The suicide of a depressed inmate at a jail in Prince George, B.C., prompted changes to how health-care and corrections staff deal with such cases, a coroner's investigation found.
Paul Judge, 47, died in hospital on Christmas Day in 2012, five days after he injured himself with a jail-issued razor.
A report released by the BC Coroners Service on Friday said Judge was transferred to the Prince George Regional Correctional Centre a week earlier to await a court appearance over an altercation involving weapons.
The report said Judge had no history of mental health or emotional problems until a few months before his death, when a fire and explosion where he worked, at the Lakeland Mills sawmill, on April 23, 2012 killed two workers and destroyed the facility.
"Although Mr. Judge was not working at the time of the explosion, his emotional state began to deteriorate following the event," coroner Lynne Hyatt said in her report.
Over the next few months, Judge sought help from his doctor, went for counselling and at one point was taken to the local emergency ward because he was suicidal, though he declined to be admitted to hospital, the report said.
Judge was described as suffering from depression and an anxiety disorder but he did not take medication as prescribed, Hyatt said.
On Dec. 17, 2012, Judge was transferred from police custody to the jail and assessed by a corrections official, two mental-health professionals and a nurse. He consistently denied any intention of attempting suicide, the report said.
Judge was therefore not placed on suicide watch and was provided with a plastic razor for hygiene reasons.
On the morning of Dec. 20, 2012, during half-hour checks of the protective custody unit where Judge had asked to be placed, a correctional officer discovered the inmate on his hands and knees in a pool of blood.
"Mr. Judge told the medical staff he had slashed his neck with a razor," the report said, adding his jugular vein was cut, leading to cardiac arrest and brain injury.
The coroner's report noted that the province's corrections branch implemented seven recommendations after an internal investigation into the incident.
The report highlighted the need for a standardized suicide assessment tool and training for staff to use it.
The investigation also found that while information about Judge's mood was entered on one computer system accessible to health-care personnel, it was not entered on another one used by correctional staff.
"The review recommended that in future, any such warnings or cautions were to be placed on both systems so corrections officers, as well as health professionals, were aware of any potential issues with an individual prisoner."