Jury calls for timely access to elders at inquest into death of inmate at Regina Correctional Centre

After three days of testimony, the jury presented its findings at the coroner's inquest into the 2017 death of Waylon Starr, who was an inmate at the Regina Correctional Centre at the time.

Jury at inquest into 2017 death of Waylon Starr gave 8 recommendations

Starr was found unresponsive in his cell at the Regina Provincial Correctional Centre on Aug. 24, 2017. (CBC News)

WARNING: Some offensive language used. 

The jury has presented its findings at the coroner's inquest into the 2017 death of Waylon Starr, who was an inmate at the Regina Correctional Centre when he died.

Starr was found unresponsive in his cell at the correctional centre on Aug. 24, 2017. He was pronounced dead at 11:23 p.m.

Starr's death was the focus of a coroner's inquest this week. The coroner instructed the jury Thursday morning, following three days of witness testimony. 

The six-person jury found that the 27-year-old died by suicide. His medical cause of death was asphyxiation. 

Witnesses told the inquest he had covered his window with a white garbage bag before he died.

Waylon Starr, pictured, was 27 when he died in custody at Regina Provincial Correctional Centre. (Submitted by Reah Starr)

Starr's mother Verna Starr told the inquest her son called her to say he asked to see an elder but was denied.

She said she also called the facility to see if she could set up the appointment herself. 

Verna said spiritual care could've helped her son. 

The Correctional Centre said it has two elders on staff and said according to records, Starr didn't make a request to see them. 

Coroner's inquests are not intended to determine any criminal responsibility, but jurors can make recommendations to prevent similar deaths.

Jury recommendations:

  1. Provide timely access to elders. Meetings with elders should be offered on intake forms and during every medical visit. This may require more elders on staff. 
  2. Require mandatory suicide prevention training for all staff, with re-certification every three years. 
  3. Review cultural awareness training offered to staff with consultation from Indigenous elders.
  4. Require staff briefing at shift changes. Audit log books regularly to check for correct record keeping and legibility.
  5. Create a policy regarding in-cell privacy and inmates blocking their windows. Do not allow subjective interpretations of the policy by staff. 
  6. Determine if there are times when incidents are more likely to occur and increase staffing and checks at those times. The jury suggested this might apply to the night shift. 
  7. Develop a formal method for family of inmates to alert staff and leave messages if there are issues.
  8. Conduct mock rescue drills with staff to prepare for emergency situations.

Starr's mother said she approved of the recommendations regarding elders and a new system for families to contact workers.  

"I was very happy because maybe they'll lift their phones up and get off their asses and stand up and listen to some people that need help," Verna Starr said.

The jury expressed condolences to the family and the foreperson said some of them had lost family members to suicide.

Following the inquest, Coroner Brent Gough thanked the family for attending and asking questions. 

"I cannot tell you how important it is for the operation of the system for people to participate," Gough said. 

Gough said their input was reflected in the recommendations and may prevent deaths in the future.

"It is my hope, because I have a lot of relatives that are in the same situation and some of them did try and commit suicide but they were there for them right away," Verna said. 

When asked if she thought the inquest went far enough or if someone should be found guilty, Verna said she wants to see someone held accountable for her son's death through the justice system. 

Jury follows coroner findings closely 

When instructing the jury, Gough said the evidence pointed to an intentional, self-inflicted act intended to cause self-harm or death. 

He said there was no evidence that anyone had physical contact with Starr between 7 p.m. and 10:27 p.m., when he was found by correctional worker Justin Amyotte. 

Starr did not have a cellmate at the time and his door remained closed, according to security footage, Gough said. Starr's window was covered for about 30 minutes. 

Gough also gave some suggestions for recommendations.

He said the facility should establish a clear policy on window coverings in the jail. One witness said they should be taken down immediately, while another said there should be a balance between an inmate's dignity and safety, and a third said they could be left up for about 20 minutes.

Gough also said there should be a timely process to access elders and chaplins at the facility, he called for suicide prevention training and re-certification for all staff and staff briefings during shift changes. 

About the Author

Alex Soloducha is a reporter for CBC Saskatchewan.