Cantre’s mental health deteriorated before his death, inquest hears

A public inquest began Monday into the death of Shane Cantre, 43, who died at the Regional Psychiatric Centre on July 16, 2021.

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Warning: Distressing content

A correctional officer who had built a rapport with a 43-year-old inmate at the Regional Psychiatric Centre in Saskatoon who later died in custody told an inquest jury that he noticed the man’s mental health worsening in the year before he died.

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Shane Cantre was found unresponsive in his cell at the federal facility on July 16, 2021. Staff and paramedics responded, and despite life-saving efforts, he was pronounced dead. A public inquest into his death began on Monday.

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Correctional officer Alan Wong told the jury he had worked with Cantre since he started in his position at the forensic psychiatric facility. In the last year before his death, Cantre had engaged in self-harming behaviour, Wong said.

“He definitely wasn’t happy.”

Jurors heard Cantre climbed over a railing overlooking the staff “bubble” in the Bow unit and threatened to jump multiple times.

Wong testified that on one occasion, before he talked Cantre down, he saw him crying. That day, Cantre told him he wanted to go to another unit; he told Cantre he’d take him wherever he wanted to go, and took him to another unit. He said Cantre was adamant he didn’t want to stay on the Bow unit.

Wong said he was confused about why Cantre was still housed on the upper tier of the unit.

Jurors heard all inmates of the unit are checked on within every hour.

Wong said he was doing his rounds, checking cells, on July 16, 2021 and when he got to Cantre’s cell in the unit’s upper tier, he didn’t see anyone inside. As he walked away, something told him to go back, so he did, he testified.

He saw Cantre slouched beside the toilet in the cell, with a ligature made from a thin blue bedsheet connected to a cabinet above the toilet.

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Wong said he and two other guards entered the cell, and the ligature broke. He said the guards took Cantre out from beside the toilet and began CPR, and nurses arrived within three to five minutes.

Saskatoon police Staff Sgt. Andy Johnstone told the jury the police investigation concluded Cantre’s death was not criminal in nature.

Cantre’s mother, Joyce Cantre, who has standing at the inquest, asked Johnstone how her son would have been able to cut the bedsheet up. Johnstone responded that it wouldn’t be “unthinkable” for him to have torn it.

Wong told jurors that in recent months he noticed that hygiene cabinets had been removed from cells.

The cells are subject to inspections, and among the issues they look for are potential suspension points that can be used for ligatures.

“Now the cabinets are gone, which I think is good,” Wong said.

He told the inquest he would recommend that responding and unit officers carry a “911 tool” — designed to cut ligatures. The tool wasn’t needed that day because the material used for the ligature was thin and had broken. He also recommended that some type of fencing be installed along the unit’s railings.

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When asked, Wong testified that he had not been told that Cantre told his parole officer in April 2021 that he planned to use a cupboard knob to hang himself.

A second correctional officer, Joseph Landry, testified that he was a sector coordinator at RPC and that day would have been the second-in-command for correctional officers in the building.

Landry acknowledged that cabinets like the one used by Cantre were removed from the cells.

He described Cantre as a friendly, muscular man who sometimes was dealing with “his own problems.”

Landry said he was present for one incident when Cantre climbed up on the second floor railing. He offered a caution about installing fencing around the railings, since fires are sometimes set at RPC and jumping over the railing can be a means of escape from the second floor.

Landry recommended the windows into the cells be larger or that cells be better shaped, since where Cantre was positioned, it was very difficult for anyone to see him through a two- to three-inch window.

Ashlyn Rupps, a registered psychiatric nurse, was the final witness to testify on Monday. She was new to the facility, worked part-time and hadn’t known Cantre well, she said.

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This was the first emergency incident she responded to at RPC and she believes being trained in simulated emergency scenarios would have helped, she said.

Rupps said the nurse who had administered Cantre’s medication that day had told her she had a positive interaction with him.

Inquests are a public fact-finding, not fault-finding, process that establishes who died, when and how. The process may also highlight dangerous conditions or practices, and the six-member jury can make non-binding recommendations.

The inquest continues Tuesday.

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If you or someone you know is in immediate danger of self-harm or experiencing suicidal thoughts, please contact Crisis Services Canada (1-833-456-4566), Saskatoon Mobile Crisis (306-933-6200), Prince Albert Mobile Crisis Unit (306-764-1011), Regina Mobile Crisis Services (306-525-5333) or the Hope for Wellness Help Line, which provides culturally competent crisis intervention counselling support for Indigenous peoples (1-855-242-3310).

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