The inquest looking in to the death of Curtis Mckenzie is finished hearing testimony.

On the final day of testimony Thursday at the Coronet Hotel in Prince Albert the inquest heard from three witnesses, including the Warden of the Saskatchewan Penitentiary, where Mckenzie was found hanging in his cell by his neck in February of 2020.

The first witness heard from was Skylar Ursu, who at the time of Mckenzie’s death was the acting mental health worker at the penitentiary, who made the recommendation to release Mckenzie from a medical observation cell he was place in after he came back from the hospital, where he was sent after cutting his own nose. Ursu told the inquest at the time she was still working on finishing up her degree in sociology with a minor in psychology, but had gotten some suicide training through Corrections Canada (CSC) and was also consulting with some colleagues in the mental health unit in regards to Mckenzie.

“I did feel confident in my recommendation,” she said.

Speaking about the assessment, Ursu said when she spoke with Mckenzie while he was in the observation cell he told her that he had cut himself because he was feeling stressed about his coming release from the facility. However, Ursu testified he told her it would be better for him to go back on the mental health range to his regular cell where he had tools to help him cope with stress, which had been successful for him in the past.

“On range he had access to his friends, his drawings, his music,” she said.

While she was speaking with him, Ursu said Mckenzie maintained eye contact and was engaged while speaking to her in a low tone of voice.

Ursu became emotional at times during her testimony and wiped away tears a few times while on the stand. When asked by Coroner’s Council Robin Ritter about what possible changes could be made at the penitentiary to prevent similar deaths in the future, Ursu told him having more mental health staff working at the facility and available during more hours would be helpful. She as well agreed it would be good to have an interview space where mental health staff could speak with people who are in observation cells, instead of just speaking to the person through a hole in the cell door.

The final witness to give evidence at the inquest was Shawn Bird, the Warden of the Saskatchewan Penitentiary. During his testimony Bird was asked by Coroner’s Council Ritter about changes made at the institution since Mckenzie’s death in 2020. The warden said there was an internal review and report done, which made some recommendation, however he was not able to provide specifics when asked.

“I don’t have that document with me today,” said Bird.

The issue of offenders not properly using their prescribed medications was brought up during the warden’s testimony. In Mckenzie’s case he was taken off his anti depressant medication after he was suspected of using it improperly, a fellow inmate also testified he witnessed Mckenzie snorting his medication. In response to the questioning Bird said they have worked to find other ways to get offenders their medications, which has included giving it to them in a non pill form. Bird said the issue is one that all correctional institutions are dealing with.

“Diversion of medication is an ongoing problem,” he said.

Bird said since Mckenzie’s death, Saskatchewan Penitentiary now makes sure only licensed mental health workers make referrals on releasing people from observation cells. The warden added they do not like to keep people in observation cells for too long a time as when people are inside the cells they are constantly watched and deprived of many things they would normally have access to.

“That’s one of the most intrusive things we do to individuals,” he said.

With testimony finished the jury which is made up of three men and three women will now begin their deliberations. The jury will determine the facts of what happened which includes who died, where and what the cause of death was. They may also put forward recommendations to prevent similar deaths in the future.

Day 3

The third day of testimony at the inquest into the death of Curtis Mckenzie heard some details about him as a person Wednesday.

One of the witnesses who took the stand was Corrie Sander, who at the time of Mckenzie’s death was working at the Saskatchewan Penitentiary as a clinical social worker. Sander testified she knew Mckenzie well and had met with him while he was in crisis multiple times. She explained when Mckenzie was returned after violating his parole he was placed on the mental health unit in the facility due to the resources available there.

“There were different supports you could access there,” she said.

Sander said Mckenzie would often attend group therapy sessions with other inmates but did not speak with her about accessing one on one therapy and when she brought up the idea he would tell her that he was not ready for it. Sander added when it comes to providing mental health treatment to people incarcerated at the prison staff need to respect the wishes of the offender.

“There has to be consent and they have to want to go,” she said.

Sander’s testimony as well touched on the issue of Mckenzie’s anti depressant medications being taken away. Sander testified she had spoken with Mckenzie about a previous incident where he was observed by staff to have not swallowed his medication and when confronted about it walking away. Sander said she explained to Mckenzie the consequences for these actions and also added that in her experience offenders sometimes have trouble dealing with doctors.

“A lot of times they really struggle with communication,” she said.

During her testimony, Sander became emotional on two occasions, when she first sat down to testify she became upset when Coroner’s Council Robin Ritter began questioning her. The Coroner overseeing the inquest granted a break to allow her time to collect herself. Later on in her testimony she spoke about how Mckenzie was an artist who would regularly draw, this included sketching a mural on the wall of the office where mental health staff at the prison worked. Near the end of her testimony Sander wiping away tears told the inquest in her time working in corrections she had dealt with some truly bad people and that Mckenzie was not one of those people.

