WARNING: This story discusses suicide and suicidal ideation.
Mental health resources in the Edmonton Remand Centre (ERC) are “completely inadequate” and inmates are at risk without more specialized staff, an Alberta judge says.
After a fatality inquiry into the death of Jonathan Anderson, Justice Marilena Carminati concluded the jail isn’t equipped to deal with the volume of inmates who might be depressed or suicidal.
Anderson died in hospital on March 14, 2020, nine days after remand centre guards found him without a pulse in his cell after a suicide attempt. He’d been in custody since January, and had asked to see a psychologist and get medication, but didn’t receive treatment.
“Mr. Anderson killed himself less than a month after he unsuccessfully sought help for depression from [Alberta Health Services] at ERC,” Carminati wrote in her recommendations, issued last month.
“Unless staffing levels for mental health services at ERC are increased, similar deaths are likely to occur in the future.”
Fatality inquiries are held to help clarify the circumstances of a death and can lead to recommendations for preventing similar deaths. They are not meant to determine legal responsibility.
The Alberta Court of Justice heard evidence in Anderson’s fatality inquiry in fall 2022. At the time, there were 16 mental health staff employed by AHS at the remand centre.
One employee testified that the team had been short-staffed for years, with the potential for five people on shift to respond to the mental health concerns of 1,500 inmates or more.
“The evidence was clear that the staff on the team are overwhelmed by the very high number of requests they receive for help with mental health issues,” Carminati wrote.
“They receive 50 to 60 requests a day on average and as a result, there is a substantial backlog.”
Carminati’s report calls for changes to mental health staffing and correctional officer duties, making one guard solely responsible for monitoring video surveillance of cells so “concerning behaviours” aren’t missed.
Hunter Baril, press secretary for Mental Health and Addiction Minister Dan Williams, said in a statement that Anderson’s death is a tragedy.
“Mental Health and Addiction now oversees correctional health care through Recovery Alberta, an area that has long been overlooked,” he said.
“We want correctional facilities to be used for corrections, putting people on a better path of wellness and recovery.”
AHS spokesperson Kerry Williamson said Recovery Alberta is reviewing the judge’s recommendations “and will implement additional measures where possible.”
He told CBC in a statement that there are 34 “specialized addiction and mental health staff” working at the ERC, including addictions counsellors — a job Carminati doesn’t mention in her report’s count of mental health staff.
Health services have also been “enhanced” at the remand centre since 2020, Williamson said, “including adjusting staffing to enable enhanced patient education, support for patients following release and the ability to connect patients to additional treatment such as immediate access to opioid dependency treatment and other recovery-based services.”
‘Low mood’ attributed to substance withdrawal
Anderson, 40, was wanted by police for a number of robberies in December 2019 and January 2020 involving firearms. He was arrested on Jan. 14, 2020, after police executed a search warrant at an Edmonton home.
About three weeks into his time at the remand centre, he submitted a health service request saying he was struggling with persistent feelings of sadness and fear, and he needed help with depression that he reported experiencing as far back as age 12.
“I have no one to talk to and I’m hoping there is something I can take to make this feeling go away,” Anderson wrote.
The fatality inquiry heard that Anderson got a response 11 days later. It said that his low mood was likely a withdrawal symptom from his daily alcohol and stimulant use prior to his arrest, and it would “take time to stabilize.”
Anderson was told that if he wanted to “discuss coping strategies,” he should submit another request.
“In other words, fill out another form,” Carminati wrote in her report.
“He was not placed on a wait list to see a psychologist. No one met with Mr. Anderson to get more information about his depressive symptoms. He was never seen by a psychologist or mental health team member in relation specifically to this request.”
Anderson also submitted several requests asking to get on the suboxone program, but he wasn’t assessed for it.
The inquiry heard that at the time, there was a six-month wait for an assessment at the remand centre. That has since improved, according to evidence given by a health manager for the facility, through a pilot program that offers a virtual assessment with a doctor as soon as someone goes into custody.
Anderson posted this video on Youtube under the name ‘Tommy Da’, he was a former remand centre inmate who was pulled off life support on Saturday March 14.
Anderson was a musical artist and rapper who went by the name Tommy Da. His former wife told CBC in 2020 that he’d been on the run from police in Regina and Edmonton, and he told her that he suffered multiple injuries at the hands of the Edmonton Police Service officers who arrested him.
The fatality inquiry heard that Anderson’s shoulder was dislocated during the arrest, and he was taken to several medical appointments as a result.
An EPS spokesperson acknowledged in 2020 that the officers had used force, but Anderson’s injury didn’t meet the threshold for a notification that could lead to an Alberta Serious Incident Response Team investigation.
Events before Anderson’s death
The day before his suicide attempt, Anderson was taken to an appointment at an Edmonton clinic where he made a “dramatic escape attempt” that required a “significant pursuit” and a series of physical struggles, according to the fatality inquiry report.
When Anderson returned to the remand centre, staff put him on a body scan to check for contraband. They believed he might have a foreign object in his body, so he was sent to a “dry cell” — a segregated cell with no toilet where inmates suspected of drug use are kept until they have had several bowel movements, to determine if they have any drugs on them.
Dry cells are monitored through a camera, and inmates are supposed to be checked on every 30 minutes.
Video footage from the cell shows the next day, March 5, 2020, Anderson threw food at the camera and ripped part of his inmate coveralls. He was found unresponsive by a guard at around 3:30 p.m.
“Mr. Anderson did a number of things that were captured on video suggestive of a problem, and none of those activities appear to have been seen,” Carminati said.
While the judge made a specific recommendation to address that, she said the remand centre has already made some changes to how guards do visual checks and record them at the door of a cell.
Carminati noted it’s “perhaps ironic” that mental health staff couldn’t get to Anderson when he first asked for treatment for his depression because at the time, they were dealing with urgent issues in the dry cells.
“…[That] is where Mr. Anderson was asked on March 5th by a mental health team member about suicidality, which he denied, at a time when, in retrospect, his need was urgent, but it was too late to offer him effective assistance.”
If you or someone you know is struggling, here’s where to get help: