The jury for the coroners inquest into the in-custody hanging death of Collan Kohalyk delivered two recommendations late Wednesday evening at the Cranbrook law courts.
The three-man, two-woman jury recommended to presiding coroner T.E. Chico Newell that all clothing removed by prisoners in the Cranbrook detachment’s older cells should be taken from the cell immediately and that blood and urine samples taken from patients at admission to hospital for an unnatural death or injury be retained in a frozen state for a month.
Kohalyk’s mother, Irene Kohalyk, said afterwards that her son fell through the cracks when he was left unattended in the cell block.
“I think he was missed. He was able to do what he did because he disappeared off camera,” she said.
Collan Kohalyk used his own T-shirt tied to the bars of his cell door to hang himself after he was arrested for a domestic assault. A guard noticed him standing with his back to the bars, but did not physically check him for just under 15 minutes. The guard told the inquest Tuesday that he was busy with other tasks while the incident occurred. Policy states that checks must happen at least every 15 minutes. Irene Kohalyk wondered why more staff isn’t available to assist in these situations.
Half of the Cranbrook detachment cellblock was already under renovations to retrofit the barred cells to new steel and cinderblock ones when Kohalyk was arrested. Those renovations were a directive handed down Canada-wide.
After Collan Kohalyk’s death the detachment made several swift changes including only using the old cells with low-risk prisoners and changing the camera angle to prevent blind spots.
“They have already made some changes, which is good,” Irene Kohalyk said.
The mother spoke to the inquest Wednesday morning to speak about her son in life, an opportunity she said she had to take.
“There was so much more to him. He was a worthwhile life.”
The recommendation to retain patient admission samples arose when the jury heard Wednesday from pathologist Dr. Susan Tebbutt who performed the autopsy on Collan Kohalyk. She told the inquest she was unable to determine what narcotics were in the deceased’s system because samples taken at admission are automatically destroyed after seven days unless the RCMP gets a court order to retain them. Kohalyk died 10 days after he was admitted to hospital.
“These samples need to be treated differently,” Tebbutt said. “I absolutely have a problem with that because I know we can’t get those samples back. To me we are losing valuable evidence and I think we can do better”
When Kohalyk was admitted, his samples tested positive for an unknown opioid and a more detailed toxicology test was never done before the sample was destroyed.
Tebbutt said the policy is in place because those samples are often not viable after seven days, except for toxicology tests. She recommended to the jury that these critical samples be frozen for at least a month to ensure they remain viable.
“This would give us the time that we need,” she said.
The pathologist said Kohalyk’s case is one of many where the samples were destroyed before actual death.
“We know this is not an isolated incident.”
The jury took almost three hours for their deliberations before the inquest reconvened Wednesday evening.
Inquest Counsel Rodrick Mackenzie said after the recommendations were announced that the coroner will now write letters to the RCMP E Division and provincial Minister of Health. While the RCMP and Health Ministry are not bound to implement any recommendation made by a coroner’s inquest, Mackenzie said they are bound by the public will to prevent another similar tragedy from happening.
“It will eventually become a matter of public record, the response,” he said.