal ideation assessment are not a pleasant experience for the inmates who need to use them.

The jury also heard from the paramedics who attended to Nicotine’s medical distress.

The inquest will continue on Tuesday.

Important to note an inquest is not used to find guilt or innocence; it is used to determine the circumstances around Nicotine’s death and to help prevent similar deaths in the future.

The coroner’s office only calls an inquest into an in-custody death if they feel the death could have been preventable.

(PHOTO: Randal Nicotine – courtesy Facebook)