Shane Cantre died by suicide at the Regional Psychiatric Centre in Saskatoon on July 16, 2021.
A coroner’s inquest has been taking place in Saskatoon this week examining the circumstances around his death.
The inquest has heard how Cantre was found hanging in his cell, his mental health leading up to his death, and the mental health supports he received while as an inmate at RPC.
A recap of the first day can be found here.
The first witness on Tuesday was Dr. Shawn Ladham, a forensic pathologist who performed the autopsy on Cantre. Ladham was declared an expert witness and confirmed Shane Cantre died due to asphyxiation by hanging and that there was no evidence for any other cause of death.
The inquest also heard from Dr. Carlo Di Gregorio who was working at RPC the day Cantre passed away. Di Gregorio practices family medicine in the city and was a fill-in doctor at the facility at the time.
Di Gregorio says he rushed to Cantre’s cell when he heard the call of an unresponsive person. He says when he arrived Cantre was cut down and was getting CPR from a prison guard. He says when EMS arrived they did have an AED, but there was no heartbeat to suggest a shock.
There was discussion about RPC’s AED device compared to ones held by the paramedics and it was suggested the paramedics had a more sophisticated AED device. When asked if RPC should have a better AED device Dr. Di Gregorio says that would be a good recommendation.
Di Gregorio was also asked why he didn’t take over rescusitation efforts from the paramedics and he says the paramedics seemed to be doing a good job.
The inquest also heard from paramedic Jeff Maxim. Maxim spoke on equipment used by paramedics including a Life Pack 15 (A more advanced AED), and a “lucas” device which is a machine which automates chest compressions for CPR. When asked if RPC should have these devices he says he is unaware of the needs of the facility and says those devices require a significant amount of onboard training and wasn’t sure if their level of use at RPC would warrant their acqusition.
Maxim aslo added that he felt an AED would not have saved Cantre as he was not in cardiac arrest and had no pulse. He believes Cantre died due to a lack of oxygen to the brain, which an AED cannot provide. He says Cantre’s best chance for survival was if he was found sooner.
Maxim was also asked if he was aware there was a doctor in the cell. He says he only found out afterward that there was a doctor there and says he was “surprised” when he learned the doctor left during rescuscitation efforts. It was Maxim’s understanding that a physician at scene would take over lead of the life-saving attempts.
He confirmed that the paramedics pronounced Cantre dead after what he described as an “aggressive” rescuscitation effort. .
The inquest is scheduled to conclude with one final witness on Wednesday morning before a jury of 6 people will deliberate to make recommendations to prevent similar deaths in the future.