Inadequate care at Edmonton jail has inmates 'falling through the cracks,' inquiry finds

WARNING: This story contains discussions of suicide. 

Canada's largest jail is again facing calls to improve mental health care for inmates following an investigation into the death of a 23-year-old man who died by suicide inside his cell.

A fatality inquiry into the death of Timothy "TJ" McConnell found that mental health and addictions services at the Edmonton Remand Centre are inadequate to meet the complex demands of its prisoner population, allowing some inmates to "fall through the cracks."   

McConnell, who died on Jan. 11, 2021, had repeatedly asked for medical intervention to help him with pain, addiction issues and mental illness. 

His requests for treatment went unmet in the weeks before he took his own life, according to the inquiry report written by Justice Olugbenga Shoyele.

Shoyele is calling for changes at the remand centre, including the establishment of a specialized clinic that would function like a psychiatric unit at a hospital and offer services around the clock.  

The report also included recommendations that came directly from the testimony of McConnell's mother, Lana Greene. She called for increased mental health staffing, the hiring of a full-time psychiatrist, and stringent protocols to monitor inmates confined to segregation. 

Greene said there will be no justice for her son but feels vindicated that her calls for reform were heard.

"This isn't just about my son. This isn't about just one person." 

String of inmate deaths

The Edmonton jail, operated by the Ministry of Justice and Solicitor General, has repeatedly faced criticism for how it cares for the mental health needs of men in its custody. 

Shoyele's report is the latest to paint a dire picture of the facility's psychiatric and addictions programs. A string of deaths inside the remand centre — where people can be housed for years awaiting trial — have been the subject of other provincial inquiries. 

Last December, two inmates died within two days, bringing the total number of fatalities recorded at the jail in 2024 to six.

The jail serves a population of more than 1,500 inmates, many of whom have severe mental health issues and require more medical and addictions care than is currently available. Its three clinics are "packed to the brim" and susceptible to overcrowding, Shoyele wrote in his report.

A key challenge is recruiting forensic psychiatrists trained to work in correctional facilities, wrote Shoyele, a judge at the Alberta Court of Justice.

"The current system is overwhelmed because it faces limitations in terms of staffing and resources, leading to long wait times and inadequate care, with the potential for some inmates who are not as acutely unwell to fall through the cracks."

Services are spotty with clinics operating with limited hours and constrained staffing. The result is ballooning caseloads and a medical system pushed past its capacity, Shoyele found.

A hospital-grade clinic, with a full-time forensic psychiatrist available 24/7, is necessary to serve the population, Shoyele said.  Such a clinic would expedite care, improve screening and result in the addition of new medical staff, including nurses, social workers and addictions counsellors. 

Shoyele cited the investigation into the death of John Wayne Anderson, who died by suicide in March 2020 less than a month after he unsuccessfully sought help for depression from medical staff at the jail. That inquiry found the size of the mental health team — 16 people, spread out over various shifts — to be "completely inadequate" and that similar deaths were likely unless improvements were made.

Another fatality inquiry, this one into the death of inmate Jonathan Anderson, concluded last September that the jail isn't equipped to deal with the volume of inmates who might be depressed or suicidal.

Greene launched a lawsuit against Alberta Health Services and the province in 2022, alleging negligence in her son's medical care led to his suicide. She said she remains haunted knowing that her son, who had long struggled with mental health issues and substance abuse issues, begged for care that never came. 

She hopes the ongoing case will pressure the facility's operators to adopt the recommendations.

'Struggling to live' 

Medical documents paint a haunting picture of McConnell's final days. 

In the weeks that followed his arrest in Edmonton in September 2020 on theft and shopbreaking charges, he was shuffled between the jail's general population and full segregation. 

He submitted multiple request forms to Alberta Health Services staff, complaining of anxiety, depression, physical pain and difficulty sleeping. The tenor and the frequency of his requests became increasingly desperate between the time of his arrest and his death four months later.  

On Nov. 14, 2020, he submitted three forms asking to see a psychiatrist and to be provided Suboxone, a medication used to treat symptoms of opioid withdrawal, and the anti-psychotic drug Seroquel.

"I'm having a lot of trouble refraining from using drugs in here, and I'm scared I'm gonna lose my life when I get outside," he wrote.

On Jan. 1, while he was in full segregation, he submitted two more requests. 

"I'm sorry to bug," McConnell wrote that day. "I know I'm on the waiting list but I've been here four months and soon I'll be back on the streets.… Please let me start my Suboxone treatment. I won't abuse this privilege."

In another form submitted on Jan. 1, McConnell wrote that he was "having trouble living day to day" without medication.

McConnell met with a nurse at his cell but never saw a psychiatrist, missing the single appointment he had been provided. 

He was never prescribed any other medication and remained in segregation, on the waiting list for care, until his death. 

Greene said the system at the remand centre leaves vulnerable people trapped in the cycle of addiction and mental illness during what could be a critical window for rehabilitation and healing.

"They're losing their life or they're coming out of there worse because we've missed that opportunity," she said. 

"They've fallen through the cracks and come out severely traumatized from what they've gone through in there. Or they don't come out, like my son. And it's devastating."

No change needed, prison officials say

Officials who operate the facility and its mental health clinics testified that care within the prison is adequate and that McConnell's death did not warrant any changes. 

During the inquiry proceedings, which concluded in an Edmonton courtroom last year, lawyers said there was no evidence that policies within the prison contributed to McConnell's death. 

Health officials, meanwhile, testified that protocols followed in McConnell's case were in line with current policies.

The inquiry heard that improvements had been made to medical services since McConnell's death, including improved suicide screening for inmates. A lawyer representing Recovery Alberta said the remand centre's Opioid Agonist Therapy program — a treatment for opioid addiction — was better managed to handle the one- to two-month wait currently faced by inmates to access addictions treatment.

'They're just warehousing people'

Amy Matychuk, an Alberta-based lawyer specializing in prison law, said the problems with access to and continuity of medical care at the remand centre are chronic and long-standing. Clients awaiting trial there have struggled to access both basic and acute medical care, she said. 

"It's this really unfortunate pressure cooker of an environment where no one there seems to feel they have a duty to support and provide services," she told CBC. "There's an attitude that they're just warehousing people, that people are just sort of animals to be warehoused." 

She said services within remand centres across Canada have been worsening for decades as tough-on-crime policies undercut funding and eroded any public sympathy for incarcerated people.

There are public safety ramifications if the facility doesn't change how it addresses the needs of its vulnerable population, she said.  

"People don't stay in prison forever," she said.

"A culture change is required so that staff at these institutions don't view themselves as just managing a warehouse full of violent people and actually view themselves as [being] part of the rehabilitative process."

For her part, McConnell's mother said it would be "inhumane" for the centre to neglect calls to improve inmate access to mental health care. 

If improvements are not made, Greene fears another family will face tragedy.

 "My hope is now is that there's follow up, that the recommendations get followed through," Greene said. "So many families are crying out saying these deaths could be prevented."  

If you or someone you know is struggling, here's where to look for help:

• Canada's Suicide Crisis Helpline: Call or text 988.

• Kids Help Phone: 1-800-668-6868. Text 686868. Live chat counselling on the website.

• Canadian Association for Suicide Prevention: Find a 24-hour crisis centre.

• This guide from the Centre for Addiction and Mental Health outlines how to talk about suicide with someone you're worried about.