Inquest jury recommends better and faster communication

However, a determined person will find a way, she told the jury.

“Unfortunately, when you have an individual who is suicidal, that’s all it takes is one little break down in areas like communication,” Shynkaruk said.

In Pine Grove, Behm was initially under a 30-minute watch from a nurse, but that was extended to one hour as she became calmer and more used to her surroundings.

The psychiatric hospital will do checks at similar intervals, but if a person is deemed high risk, they will hire another staff member to be with that person all the time.

One consistent refrain throughout the inquest has been Robin Ritters (Coroner’s counsel) questions regarding why Behm was not transferred to North Battleford after a judge ordered her to be on September 10, 2020.

She was still in Pine Grove on Oct. 1 when she died. Pine Grove staff were not aware of the date of the planned transfer or the judicial order but, according to information from North Battleford, Behm would have been transferred for assessment on October 7.

An inquest jury has made multiple recommendations to prevent deaths like that of Elaine Behm in Pine Grove in 2020. (file photo)

It can take about a month for a remand assessment to be done, something that is likely due to a shortage of psychiatrists and psychologists in North Battleford but there is also a shortage of psychiatric nurses at Pine Grove.

Of the six full time positions that should be working with the corrections side of the Saskatchewan Hospital, only three are filled. They have also gotten so far behind, they hired locums from Saskatoon to help complete some.

Another theme heard yesterday and today is the length of remand time accused offenders now face.

Pine Grove, for instance, is supposed to hold 166 offenders but regularly has about 230 women and, as the inquest heard from one staff member, recently 147 were on remand.

Sentenced prisoners have more access to programming and, with a continuously busier court system remanded prisoners wait longer for trials.

Tuesday afternoon, the deputy director of personnel from Pine Grove, Esther Wolfe, said filling staff positions in the jail has become even more of a struggle.

She would like to offer more for remanded inmates, but a ministry directive said it should be focused on sentenced offenders.

“With a large amount of our inmates remanded, it really puts a lot of restrictions on programming,” Wolfe said.

She also would like a dedicated substance abuse program but can’t make it happen.

“We need to have the staff in place to facilitate them,” Wolfe said. On Monday, staff nurses told the inquest there were three or four full time nurses, but Wolfe said there are six and should be 11.

In addition to having a hard time getting applications, the staff has a high turnover rate with a universal shortage and constant recruitment efforts from other groups.

Unlike North Battleford where a facility committee decides who is admitted, Pine Grove has no choice. If there is a detention warrant, they must take the person.

Intake for the 12 remand beds in the hospital usually takes about a month, said Lynda Shynkaruk, the hospital’s director but the scope is very specific.

“That is all we are mandated to do. Once the assessment is done, the patient would go back to the correctional facility they came from,” Shynkaruk told the six person jury.

Behm was in prison charged with the murder of her husband Darren in Lloydminster on August 25, 2020. She was admitted to Pine Grove several days later and ordered by a judge to have a psychiatric assessment to determine if she could be held criminally responsible on Sept. 10.

She was to have been in North Battleford at the forensic hospital on October 7 but died seven days earlier.

Previous testimony has revealed a significant shortage of nurses at Pine Grove and an overworked, understaffed facility.

Her nurses there were not aware of her previous suicide attempt and correctional officers noted that she showed signs of paranoid behaviour but none raised serious flags.

In their recommendations, the jury suggested increased communication between the various facilities and staff and that it be sped up.

All correspondence from courts and health care should be in the prisoner’s file with Corrections and a suicide or several mental health warning pop up message be placed in the information management system when the patient’s file is accessed.

When inmates choose to stay in their room or cell, as Behm did, it should be recorded and there should be more frequent checks.

They recommended that inmates be allowed to have their information shared with family members.

Another recommendation was that all staff be given ASIST suicide prevention training and that it be refreshed regularly.

Counselling and programming needs to be available for remanded prisoners and operational debriefs should be mandatory for all staff involved following a serious incident.

The final recommendation was for Critical Incident Stress Management should remain optional but must occur separately from the debrief.

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susan.mcneil@pattisonmedia.com

by Susan McNeil

Inquest jury recommends better and faster communication

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