Inquest into death of inmate Mark Jeffrey begins in Toronto

An inquest into the circumstances surrounding the 2015 death of inmate Mark Jeffrey began Monday in Toronto.

Jeffrey, a 34-year-old Inuk man from Iqaluit, died on June 29 while in custody at the Beaver Creek Institution, a medium-security federal penitentiary in Gravenhurst, Ont., operated by the Correctional Service of Canada.

Dr. Steven Bodley is presiding over the inquest, while Ashley Jacobs and Kate Forget are serving as the inquest co-counsels. Jacobs and Forget are lawyers with the Indigenous justice division of Ontario’s Ministry of the Attorney General, established in 2015 as “a means of addressing the failure of the Ontario justice system to serve Indigenous communities,” Jacobs said.

Jeffrey was found hanging in his cell after spending 74 days in segregation. He was serving a life sentence for the 2002 murder of 13-year-old Jennifer Naglingniq in Iqaluit.

Jeffrey was placed in segregation on April 17 after purchasing and consuming prescription drugs from another inmate.

“Mr. Jeffrey’s death tells us to think about whether or not the Canadian justice system meets the unique circumstances of Inuit in this country and whether we can do better,” Forget said in her opening statements.

Correctional officer Carrie Ludlow took the witness stand first and testified that around 3:40 p.m. on June 29 she was conducting a routine security patrol of the institution. When she arrived in front of Jeffrey’s cell, she saw that the window into his cell was covered in paper from the inside.

“It’s not unusual for an inmate to have their window covered, especially … [when] they’re using the bathroom,” Ludlow said, adding that she thought she “heard a response” when she initially knocked on the door. She then indicated to another officer that the window was covered before she proceeded to complete further cell checks.

When she returned to Jeffrey’s cell but could not get a response from him, the cell door was opened and Ludlow discovered Jeffrey with a noose, made of what another witness said was a bedsheet, around his neck, suspended from the window frame on the other side of his cell.

Correctional officer Ivan Misevic testified that he entered the cell and pulled Jeffrey down.

“That’s when I grabbed him by under … his knees and lifted him up. I was able to pull the noose down and I started compressions. He was still warm,” Misevic said, who then began assisting with CPR along with paramedics who responded to the scene.

“His eyes closed when I started the compressions. I remember that I thought maybe we got him in time, but he wasn’t breathing,” he said.

After attempting to revive him, medics pronounced Jeffrey dead at 4:08 p.m., the coroner’s counsel said.

Misevic testified that Jeffrey worked as a unit cleaner at Beaver Creek and “kept to himself” mostly.

“He was pretty quiet,” Misevic said, adding that he and Jeffrey would sometimes talk about hockey.

He said that as a cleaner, Jeffrey would have had access to additional bedsheets. The makeshift ligature discovered in his cell appeared to be made from bedsheets knotted together, Misevic said.

Both Ludlow and Misevic testified that they felt nothing more could have been done that day to change the outcome of Jeffrey’s death.

Christine Blasko is a registered nurse with Corrections Services Canada who administered CPR on Jeffrey and used an automated external defibrillator in an attempt to revive him.

When asked what could be done to prevent deaths like Jeffrey’s in the future, Blasko testified that a “major” policy change has been the removal of segregation units at the institution.

“[We] no longer [have] segregation within corrections, [but have] created a different unit, what they call a ‘structure intervention unit’ which offers more programming and more access to offenders who are needing to be housed in different units other than general population,” Blasko explained.

The coroner’s inquest is expected to last eight days and will call 18 witnesses, including experts in mental health and specialized Indigenous services. Representatives from Corrections Services Canada, Aboriginal Legal Services and Tungasuvvingat Inuit are also serving as counsel with standing.

The jury must determine the facts of the case and may offer recommendations aimed at preventing similar deaths in the future in its final verdict. A simple majority, not a unanimous one, is required to make a decision. The jury will not make any finding of legal responsibility in the case.