Choking inmate’s gestures for help unmonitored: judge

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A judge has recommended corrections officers assigned to monitor video feeds of segregated cells at Manitoba’s women’s jail keep a close eye on inmates after an inquest into a choking death.

Provincial court Judge Kael McKenzie oversaw the inquest into the May 15, 2021 death of 40-year-old Amanda Lee Zygarliski in her cell at the Women’s Correctional Centre in Headingley.

She choked on a chicken wrap, which went unaddressed for more than a half hour. By then, she was already dead.

“While the cause of this tragic death was accidental and may not have been preventable, had Ms. Zygarliski’s gestures for help been noticed and acted upon immediately, at a minimum there may have been a chance to save her life,” McKenzie wrote in the newly released report on the inquest, which was held in January.

“This is not an assignment of fault, but rather an acknowledgment that there appeared from the evidence that the officer monitoring (a video feed of her cell) did not observe Ms. Zygarliski for nearly five minutes while she was in medical distress.”

She laid motionless for 34 minutes before a medical code was called in the jail.

Zygarliski, described by the judge as a “kind, loving and fun person” who was loved despite her mental health struggles, was arrested on May 10 that year after police learned from paramedics that she had cut herself and been violent.

Officers tried to arrest Zygarliski under the Mental Health Act, but she assaulted them, McKenzie wrote. She was already facing other charges, so police transported her to the Winnipeg Remand Centre.

The remand centre, McKenzie wrote, was aware of her mental health issues and deemed her an acute security risk and a medium risk for suicide. She was given “red flag” status and put into segregation.

Zygarliski was transferred to the women’s jail on May 14 because of overcrowding at the remand centre. She had been granted judicial interim release on the condition that she be released to a representative of Turning Leaf Support Services, a non-profit organization that provides help to people with mental health challenges.

A representative from the organization did not have the appropriate paperwork for her immediate release, McKenzie wrote. The judge noted the jail has since revamped its policy on alternate forms of release.

Zygarliski was still considered a red flag inmate and was kept in a cell in a secure wing. The cell, like others in the wing, was monitored by video, with an officer assigned to watch screens of the cells and access points. Corrections officers are also required to physically check on inmates.

Zygarliski was upset upon learning her release was to be delayed, the judge wrote, but initially seemed fine.

A corrections officer, identified by his surname Ogums, brought her a dinner tray at 4:09 p.m. that day, which she was reluctant to take until the officer convinced her. She threw her food on her bed before eventually picking it up to eat the wrap.

She began to show signs of choking at 4:13 p.m., appearing to try to cough or throw up, holding her throat and waving at the security camera, the judge wrote, and pushed an intercom button in her cell.

Zygarliski continued to show signs of distress before she fell to the floor face down and stopped moving at 4:17 p.m., the judge wrote.

Ogums checked on Zygarliski at 4:30 p.m. and saw she was on the floor. He asked the officer in the video monitoring pod if there had been any communication with Zygarliski via the intercom. The pod officer tried to communicate with Zygarliski, with no response.

Another officer, Corby, opened the cell’s food slot at 4:42 p.m. after another officer had joined her, as policy dictated. Corby yelled at Zygarliski and kicked at the door, but the inmate didn’t move. Corby couldn’t see any signs of trauma or of life.

Corby went to get water to throw at the woman, but Ogums advised against it.

A senior officer, M. Koersvelt, attended at 4:50 p.m. and called a medical emergency code at 4:51 p.m., after Zygarliski didn’t respond to a kick of the door or a yell.

Officers breached the cell at 4:53 p.m. Nurses tried to resuscitate Zygarliski, but the first oxygen tank brought to the cell was empty.

She was taken to the coroner at Health Sciences Centre, who determined she had choked to death.

McKenzie wrote that several officers were coming and going for their meal breaks, while others were bringing meals to prisoners, meaning the officer monitoring the video feeds might have been distracted while Zygarliski was choking.

The judge recommended the jail review the duties assigned to the video pod officer so they maintain visual contact on the inmates, with minimal other duties assigned.

McKenzie also said it appears there was reluctance to call a code red, a reluctance among male officers to check on inmates because of policy on gender and privacy, and a reluctance to believe inmates need help and aren’t “acting.”

The judge said some of those issues were addressed in the jail’s internal review of the incident.

McKenzie recommended all corrections officer training should reinforce the safety of inmates as a priority.

“The inconvenience of attending a code and shutting down the facility is negligible in comparison to a loss of life,” the judge said.

erik.pindera@freepress.mb.ca