Natasha Martin says a report released Wednesday confirms much of what she had come to learn in the 10 months since her daughter died at the Newfoundland and Labrador Correctional Centre for Women in Clarenville.
And that is that her daughter — Skye Martin, 27 — was in severe mental distress while being kept in segregation at the women’s correctional facility and that — over a short period of time — the medications she had been taking to treat her mental illness had been reduced or altered.
“When you are on medication for a mental health condition and that medication is taken from you, not gradually — Skye was in Clarenville four weeks and she left the Waterford with not just one medication, but several — whoever administers the medication was fully aware that one week Skye was getting these pills, the next week she was getting half of these pills, the week after she was getting less again. The reduction in medication and the increase in the mental distress came hand in hand,” Martin said.
“They knew she came from a mental hospital. When her mental health started to deteriorate, why wasn’t she sent back to the Waterford Hospital?”
Specifics of the circumstances surrounding Skye Martin’s death were removed from the report, “Newfoundland and Labrador Corrections and Community Services: Deaths in Custody Review.”
The review, carried out by retired RNC Supt. Marlene Jesso, was released publicly on Wednesday by the provincial government. There were about 32 pages removed from the report regarding specific details deemed private surrounding the deaths of Skye Martin, Douglas Neary, Samantha Piercey and Christopher Sutton — at Her Majesty’s Penitentiary and the Newfoundland and Labrador Correctional Centre for Women between Aug. 31, 2017 and June 30, 2018.
Natasha Martin, however, said although she would prefer some things remain private, most of the seven pages involving her daughter should be available to the public.
“I think the public needs to know the details regarding what happened to Skye,” she said. “She left a mental health hospital and went to Clarenville where there is no (mental health) resources. A guard told me during a visit in early April they did not know what to do with her.”
Many of the issues outlined in Jesso’s report have been highlighted in previous reports and inquiries over the years — the need to modernize legislation, construct new or improve upon facilities, expand programs, and improve communication and information sharing.
Jesso makes 17 recommendations to improve the delivery of services and practices within adult custody in the province.
“The current system cannot adequately address mental health and addictions issues. Due to the extraordinary number of daily challenges and systemic problems that exist, the services and programming available are focused on addressing immediate or crisis issues,” Jesso wrote.
“This prevents Adult Custody from keeping pace with best practices in modern corrections and takes the focus away from the overall well-being of inmates. There is a disconnect between the various mental health services available to an individual before, during and after incarceration. Offenders may be released without having participated in programs and services that are necessary for safe rehabilitation and reintegration into the community.”
Skye Martin was pronounced dead at the Dr. G.B. Cross Memorial Hospital in Clarenville in the early morning of April 21, 2018. Correctional officers found her collapsed in her cell the day before. Information Natasha Martin received at the time was that a piece of sandwich became lodged in her windpipe. CPR by correctional officers and transport to hospital failed to save her.
The report states that Skye had been placed in the facility’s special handling unit (SHU) — also know by staff as the Dissociation Unit (DU). Although not on suicide watch at the time, it was a CCTV-monitored cell.
“At 1313 hours, video captured her eating the sandwich wrap and then forcing the full sandwich down her throat,” the report states. “Correctional officers reported that they did not observe this.”
Skye then “viciously kicked” the door as she had been doing earlier in the day. Staff went to her cell and found her lying on the floor, then getting up swinging her arms, “and her lips were blue.” She fell back on the floor unresponsive.
“I did not know what happened on that Friday,” Natasha said. “Skye shouldn’t have been in segregation because she had a diagnosis of mental illness.
“I wanted to find out what happened to my daughter and now I know. I also know now that her death could have been prevented.”
Natasha says a public inquiry is needed to get to the bottom of the events surrounding all the deaths.
“I wanted to find out what happened to my daughter and now I know. I also know now that her death could have been prevented.” — Natasha Martin
“While Marlene Jesso’s report is thorough, it is a review, and it’s not the first set of recommendations that has been sent to the government,” she said. “I do believe there will be some change. You have four deaths in the prison system, so there has to be change. Will the changes address the absence of the resources or the policies to help people with mental health and addiction issues? The public needs to know.”
Justice Minister Andrew Parsons said Wednesday the removed pages contained “very painful information belonging to these individuals whose right to privacy still exists.”
“There’s a balancing act here. We’ve had families indicate that they did not wish that information to be made public,” he said. “As well, we have legislation that requires that person’s privacy be protected.
“I get why people would want to know, but those families now are satisfied in the sense that they’ve been shown everything that Ms. Jesso showed us. I can’t say if the families are happy about it or not. There’s nothing that brings their loved ones back. The important part to me – our weaknesses are very public. We need to fix those. There’s 17 recommendations laid out. We’ve accepted every single one. We’ve been working on them before this, during the report being done, and we’ll continue to work on them.”
One of the recommendations suggests that members of the medical community be tasked with reviewing whether the treatment provided to Neary, Martin, Piercey and Sutton while in custody was in accordance with medical standards.
“Marlene Jesso gave to me what happened to Skye the day she died and I will be forever thankful for that,” Natasha Martin said. “In reading the report you realize there are so many things that could have been done differently, that I wish would have been done differently. And if they were, I could still have my daughter today.”
Some of the recommendations in the report include:
- Developing alternative options to incarceration such as electronic monitoring, supervised bail verification, community-based supervised housing, and increased community supervised programs.
- Replace Her Majesty’s Penitentiary in St. John’s with a modern facility with dedicated space to address mental health housing and programming needs.
- Institutional counts occur at least hourly.
- Implement a comprehensive mental health strategy, and space made available for a mental health unit staffed with mental health professionals and correctional officers with enhanced mental health training.
- The report also recommends that appropriate members of the medical community be tasked with reviewing whether the treatment provided to Neary, Martin, Piercey and Sutton while in custody was in accordance with medical standards.