Why a suicidal 26-year-old man was brought to Montreal's Bordeaux jail instead of the hospital has his family demanding answers and is the subject of a CBC News investigation.
Christopher Clarke of Cornwall, Ont., climbed over a railing outside his third-floor cell and plummeted to his death on April 27, just 13 days after arriving at the provincial jail.
Clarke's family was shocked and are still wondering how it could have possibly happened.
Cornwall police, who picked up Clarke on a warrant for an unpaid fine, will not speak directly to the case, only saying that they have strict policies about mental health issues which include clearly identifiying people as suicide risks and sharing that information with other police forces.
Clarke's family and fiancée are questioning the way his case was handled once he was taken to Bordeaux.
"I want somebody to take some ownership and tell me exactly why he didn't get the help he needed," Clarke's sister Melissa Harrison said in an interview outside the jail after collecting her brother's belongings.
"I don’t see that they kept him safe," she said.
Janick Ménard woke up early on April 14 to find Clarke, her fiancé, yelling and throwing things out onto the couple's front lawn on a quiet Cornwall street. He said he wanted to kill himself.
Ménard convinced Clarke to get into her car and drove him to emergency at Cornwall hospital.
Clarke's behaviour was increasingly erratic throughout the winter and early spring, Ménard said.
Two weeks earlier, Cornwall police and a member of Cornwall Community Hospital's Mental Health Crisis Team were called to the home by Ménard after Clarke threatened to take his own life.
'They told me they were going to ... pick him up and bring him to the hospital.' —Janick Menard, fiancée of Christopher Clarke
"He was just suicidal," Ménard said. "He was not well, he needed help. He was in a bad place in his life."
On April 14, Clarke arrived at Cornwall Hospital just after 8:30 a.m. ET, records obtained by CBC News show. He was seen by a doctor half an hour later. "Patient feeling depressed lately, wants to see MHCT (Mental Health Crisis Team)" the medical file reads.
But Clarke did not stay at the hospital, and went back home instead.
Concerned for Clarke's safety and her own, Ménard called Cornwall police. Clarke had taken off by the time the two officers arrived around 9:30 a.m.
Ménard said she called Clarke and spoke to him for a few minutes. Then one of the officers took the phone.
"She [the police officer] was just telling him, 'We are not going to arrest you, we are going to drive you to the hospital, there is going to be a bed waiting for you,' " Ménard said.
On Clarke's hospital records, a handwritten note reads: "MHCT, police looking for patient, their request" — indicating that the hospital staff knew the police were looking for him.
There is no record Clarke was ever taken to Cornwall hospital by police. Instead, the officers brought him back to the Cornwall police station.
"About an hour after they picked him up, I got a phone call from the female officer that had responded initially, saying he had been booked and that Quebec wanted him and he was on his way to Valleyfield," Ménard said.
RCMP officers from Quebec picked Clarke up and took him to Bordeaux jail at 2:06 p.m., Corporal Luc Thibault of the RCMP said.
It is not known whether Clarke's mental state was ever discussed between Cornwall police and the RCMP.
Arrested in 2008 in Quebec
Court records show this was not Clarke's first run-in with police. In 2008, he was arrested while driving a car loaded with contraband cigarettes. He tried to get away but was caught by Quebec provincial police and later pleaded guilty to dangerous driving, evading police and contravening the federal laws on cigarette and alcohol taxes.
He was put on probation and ordered to pay a $48,960 fine. Clarke paid off a small portion of the fine, but fell behind on his payments.
Documents show Clarke was wanted by police for not paying his fine. On Oct. 24, 2012, the Public Prosecution Service of Canada issued a warrant of committal against Clarke, giving police the power to immediately place him in jail if he could not pay the remainder of his fine.
Strict policies on suicidal behaviour
Cornwall police declined to be interviewed and said they could not discuss the specifics of Clarke's case.
But in a telephone conversation, Staff Sgt. Brian Snyder said police have clear guidelines in cases involving suicidal behaviour.
"The policies are strict around mental health issues. When we arrest someone, we write at the top 'suicidal' in big bold letters," he said.
Snyder said in cases involving mental health, suspects must be cleared by a doctor before being brought to a cell.
He said it is police policy to share any information about mental illness or suicidal behaviour with other forces involved.
Snyder said Cornwall police are conducting an internal investigation.
Earlier this month, Clarke's family requested his police file from April 14 under the Freedom of Information Act. Cornwall police haven't responded yet.
"Cornwall police say their number-one priority is the preservation of life, and I don’t see that here," said Clarke's sister, Melissa Harrison.
Clarke was screened for suicidal behaviour when he arrived at Bordeaux jail.
A high-ranking official at Bordeaux jail with access to Clarke's file told CBC News Clarke was not deemed to be a suicide risk after the screening.
Quebec Public Security ministry spokesman Clément Falardeau declined a formal interview, but told CBC News all inmates are asked a series of questions to determine their suicide risk.
There is no psychologist on staff at the jail, but the screening procedure is done by personnel who have received special training from the Quebec Suicide Prevention Association, Falardeau said.
Clarke did not speak French, but Falardeau said the suicide questionnaire was available in English.
He was placed alone in a cell in a section of the institution for inmates with lighter sentences, said the Bordeaux jail official.
Messages not returned
Harrison began calling the jail the day after Clarke arrived because she was worried about his mental state. She said she was never able to speak to anyone directly, but left many messages on answering machines.
Cell phone records show Harrison called and left messages in English at least 12 times during the 13 days leading up to Clarke's death.
Clarke's fiancée, Ménard, said she also called the jail many times, leaving messages in both French and English. Both women claim their calls were never returned.
CBC News also called the health services department at Bordeaux jail at various times, but ended up with a voicemail message. After jail officials were eventually contacted by CBC News, two of five subsequent calls to the jail were answered.
Falardeau of Quebec's public security ministry could not confirm whether Bordeaux personnel called Harrison and Ménard, but said jail policy was to return calls within 24 hours.
'I need a doctor ASAP'
Ménard visited him twice at Bordeaux, and he told her not to worry. But a few days later, he obtained an illicit cellphone and his calls and text messages told a different story.
He said he wasn't feeling well, wasn't eating and would rarely leave his cell. He was being picked on by other inmates.
Clarke took photos of himself, his jail cell and a railing on the third floor.
He was getting increasingly desperate, Harrison said, and she and Ménard continued to phone and leave messages at the jail.
On April 24, Clarke filled out an official medical request. It reads: "I need to see a doctor ASAP. Thanks."
Bordeaux officials confirm Clarke was never seen by a doctor; however, Falardeau said medical requests can take up to seven days.
Video shows Clarke climbing over railing
Clarke spent most of Saturday, April 27, on the phone. Relatives described him as despondent — Harrison, Ménard and others tried to calm him down. Harrison said they left messages at the jail and searched the website for an emergency number.
Clarke sent his last text message just after 8 p.m.
Sûreté du Québec investigators, who looked into Clarke’s death, told the family a security camera video from the jail shows Clarke climbing over a third-floor railing and disappearing.
Police ruled the death a suicide.
Phone records show Harrison made her last call to Bordeaux jail that day at 9:19 p.m.
Ménard said she received a message on her voicemail at home at about 10:40 p.m. from the priest at Bordeaux telling her Clarke had died.
A memorial service was held in Cornwall on May 18.