Report into suicide of inmate determines communication failures

The results of a public inquiry into the Aug. 27, 2009, death of Raymond Charles Yellowknee, 37, incarcerated at the Edmonton Institution, have been released. Yellowknee hanged himself using a belt looped through an exposed conduit. The investigation determined that leading up to his suicide, Yellowknee had been assaulted by two inmates and following that incident had been threatened. After correctional officers heard Yellowknee comment he might take his life, he was assessed on Aug. 21 by a psychologist, who determined Yellowknee was not in imminent danger. A report filed Sept. 8, 2010, made recommendations to prevent similar deaths and noted “critical information sharing failures” between clinical and front-line staff as well as “issues related to unprotected suspension points.” Yellowknee was serving a 16-year sentence after being convicted of a number of charges including four counts of impaired driving causing death and four counts of evading police in a vehicle causing death. A public fatality inquiry is held to establish the cause, manner, time, place and circumstances of death. Once the inquiry is complete, the judge provides a written report and may make recommendations for prevention of similar incidents. Fatality inquiries do not include any findings of legal responsibility.