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Lucia Vega Jimenez is shown in a coroner's inquest handout photo released on Sept. 29, 2014.The Canadian Press

A B.C. coroner's jury hearing evidence into the death of a Mexican woman who hanged herself while in custody says the Canada Border Services Agency should create and staff a dedicated holding centre for immigration detainees within a 30-minute drive of Vancouver's airport.

The suggestion follows a six-day inquest into the December 2013 suicide of Lucia Vega Jimenez, who was found by private security guards inside a shower stall in the dungeon-like holding facility below the airport's hotel.

The almost three pages of recommendations say the new holding centre should be above ground where there is ventilation and natural light and have an on-site courtroom for immigration hearings.

While the current detention centre is staffed by contractors, border-agency officials should monitor airport holding cells by video, said the jury. Legal counsel and non-governmental officials should be allowed into the facility, and bathrooms and sleeping rooms should be made self-harm proof, it added.

The jury said detainees should receive mental- and physical-health assessments within the first 72 hours in custody, that border-agency officials and contractors be given suicide-prevention and diversity training, and a mental-health professional should be present when somebody is informed that they'll be deported.

Translators must also be available for detainees who can't understand English, the jury recommended.

"I'm blown away, basically," said Rocco Trigueros of the group Mexicans in Vancouver. "I'm very happy to read the recommendations because they are great, they are profound, they are responsible, and I think we were lucky to have a great jury because they were sensitive."

Not included in the recommendations were other deportation models, said Trigueros who noted immigration detainees are not kept in jail in some provinces and can self-report to officials. Adopting such a model, he added, would save taxpayers money and reduce the stress on detainees.

The border agency released a statement after the ruling.

"This is not the end of the matter," said the statement. "The CBSA will carefully review all findings and recommendations resulting from the inquest."

The agency said it has already reviewed the private security company's contract to ensure it is consistent with its national detention program, updated the standing orders for its holding cells in B.C., increased monitoring and oversight, and modified infrastructure to reduce the risk of self-harm.

The agency said all contracted security guards are now required to receive enhanced suicide and self-injury prevention training.

"This is a clear wake-up call to Canada Border Services Agency," said Josh Paterson, executive director of the B.C. Civil Liberties Association. "This coroner's jury listened to six days of evidence and it is absolutely crystal clear that they understood that Canada Border Services had made just so many mistakes, had so many problems that contributed to the death of Lucia Vega Jimenez."

Transit police stopped Jimenez for fare evasion on her way home from work at a Vancouver hotel on Dec. 1, 2013. Const. Jason Schuss testified he contacted the border agency after she produced two different ID cards and spoke with an accent.

A CBSA officer arrested Jimenez after a database check that showed the woman had been previously deported from Canada when her refugee claim was rejected. Inland enforcement officer Josie Perri testified the woman told her she had sneaked back into Canada through the bushes in Surrey, B.C., in April 2013.

Jimenez was incarcerated as an immigration detainee in the maximum security wing of the Alouette Correctional Centre for Women. For two weeks, she tried to get a lawyer to help her with filing a pre-removal risk assessment, a crucial document that would have extended her time to fight deportation.

Two inmates who befriended Jimenez testified she grew increasingly tense and lost her appetite, confiding fears she would be killed or tortured if returned to Mexico. American Barbara Dennis believed the woman faced problems with a gang or drug cartel, but other witnesses say they were simply told about an abusive ex-boyfriend.

Jimenez retained a lawyer five days before the all-important deadline, but the document was never filed. CBSA case officer Raman Vandher testified that Jimenez appeared calm and accepting when told she would be ejected.

A nurse at the prison testified the woman had been scheduled for an appointment with a mental health co-ordinator, just days before she died, but for some reason it was cancelled.

The inquest watched two harrowing videos depicting the hours and moments before Jimenez attempted suicide. On Dec. 19, the curly haired woman in green prison-issue sweatsuit was led down a dimly lit corridor into the holding cells below a Vancouver airport hotel. She was cuffed and searched.

On Dec. 20, the close-circuit video captured her entering a bathroom carrying a yellow towel. More than 40 minutes pass before other cellmates alerted a guard, sitting behind curtained windows, that the woman hadn't emerged.

Guard Jivan Sandhu entered the women's common area, knocked on the door and peeked in. He testified that he found Jimenez hanging by her neck from a shower rod. He held her up and cut her down, then launched into resuscitation.

Paramedics arrived and Jimenez was rushed to hospital. She was taken off life-support Dec. 28.

The inquest heard that the private firm Genesis Security, hired by the CBSA to watch detainees, made a series of errors leading to Jimenez's death.

Protocol stated guards were required to check their charges every 30 minutes, although Sandhu admitted that understaffing meant he sometimes worked alone and so fabricated log entries. A female guard was off-site for another duty when he discovered Jimenez. Thick curtains shielded the view into the women's common room and guards did not receive suicide-prevention training.

CBSA did not immediately publicly disclose the suicide, unlike the practise of other police when a death occurs in their charge. Word of the tragedy was revealed through social media and a vocal Mexican community in Vancouver.

The inquest was called in February, with the coroner's service noting the circumstances required an extra responsibility of care.

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