Coroner's jury recommends changes inside Saint John correctional centre, following inmate's COVID-19 death

Family members of an inmate who died from COVID-19 sobbed in court on Thursday, as recommendations were read at the end of a Saint John coroner’s inquest.

Skylar Sappier died on Jan. 31, 2022 in Saint John Regional Hospital, two days after leaving the Saint John Regional Correctional Centre where he was nearing the end of a 96-day sentence.

A total of 23 witnesses, from the correctional centre, hospital, Horizon Health, and the Department of Justice and Public Safety, gave two-days worth of testimony during the inquest.

The juror’s 21 recommendations focused on policies and procedures within the Saint John Regional Correctional Centre.

“I think we’re all devastated,” said Sappier’s sister, Sierra Sappier, to reporters outside of court on Thursday. “A big part of it is, an inquest doesn’t allow us to lay blame or judgement. So we feel robbed of that.”

The family said they were considering a civil lawsuit going forward.

As part of instructions at the inquest, the five-person jury was also tasked with determining if Sappier’s death was natural, accidental, a homicide, a suicide, or undetermined.

The jury determined Sappier’s death was natural.

“Nothing natural about that,” said Sappier’s mother, Dora Sappier, in court as the inquest was nearing its end.

Sappier first reported feeling sick to a correctional officer at the Saint John Regional Correctional Centre on Jan. 28, 2022, in the midst of a COVID-19 outbreak within the facility.

Sappier tested positive for COVID-19 in a PCR test, just prior to arriving at the Saint John Regional Hospital on Jan. 29, 2022. By the end of the day, Sappier would be in a medically induced coma.

Sappier, a father of two young children, was 28-years-old when he died.

MEDICAL TRANSPORTATION FROM CORRECTIONAL CENTRE TO HOSPITAL

Sappier was transported to the hospital in a correctional centre vehicle by two officers.

A correctional centre nurse testified the decision to avoid calling an ambulance was made because Sappier’s condition at the time appeared to be stable and he was coherent.

When Sappier arrived in hospital, he was triaged as a "Level 2" patient (the second most urgent triage level).

The jury made a recommendation for correctional centre staff to receive calcification on when unwell inmates should be sent to hospital, and specifically when an ambulance should be called.

The jury made a recommendation for officials to explore the potential addition of paramedics within the correctional centre, to provide medical care for inmates when and where appropriate.

The jury heard testimony about a major snowstorm on the day Sappier was taken to hospital, causing a delay in leaving the facility and getting to hospital.

The jury made a recommendation for all correctional centre vehicles to be equipped with four-wheel drive, along with a review of the facility’s snow plowing procedures during storms.

MEDICAL CARE INSIDE THE CORRECTIONAL FACILITY

The jury heard testimony about the potential usefulness of an on-site blood analysis system within the correctional centre, to offer more information about an inmate’s health status. The jury made a recommendation to “investigate the feasibility” of adding such a system to the facility.

Sappier was placed in the correctional centre’s designated medical-unit cell for about four hours on Jan. 29, 2022, before going to hospital. Evidence was presented during the inquest of Sappier being checked roughly every 30 minutes during his time in the medical unit cell, but not by verbal means for about three of those hours.

The jury made a recommendation for video and audio surveillance capabilities to be installed inside the facility’s medical unit cell, and that all inmates who are sick be checked every 15 minutes both visually and verbally.

The jury also made a recommendation for an overnight nurse to be scheduled in the facility between 11 p.m. and 7 a.m.

RECORD KEEPING CONCERNS

The jury made several recommendations related to record-keeping and log book entries within the Saint John Regional Correctional Centre.

Testimony from several staff members indicated not all actions were documented, including Tylenol and Advil being given to Sappier.

The jury made a recommendation for supervisors to conduct a monthly note-taking audit within the facility, coupled with another recommendation for all medical related information to be entered into a computer system where specific IDs are used.

Correctional centre staff didn’t have up-to-date information to contact Sappier’s family during his decline, according to testimony.

The jury made a recommendation for next-of-kin contact information to be updated each time an inmate arrived on-site.

Discrepancies in surveillance video timecodes within the correctional centre were also noted during the inquest.

The jury heard testimony of there being no evidence the video had been edited or tampered with. The jury made a recommendation for timestamps to be “synchronized and accurate” inside the facility.

“WE NEED IMMEDIATE ACTION BEFORE MORE PEOPLE DIE’’

Skyler Sappier’s family also offered recommendations after the testimony of all witnesses, but were told not every recommendation would be read in court because they fell outside the inquiry’s focus.

"If every recommendation is followed, I believe that change can happen," said Sierra Sappier, to reporters. “But if they pick and choose out of the recommendations, it's not going to be something that makes a big impact."

Neqotkuk (Tobique) Chief Ross Perley was one of the family’s supporters who attended the inquiry. Sappier was a member of Neqotkuk.

“There was a shocking contrast between the compassionate, caring testimony provided by hospital staff and the level of ambivalence displayed by correctional staff in this incident,” said Perley, in a statement Thursday. “I have no faith, after sitting through this inquest, that other Indigenous people will not face the same risk to their life in provincial correctional facilities,”

“As a result of this inquest, I am left with one demand – the calling of an Indigenous-led inquiry into the systemic racism that is on full display in today’s justice system. We need immediate action before more people die.’’

An update on the status of all recommendations made from the inquest will be provided in the provincial coroner’s next annual report.

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