An inquest into the 2020 death of an inmate in Toronto makes 11 recommendations

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Four years after an inmate died in Toronto custody, a coroner's inquest made 11 recommendations to the province.

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According to the Office of the Chief Coroner, Abdurazak Mussa was booked into the Toronto East Detention Center (TEDC) in Scarborough on July 24, 2020. He faces criminal charges and is out on bail.

On August 5, Mussa was informed that he would remain in custody for two months. He requested a psychiatric evaluation, which was performed by an officer.

On August 30, shortly after 4 a.m., a night shift officer was conducting a security check when Mussa was spotted hanging in his cell with a ligature around his neck. Nursing and corrections staff responded and immediately performed cardiopulmonary resuscitation (CPR). He was transferred to Scarborough General Hospital for further treatment.

On September 2, the ventilator keeping Mussa alive was disconnected when doctors declared the 41-year-old brain dead.

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The inquest, which lasted five days and was required under the Coroners Act, heard from more than a dozen witnesses.

On Friday, the investigative jury issued its recommendations to the Ministry of the Attorney General.

The first recommendation was to immediately begin a review to determine the potential need at TEDC for 24/7 on-site mental health care.

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“For greater clarity, the possible benefits of having a mental health nurse physically present on-site at TEDC 24 hours a day, 7 days a week should be immediately assessed to ensure adequate care during night hours and ensure that at least two nurses are on-site all the time,” the jury wrote.

Additionally, over the next year, the jury recommended that “all correctional officers, sergeants, and supervisors at TEDC register for enhanced or additional training beyond that currently in effect for suicide prevention training.” An annual mandatory refresher course to prevent suicide was also proposed.

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The Attorney General was also asked to review and investigate the suicide assessment scale used at the detention center to help identify inmates who may be at “an increased risk of suicide or self-harm.”

Guards working the night shift should continue to follow ministry rules that require them to conduct “irregular and sporadic” inspections to prevent them being predictable to prisoners, as well as conduct quality checks on ministry-issued flashlights, the report said.

The three recommendations concerned better record-keeping and documentation, as well as making information available to all provincial institutions.

The jury suggested that on-duty officers should have mobile phones to ensure faster communication between prison staff in medical emergencies.

It also recommended that the ministry conduct a review of “ongoing peer support and other support offered to nursing staff, corrections staff and witnesses following a critical incident to ensure it is consistent across the province…”.

The final recommendation suggested that if cardiopulmonary resuscitation is necessary, the use of an artificial manual breathing apparatus should be considered.

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