A clear cause of Christopher Coaster’s death remains unidentified, nearly eight years after the 29-year-old was found dead inside a jail cell.
The Marten Falls First Nation man, who had been put in a segregated cell as a result of being put on suicide watch and erratic behaviour while in the grips of alcohol withdrawal, was found dead on Aug. 3, 2008 after Thunder Bay District Jail staff thought he had finally fallen asleep.
A long-awaited, mandatory inquest into Coaster’s death finally began Wednesday morning at the provincial government building on Red River Road, with Dr. Michael Wilson serving as the presiding coroner.
“Eight years later we are struggling to know what happened to Mr. Coaster,” coroner’s counsel Dan Mitchell said during his opening address, adding an anatomical cause of death was never determined.
Mitchell told the five jurors, who will hear from as many as 18 witnesses during the scheduled five days, evidence will be presented about Coaster’s life leading up to him being in the jail, as well as what happened in the days and hours prior to his death.
Coaster had been arrested in May 2008 on a number of charges and conditionally released, with one requirement that he abstain from consuming alcohol.
However, he was arrested by OPP officers in Geraldton after he had been drinking.
He was transported into the custody of the Thunder Bay Police Service and held in lockup at the Balmoral Street station while awaiting a court appearance.
He then appeared via video connection the next day and after being unable to connect with his lawyer was ordered remanded at the district jail through the August civic long weekend until an appearance the next week.
In the opening hours of the proceeding the inquest heard from a series of four witnesses, who were working as correctional officers on the morning of Coaster’s death.
Coaster had been in a cell block on the northeast corner of the McDougall Street jail, adjacent to a cell holding an inmate who was under constant watch. While that correctional officer could still see inside Coaster’s cell, other officers did 10-minute checks on Coaster.
Suffering from delirium tremens, multiple witnesses said Coaster appeared to be disoriented, yelling and banging on the walls while periodically laughing psychotically and showing signs of hallucinations.
As well, he was being held in a cell enclosed by Plexiglas without air conditioning and lack of air circulation. Exacerbated by a hot weekend, correctional officers described conditions as “hot as hell” and “disgusting” during that weekend.
While guards were permitted to have a small fan to stay cool, there was nothing for inmates.
Correctional officer Renee Perrier said Coaster had been engaged in high-activity, intense behaviour for the proceeding day and that night. He was not consuming food or liquid, could not focus and did not respond to any of the officers or medical staff.
“It was like we weren’t even there,” she said.
A discussion was held between officers and the jail’s medical staff on whether to transport him for outside care. Perrier said she thought Coaster needed to be taken to a hospital but correctional officers did not have the authority to make that decision or call for emergency services.
Shortly afterwards, Coaster appeared to relax and calm down. He then laid down and appeared to go to sleep, which came as a relief to officers.
Officer Blair Penney, who had been doing constant watch on the inmate in the adjacent cell, said Coaster appeared to be breathing and thought his chest and feet were moving.
However, about 90 minutes later, Coaster was unresponsive when jail staff checked on him. Resuscitation was not attempted.
When asked about possible recommendations the jury could make, the officers said there should be enhanced training, especially dealing with alcohol withdrawal, as well as ensuring temperature inside the jail is better controlled.
The inquest is scheduled to continue throughout the rest of the week.