“He wasn’t a bad guy,” she said.

The issue of Mckenzie not taking his medication as prescribed and potentially diverting it for illicit use has been a major topic of discussion at the inquest in the past three days. During his questioning the issue has been brought up by Coroner’s Council Ritter, who has stressed the fact that Corrections Canada (CSC) can only provide one report and one firm date where Mckenzie was found to not be taking his medication as prescribed.

Wednesday afternoon the inquest heard testimony from Shane Pattison, a current inmate at the Saskatchewan Penitentiary who was serving time alongside Mckenzie on the mental health unit in the prison. Pattison, who testified by phone, told the inquest he witnessed Mckenzie on a number of occasions over the time they were locked up together miss use his wellbutrin anti depressant medication.

“I had seen him snorting them,” he said.

Pattison as well told the inquest when Mckenzie returned from the isolation cell he was placed in after returning from the hospital, where he was taken after cutting his nose for a second time, he could tell Mckenzie was not doing well. He added he was not expecting to see Mckenzie return to the unit after such a short period.

“I was very surprised he was back,” said Pattison.

Pattison said while they were locked in there cells, Mckenzie asked him if the guards had done their checks, Pattison said he told Mckenzie the guards had done their checks and after that he heard sheets ripping inside Mckenzie’s cell. Pattison explained he thought Mckenzie was ripping his sheets to make a privacy curtain, which Pattison testified is not uncommon. When the cell doors were opened, Pattison said he left his cell where he and several other inmates found Mckenzie hanging by his neck. While the other inmates worked to get him down, Pattison testified he ran to get the guards.

The testimony given by Pattison in regards to Mckenzie diverting such large amounts of medication for such a long period of time was of major interest to Coroner Tim Hawryluk, who is presiding over the inquest. Following Pattison’s testimony Joele Fidler, who at the time of Mckenzie’s death was the manager responsible for health care at the penitentiary took the witness stand. Fidler had originally been called to give testimony in the morning but was provided a reprieve as she needed time to get paperwork from the penitentiary which she had not been able to access due to her not working on site currently.

Coroner Hawryluk explained to Fidler he found the testimony given by Pattison to be mostly credible and focused in on the issue of offenders not taking their medications as prescribed, telling her there appeared to be an issue.

“There may a significant blind spot there,” he said.

In response to the Coroner’s questioning Fidler said nurses do check offenders mouths after providing them their medications she added having a corrections officer posted on the line when medications are given out could be helpful in dealing with the diversion issue.

The inquest is set to continue Thursday morning in Prince Albert at the Coronet Hotel.

Day 2

The Coroner’s Inquest investigating the death of Curtis McKenzie heard from three medical witnesses Tuesday.

One of those witnesses was Dr. Eric Bol, a forensic pathologist who performed the autopsy on Mckenzie after he passed away in hospital in Prince Albert, where he was taken after he was found hanging in his cell at Saskatchewan Penitentiary in February of 2020.

Bol, who testified by phone from British Columbia, where he is now employed by the British Columbia Coroner’s Service, explained his examination found Mckenzie’s death to be from complications due to hanging and said the injuries he saw were consistent with hanging. The forensic pathologist as well noted a number of scars on Mckenzie’s body, adding there were too many to count one by one. He as well made note of the injury to his nose.

“This was the first time I had seen an amputated nose in an autopsy setting,” said Bol.

According to Bol no illicit drugs were found in Mckenzie’s system during the autopsy, however he said since Mckenzie had spent a significant period in hospital on life support before passing away, if there were illicit drugs in his system at the time of him hurting himself they would not be present at the time of the autopsy.

Another medical doctor who the jury heard evidence from was Dr. Leo Lanoie, who was one of the two doctors who was involved in providing care to Mckenzie while he was in custody. Much of Lenoie’s testimony focused on the treatments Mckenzie was getting, specifically him being prescribed an anti depressant medication containing wellbutrin. The medication was cut off after the doctor was given a report that Mckenzie was not taking it as prescribed, but rather was diverting it for improper use.

Lanoie explained when it comes to prescribing wellbutrin in a correctional setting doctors have to be cautious and get approval from Corrections Canada (CSC) before prescribing it to inmates as it can be used by inmates to get high.

“There’s a whole list of drugs that are like that,” he said.

