Sask. death inquest recommends less privacy for inmates in wake of apparent suicide

(Source: Cherished Memories Funeral Services)

On the final day of an inquest into the death of a man at Saskatchewan Penitentiary, the presiding coroner raised questions about both policy and privacy.

On Nov. 28, 2022, Brandon Lupkoski was found unresponsive in his cell and resuscitation efforts by penitentiary staff and then paramedics were unsuccessful.

The forensic pathologist who conducted the autopsy believed 28-year-old Lupkoski’s wounds to be self-inflicted. He said items in the cell would have been capable of causing the injuries.

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The forensic pathologist said on Wednesday that based on the nature of Lupkoski’s injuries, he had likely been alive for five to 10 minutes after they were inflicted before succumbing to blood loss.

When Lupkoski was found unresponsive during a regular check, he was hidden behind a blanket covering the entire cell door.

Inmates are not permitted to fully cover the cell door, but penitentiary staff said the rule is not regularly enforced to respect the inmates’ privacy.

While questioning the penitentiary’s assistant warden on the final day of the inquest, Coroner Timothy Hawryluk said this was the first time he’d seen cell doors covered.

Hawryluk said that while policy dictates during a check officers must ensure a living breathing body in each cell, without a visual, “a living breathing body could be on the verge of hanging himself or inflicting personal harm.”

Two other witnesses testified on Thursday — a staff member who was a program facilitator at the time of Lupkoski’s death, and Lupkoski’s parole officer.

In the morning the jury heard from the program facilitator, who at the time of the event worked with inmates discussing emotional management and behaviour.

She said following an incident in early October when Lupkoski was found with sharp edge tools, he stopped attending her program.

The program facilitator said Lupkoski had been under mental health observation because of the incident before he was moved to a mental health range where he stayed until his death.

Two weeks before his death the program facilitator documented significant weight loss and behavioral changes in Lupkoski, including paranoia.

When she asked Lupkoski about his weight loss, he responded that he didn’t like the penitentiary food and had been living off canteen.

She and Lupkoski’s parole officer said the inmate denied having any thoughts of self-harm.

Lupkoski’s program facilitator said she had worked with him for months and described him as someone who seemed like he wanted to change, and that “he didn’t like the life he was living.”

“I have to believe they’re all good people who made bad decisions,” she said to Lupkoski’s parents who were present at the inquest.

The program facilitator stated that the incident affected her a lot and she thought of Lupkoski as “a good kid.”

Lupkoski’s parole officer testified that when she first met the inmate that summer he came across as bold.

The parole officer said he walked into their first meeting saying that he hoped she’d be better than his last parole officer because he needed help with income taxes.

The parole officer also described how Lupkoski’s demeanor changed and described him as subdued in the month leading up to his death.

The parole officer said that it could be beneficial to have more information shared between staff about inmates’ mental health, with respect to privacy.

Staff at Saskatchewan Penitentiary said that since Lupkoski’s passing, the camera in the hallway has been moved to give a better view of the cell where he was found and that more mental health professionals have been hired.

The civilian jury decided on five recommendations.

Jurors suggested adjusting policy so that correctional officers must see a living breathing inmate during a check, that correctional officers should be required to carry two pairs of medical gloves in their duty kit, and an AED should be mandatory as part of an Emergency Response Kit.

They also recommended that healthcare workers receive scenario-based trauma training upon hiring with ongoing training after, and to enforce no covering of cell doors or obstructing the view of cells.