A judge says the military had several opportunities to prevent or lower the risk of suicide for an Edmonton soldier who hanged himself in a holding cell five years ago.
Cpl. Shaun Collins, 27, killed himself at Canadian Forces Base Edmonton after he was arrested by military police for drunk driving on March 11, 2011.
Provincial court Judge Jody Moher said in a fatality inquiry report released late Friday afternoon that things could have been done to try to save the soldier.
“It is irrefutable that there were a number of potential opportunities to obviate or lessen the likelihood of Shaun Collins committing suicide that evening,” she said.
Moher said no one did a computer search that night on Collins after his arrest.
A search would have found that Collins, a member of the 1st Battalion, Princess Patricia’s Canadian Light Infantry, had been diagnosed with post-traumatic stress disorder after he returned from his second tour in Afghanistan in 2010. He had also tried kill himself, or threatened to kill himself, four times and was being transitioned out of the military.
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The judge wrote that information on the soldier’s mental health was available on a military computer system. But a commissionaire, dispatcher and three military police officers on duty did not do a check and placed him alone in a cell.
“All three MPs readily acknowledge that had they known of Shaun Collins’ history of previous suicide attempts and mental health history, Shaun would have been handled entirely differently that evening,” Moher said.
In addition, the judge said there were no working cameras in the cell area and cell doors provided a number of ligature points. The report quoted a federal audit that found “the cellblock does not meet any current Canadian standards.”
The report detailed how Collins put his shirt through the metal bars of his cell door, wrapped it around his neck, sat down on the floor and hanged himself.
Twenty-two minutes after placing him in the cell, officers found Collins and tried to resuscitate him. Although the military police building was not equipped with an automated external defibrillator, one of the machines was brought in from the trunk of an officer’s car. It wasn’t working.
Military firefighters later arrived with a defibrillator and were able to get a spontaneous pulse from Collins, said the report.
But he was later declared dead after he arrived at an Edmonton hospital.
Canadian Forces spokesman Maj. Jean-Marc Mercier said Friday that steps have already been taken to identify and solve many of the issues, not only in Edmonton but across the country.
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“None of the recommendations really were a surprise, as we had conducted a board of inquiry ourselves,” he said.
In the Edmonton detention room, ligature points in the cells were covered with wire mesh; cell door bars were covered with plexiglass; hooks in the washroom were removed; and a camera system was installed.
Although he did not know specific dates of when those upgrades were made, Mercier said they would have taken place during or shortly after the military board of inquiry was held, which was started “in the weeks following the death” and continued on for some time.
“The fact that we’ve taken actions to correct some of the faulty aspects of the room itself, that we reviewed a full set of policies that we have, that led to new sets of orders … and that led to changing or modifying some aspect of the training of our MPs,” said Mercier.
“In itself, all those facts are a recognition that something was wrong and needed to be addressed — and we have, and we continue to do so.”
Moher said the military participated in the inquiry but “did not fully attorn” to its jurisdiction.
She also said that she can’t make recommendations for the military, but reminded all provincial and municipal detention facilities to make sure staff access computer databases and continuously monitor people in custody. She said all holding cells should also be “suicide proof” and defibrillators or similar devices be regularly maintained.