Hourly overnight checks on twice-convicted murderer Traigo Andretti were done improperly at the time of the 40-year-old’s death, according to the acting warden of the Regional Psychiatric Centre (RPC) in Saskatoon.
Correctional officers found Andretti’s body face down on his bed around 7 a.m. on July 2, 2016. His wounded left arm was hanging off the side of the bed, bleeding into a makeshift basin constructed of toilet paper, blankets and plastic bags.
Every hour, RPC officers were required to look into every inmate cell door window, looking for “living, breathing, bodies,” acting warden Lesia Sorokan told an inquest Tuesday.
“It was done too quickly,” Sorokan said of the overnight checks conducted by one officer.
On Monday, former RPC officer Jeff Salyn told the inquest Andretti “appeared to be sleeping” in a consistent position as he conducted checks through the night.
Salyn was placed on administrative leave during a review and resigned. On Monday, he testified to currently being employed at the Saskatoon Correctional Centre.
The incident contributed to a policy change at RPC, with management conducting daily, random reviews of closed-circuit video to assess correctional officer checks, Sorokan said.
Since April 2014, Andretti was serving an indeterminate sentence for murdering and dismembering two women.
Andretti was convicted of first-degree murder in 2014 in the death of his wife Jennifer McPherson in British Columbia. He then pleaded guilty to second-degree murder in the 2006 killing of Myrna Letandre in Winnipeg.
While serving a sentence at Stony Mountain Institution near Winnipeg, Andretti was moved to RPC in April due to suicidal behaviour, the centre’s acting warden said.
The 40-year-old spent roughly nine weeks at RPC, telling staff on multiple occasions he felt he should suffer for his crimes, Sorokan said.
At times, Andretti underwent additional mental health monitoring, but he was taken off monitoring days before he was found dead, according to Sorokan.
“He was managed on a level deemed appropriate by health services,” she said.
An autopsy conducted by Saskatchewan’s chief forensic pathologist, Dr. Shaun Ladham, found Andretti died of blood loss due to the cut on his arm.
A weapon was never discovered – even an X-ray of Andretti’s body revealed nothing.
Notes found by Saskatoon police in Andretti’s cell led officers and staff to conclude Andretti took his own life.
The author of the notes described the psychiatric centre as his “hospice” where “patients and staff were just wonderful.”
He also gave instructions as to where he’d like his ashes to be scattered.
Inquests are non-criminal proceedings meant to determine a person’s medical cause and manner of death. Jurors also have the opportunity to provide recommendations to prevent further deaths.
The final inquest witness is scheduled to testify Wednesday.