Coroner’s Inquest recommends additional supports for Pine Grove inmates

Soaring Eagle Whitstone, an inmate at a Quebec institution, was at the time of the incident in the cell beside the one Besic was in.

“I was talking with her at my door,” she shared.

Whitstone recalled how Besic was smashing things, throwing things against the wall, and making statements about being unable to help her young daughter.

“She was mad, she was hurt,” Whitstone said.

Rayleen Faye Angus Besic grew up in the Meadow Lake and Pierecland area. (Marshall’s Funeral Service)

Confirming they had been neighbors for awhile, Whitstone explained Besic made multiple attempts to commit suicide. She also expressed frustration that Besic was in jail and not at a mental health facility, recalling how correctional officers (CO) would take away Besic’s laundry, only to return them.

“Girls who are unstable should not be in jail in a four by five square,” she said. “It’s not where you are gonna get the help you need.”

Whitstone testified multiple attempts had been made by herself and other inmates to notify staff. She also acknowledged staff had come around regularly to do checks.

“Anything can happen in an hour,” she said.

The Council for the Ministry of Corrections, Policing and Public Safety Deena Wahba asked Whitstone if she was aware of any bullying happening amongst the women on the range, and suggested Whitstone herself had been among those to bully Besic.

“That’s what they like to say,” Whitstone responded. “I would never encourage anyone to kill themselves.”

Lucy Whitecap was in the cell directly across from Besic’s.

“She was pacing back and forth,” she said, recalling her own experience seeing Besic on the morning of April 15, 2022.

When there was no longer any movement in the cell, Whitecap stated she notified correctional staff and Besic was soon after found hanging from the cell’s sprinkler head.

“They dropped her lifeless body on to the floor and I could hear a thump,” she said.

Like Whitstone, Whitecap also testified to alerting staff about Besic’s suicide attempts, although neither woman could recall who it was they spoke to.

“We did everything we could to tell COs,” she said.

Following the incident, mental health counsellors, and an elder spoke to the traumatized inmates. Both Whitstone and Whitecap testified it wasn’t enough.

“To the day I still remember that horrible day,” Whitecap said.

The role of Fetel Alcohol Spectrum Disorder (FASD)

Andrea Kotlar, Executive Director for FASD Saskatchewan, was the final person to testify, and confirmed Besic had since 2013 been receiving services for FASD. She stated Besic had trouble understanding impulsivity and ownership of items. She also noted the effects of FASD vary and affects cognitive, sensory and emotional functions.

“There’s still a lot of unknowns,” she said.

Noting supports are client led, and privacy challenges related to reaching out to the jail to request help for an inmate, Koltar confirmed they have in the past reached out to staff to provide training.

She then explained there is a stigma attached to FASD and many correctional officers simply lack the proper knowledge.

“They don’t understand the impact,” Koltar said.

When asked if she thought Pine Grove would agree to training, Kotlar said she was unsure, adding in the past when they have reached out to correctional facilities, they’ve encountered pushback and heard people don’t have the time to take the $40 course.

Among the stats provided by Kotlar were 23 per cent of youth in jail suffer from FASD, and among adults, the rate climbs to 46 per cent.

She also stated suicides are one of the leading causes of death for people with FASD.

Recommendations from the six-person jury

The purpose of an inquest is to establish who died, when and where that person died and the medical cause and manner of death. The coroner’s jury may make recommendations to prevent similar deaths.

An inquest does not lay blame or result in any criminal charges. Just over an hour after being sequestered, the six person jury returned with seven recommendations.

1) To the Ministry of Corrections – add at least one mental health support worker or counsellor per shift

2) To the Ministry of Corrections -additional every two training for staff on how to deal with inmates with FASD

3) Have vital information about inmates being made available to staff

4) Once a month, guards review unit to ensure nothing is broken and requiring repair

5) Have a nurse on site 24 hours a day or on-call

6) Have a CPR machine available at Pine Grove as it is reliable and does not get tired

7) Families have a number they can call to report inmate’s medical history

Obituary

According to Besic’s obituary, she grew up in the Pierceland, Goodsoil, and Meadow Lake areas, and loved sports and getting dressed up.

She received her Grade 12 at Oskayak High School and had a young daughter. Hilde Besic, who lives in Saskatoon, adopted Rayleen when she was 13. Hildy sat throughout this week’s emotional hearing and asked a number of questions. She confirmed for paNOW the inquest was very helpful.

“It’s very draining, but you can see that people want the system to work better, so as long as you keep that at the forefront, then the recommendations really, really help the pain,” she said.

Noting a long three years of not knowing certain details, Hilde said the inquest did a great job answering her questions and said she appreciated the fact the witnesses included correctional staff, health care workers and a number of people who knew Rayleen.

Reflecting back on her daughter, Hilde said Rayleen was the oldest of seven siblings and was very dedicated to family and making sure, no matter what part of the province they were living in, stayed connected.

“I think probably that’s her strongest gift to her daughter is that connection with the extended family, and not every young person thinks of that so well,” Hilde said.

Rayleen’s daughter is now 10. According to the obituary, Rayleen loved watching her daughter practice jingle dancing.

“She misses her mom. We all do.”

Before closing the inquest, Coroner Brent Gough acknowledged Hilde’s courage as well as the presence of Rayleen’s grandmother and sister.

“Without you being here, we don’t have a picture of Rayleen,” he said.

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If you or someone you know is in immediate danger of self-harm or experiencing suicidal thoughts, please contact:

Canada Suicide Prevention Service (1-833-456-4566), Saskatoon Crisis Intervention Service (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 counseling support for Indigenous peoples at (1-855-242-3310).

nigel.maxwell@pattisonmedia.com

On Blue Sky: @nigelmaxwell

by Nigel Maxwell

Coroner’s Inquest recommends additional supports for Pine Grove inmates

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