Jail guards unaware of ‘critical’ docs on monitoring inmate mental health issues, Delilah Blair inquest told


WARNING: This story contains references to suicide.

The inquest into the death of Delilah Blair in Windsor, Ont., heard Wednesday from an expert on jail conditions who said care plans are critical, especially for inmates in the mental-health unit.

Kelly Hannah-Moffat testified Wednesday before a coroner’s jury examining the May 2017 death of Blair, an Indigenous woman of Cree ancestry who was found without vital signs in her cell and later was pronounced dead in hospital. Earlier in the inquest, two correctional officers at the South West Detention Centre (SWDC) who were responsible for Blair’s care testified they were unaware of a document that instructed staff to monitor inmates for depression and anxiety.

An inmate care plan was in place during Blair’s time at the Windsor jail. Two correctional officers testified earlier in the inquest that they weren’t aware of it. (Coroner’s inquest)

Those documents are “absolutely critical” for people inside jail mental health units, said Hannah-Moffat, who’s done research and consultant work on justice issues for both the Ontario and federal governments.

She’s also specifically researched conditions of confinement and prison reform.

In Blair’s case, her inmate care plan contained details about watching for signs of depression, anxiety, withdrawal and psychosis, the inquest was told.

While officials already determined Blair died by suicide, the coroner’s jury is tasked with investigating the circumstances of the death and coming up with any recommendations to prevent future deaths. An inquest automatically may be called when an inmate dies while in custody. The Blair inquest began Monday after two years of pandemic delays.

Blair, a 30-year-old mother of four who had lived in the Northwest Territories and Manitoba before arriving in Windsor, was found in her cell on May 21, 2017. Blair had been charged with robbery. She was awaiting sentencing on a guilty plea at the time of her death.

She had spent time in the women’s mental health unit at the jail, which is under indirect supervision by officers who, at the time, checked on inmates twice every hour. 

The inquest was told Blair was found in her locked cell with a bed sheet around her neck 22 minutes after she was last seen in the common area, as depicted in security camera footage shown during the inquest.

During her testimony, Hannah-Moffat was shown photos of both the male and female mental health cell blocks at SWDC.

She described the male environment to be more spacious, and as having more light and windows for the inmates to see the outside world. Male inmates also have direct access to a basketball court.

A photo of the women’s mental health unit in the Windsor detention centre following the emergency response related to Blair, who was found without vital signs in her cell. (Coroner’s inquest)

Hannah-Moffat said the Windsor jail’s female mental health unit appeared dirty, with no outdoor light or recreational activities.

“Appalling place to keep somebody if they have mental health problems,” she testified.

“This is more like segregation to me, in terms of the way it’s looking” and not a “therapeutic space.”

Indigenous inmates face more challenges: expert

As an Indigenous woman, Blair had a different set of needs and challenges while in jail, said Hannah-Moffat, noting it’s difficult to access elders or Indigenous medicine.

“When you’re talking about Indigenous women, it’s a lot harder for them being in solitary or segregation than it is for other people.”

Blair’s family says staff at the SWDC should have kept her safe. (Robert Blair/Facebook)

Christa Big Canoe is representing Blair’s family at the inquest and is the legal director for Aboriginal Legal Services.

As pointed out as evidence during the inquest, Big Canoe said the SWDC lacked Indigenous supports at the time of the Blair’s death. For instance, it didn’t have an Indigenous inmate liaison officer, and there was no Indigenous programming available in the women’s mental health unit or access to elders.

“Not having elders would be highly problematic because I think sometime talking to an elder can really, really help a person. It can really ground a person,” said Hannah-Moffat.

“Not having access to that makes you feel more lonely, isolated, more scared,” she added.

The two correctional officers and a social worker who previously testified said they didn’t know Blair was Indigenous.

A lack of meaningful contact can be harmful, even more so for Indigenous women, said Hannah-Moffat. Speaking with a health-care professional through a meal slot in a jail door isn’t meaningful contact, but rather “inhumane,” she gave as an example. 

“Especially if you’re grounded to community and nature. It’s equally problematic for them, if not worse,” Hannah-Moffat said.

The night Blair died, two other women were inside the same mental health unit.

‘Yelling and screaming’ heard 

Krystal Warnock, a former inmate at SWDC, testified she never spoke to Blair face to face because they were under a rotational unlock — where only one of the three female inmates were allowed in the common area at once.

One day before Blair died, Warnock recalled, Blair shared with her a poem she wrote about her son, by slipping it under the locked cell.

The night Blair died, Warnock recalled hearing “yelling and screaming” from her cell with a guard. She assumed it was about the TV remote being taken away.

Firefighters and paramedics arrive in the women’s mental health unit at the SWDC at roughly 8:13 p.m. ET on May 21, 2017, as shown in this still from security footage. (Coroner’s inquest)

Previous testimony from correctional officer James Wright indicated he heard Blair screaming or yelling while with his partner. He testified the remote was returned. Security camera footage showed Blair skipping around the common area within an hour before she was found in her cell.

Warnock testified Blair “seemed fine” when she saw her, but added she observed Blair feeling agitated, and that she “must have had anxiety” and seemed rowdier than usual.

“She was more hyper, more awake,” Warnock said.

Blair’s access to call mom called into question

Blair’s access to phone her mother has also been a key point of the inquest.

Warnock testified there was a phone in the common area of the unit. However, to make a long-distance call, a staff member would need to approve a written request and supply a separate telephone.

Selina McIntyre, Blair’s mom, and other family are still searching for answers into her death. (Dan Taekema/CBC)

Selina McIntyre, who lives in Hay River, N.W.T., testified Tuesday she hadn’t heard from her daughter for four or five weeks. It wasn’t until someone from the jail called to say she was dead that she learned Blair was incarcerated.

“She found safety in there. She trusted the system. She knew she had friends in there. She wasn’t scared of the system.”

The inquest is expected to last nine days.


If you or someone you know is struggling, here’s where to get help:

This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you’re worried about.

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