The Prince Albert based family physician went on to testify that Mckenzie’s medication was cut off after he did not show up to an appointment with Lanoie to discuss different treatment options besides wellbutrin. During his testimony Lanoie was pressed by Saskatchewan Coroner’s council Robin Ritter in relation to the allegations that Mckenzie had diverted his anti depressant medication on two different occasions. Ritter asserted there was only one occasion where Mckenzie was found to have diverted his medications. In response to this Lanoie said he observed a note in Mckenzie’s file indicating he had attempted to divert medication for a second time. In regards to the role cutting off anti depressant medication may have played in Mckenzie’s death, the doctor was not sure what impact the decision had.

“I can’t answer that,” he said.

During Lanoie’s testimony the inquest as well heard that Mckenzie had been sent back to the Saskatchewan Penitentiary after throwing a brick through a window at a hospital in Saskatoon, after breaking the window he waited for the police to arrive. Lanoie agreed with Coroner’s Council Ritter that such an action could be considered a cry for help and as well indicated that self harm like the kind Mckenzie did to himself is generally a symptom of some sort of personality disorder. Overall the doctor said it is not easy to determine if someone is suicidal, he added physicians generally rely on a patient to tell them they are feeling suicidal.

“We can’t predict that,” he said.

The inquest as well heard from another doctor involved with Mckenzie’s care in Dr. Vipul Parekh. Parekh was the physician who had ordered the dosage of the wellbutrin given to Mckenzie be reduced after getting a report about the medication being diverted for a second time. When pressed by Coroner’s Council Ritter on the specifics of the alleged second incident of medication diversion, Parekh like Lanoie pointed to a note in Mckenzie’s file indicating there was a second incident, but was not able to produce a detailed report of the supposed second incident. Nor could the doctor tell the inquest what date the alleged second diversion happened on. The only firm documentation that was produced when it came to Mckenzie diverting medication was a report from 2019.

The inquest is set to continue Wednesday morning at the Coronet Hotel in Prince Albert.

Day 1

Content Warning: This article contains content relating to suicide 

The Coroner’s Inquest looking in to the death of Curtis Mckenzie heard testimony from six witnesses Monday.

The inquest will be examining the circumstances surrounding the death of Mckenzie, who died while in custody at the Saskatchewan Penitentiary in February of 2020.

The first witness to speak at the inquest was one of Mckenzie’s fellow inmates, William Loney, who is still serving a sentence at the Saskatchewan Penitentiary. He testified while shackled and was under the supervision of two corrections officers.

Loney testified he had known Mckenzie for 15 years from around the prison. He said Mckenzie was depressed and had talked about wanting to end his own life and added the day before he was found hanging in his cell, he saw Mckenzie go into his cell where he cut his nose.

“He cut the rest of it off,” Loney said.

The inquest was told Mckenzie had a history of harming himself inside prison, which included a previous incident a number of years previous, where he had cut most of his nose off. Loney testified Mckenzie was removed from the cell block and taken to get medical treatment. He was returned to his cell not too long after, which was something Loney found to be strange.

“I didn’t think he should be on the range,” he said.

When Mckenzie was returned to his cell, the rest of the inmates on the block were locked inside their own units. Loney said when the cell doors were opened electronically, him and a number of inmates went to Mckenzie’s cell to check on him where they found him hanging. He added he and some of his fellow inmates were worried about Mckenzie when he was returned to the cell block after harming himself.

“We knew something was up, it was obvious,” he said.

The second witness to take the stand Monday was Constable Troy Antel, a member of the RCMP who at the time was assigned to the force’s general investigation section for northern Saskatchewan. Antel told the inquest their investigation determined Mckenzie’s death was a suicide. He explained his investigation relied on information gathered from corrections officer’s reports along with security camera footage. He added a suicide note was found in the cell on the bed where Mckenzie was found.

In total the inquest heard from six witnesses Monday, which also included the three corrections officers who responded to the inmates calls for help when they found Mckenzie hanging in his cell and one of the nurses who also attended. The final witness of the day, a member of the penitentiary’s intelligence unit, spoke about the investigation into the death and some of Mckenzie’s history of self harm. The inquest was as well told Mckenzie had a history of “diverting” his medications, which is when an inmate doesn’t actually take their prescribed medications as intended and either sells them or uses them in a manner that is not intended.

The Coroner’s jury, which is made up of three men and three women will be charged with determining the cause of Mckenzie’s death and establishing the facts of what happened. The jury may also put forward recommendations to avoid similar deaths in the future.

Four groups have been granted standing at the inquest including the federal government and the Saskatchewan Coroner’s Service. The Mckenzie family has also retained their own lawyer to represent them while the Congress of Aboriginal Peoples (CAP) is also taking part.

The inquest is set to resume hearing from witnesses Tuesday morning. In total 27 witnesses are expected to take the stand over the next five days.