Coroner’s inquest comes back with 11 recommendations after in-cell suicide

The coroner’s inquest into the in-custody death of Jeremy Sabourin wrapped up on Thursday afternoon at Moose Jaw Court of King’s Bench with 11 recommendations.

The inquest ruled that Sabourin died at 9:25 a.m. on Oct. 7, 2021, in a Moose Jaw police holding cell from a self-inflicted gunshot wound to the head. The inquest took four days and heard evidence from 13 witnesses.

Ten of the recommendations were made by the five-person jury panel (one jury member was dismissed just before the recommendations were presented for compassionate reasons) and presiding coroner Blaine Beaven made one recommendation.

The recommendations from the jury were as follows:

• The RCMP and Moose Jaw Police Service (MJPS) shall require all new members to become familiar with applicable policies and all members shall review them annually and communicate the completion of the review.
• The RCMP and MJPS implement annual testing and qualification of their members on physical and metal detector wand search techniques with testing conducted by an external police agency.
• The RCMP have a minimum of two wands available at each detachment for searches.
• The RCMP modify the C-13 prison information form to provide more space for information to be written on the document and clearly indicate which fields are mandatory to fill before a prisoner is transferred to another agency.
• The RCMP and MJPS provide its members with annual mandatory mental health and suicide crisis training.
• The MJPS ensures its members complete and fill applicable forms on prisoners coming into its custody.
• The MJPS modify its custody intake forms to include a field for non-responsiveness.
• The RCMP shall review its search procedures and the disadvantage position used by the RCMP to determine if it is effective and in line with best practices in policing.
• The RCMP and MJPS shall formalize a policy audit process with audits occurring at least once per year.
• The RCMP and MJPS shall consider that breach of policy involving the search of a prisoner is a serious matter and engage disciplinary processes where appropriate.

“I want to make a comment that the recommendations made by the jury are very thoughtful (and) very thorough, they meet all the requirements of The Coroner’s Act and I’m very impressed by your obvious attention to detail,” Beaven told the jury.

Beaven added the following recommendation:

• All Saskatchewan police services shall review and where necessary modify the wording of the jury’s recommendations to apply to their police service.

Beaven said his recommendation doesn’t infringe on the jury’s recommendations, but he believes the recommendations shouldn’t be just limited to the RCMP and Moose Jaw Police Service.

“Prisoners are taken into custody by various police and law enforcement agencies across the province on a daily basis. This incident could happen at any of them. It could still happen and so these recommendations are equally relevant to them as well,” Beaven said.