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Jury concludes Bellegarde’s death ‘undetermined’

While the first two days of the coroner's inquest painted a picture of the events around Bellegarde’s death in cells, the third day focussed on policy and procedure.
A jury heard from a total of 13 witnesses during a coroner's inquest into the death of Vance Dallas Ray Bellegarde at this hotel in Regina.

REGINA – The third and final day of the coroner’s inquest into the death of a man while at the Regina Provincial Correctional Centre in 2020 has concluded. The five-woman, one-man jury deliberated for over three hours, concluding that Vance Dallas Ray Bellegarde’s cause and manner of death was undetermined.

The jury, which ultimately issued seven recommendations, heard from a total of 13 witnesses, ranging from Corrections Officers, the Deputy Director of Operations, and nursing staff at RPCC; medical professionals, EMS personnel and a deputy sheriff. From the overall testimony, a general timeline of events emerged.

Bellegarde was arrested and charged by RPS after a situation at the Regina General Hospital on Aug. 5, 2020, when Bellegarde and another man were allegedly threatening security officers at that facility. The pair were lodged in police cells overnight, awaiting a court appearance.

The following morning, while in a holding cell outside provincial court, Bellegarde experienced a seizure, and was then transported to Regina General Hospital by EMS. After seeing an emergency room physician, he was released to RPCC until he could appear in court the following morning.

Bellegarde was discovered in Cell 17, Unit 6B, to be unresponsive during a regular check by RPCC officers, and lifesaving measures began until EMS arrived. Despite their efforts, Bellegarde could not be revived, and his time of death was declared by paramedics at 7:19 p.m. on Aug.6, 2020.

While the first two days of the inquest were spent painting a picture of the events that led up to and after Bellegarde’s death in cells, testimony on the third day focussed on policy and procedure.

Jill Thomson, a long-time nurse at the RPCC, offered her insights and explained her perspective on nursing inside the institution.

“We treat the RPCC as their home,” she said. “We’re not considered another health care facility. If they were discharged from the hospital, they would be discharged ‘home’ but instead of home, they come to the jail.”

When asked by inquest counsel Robin Ritter if it would be cause for concern to have an inmate transported directly from hospital to RPCC, Thomson stated she “would feel relieved as a nurse,” having confidence in the medical system that the person had been observed and cleared for release.

She stressed the importance of a discharge summary — notes a patient would receive from a physician that detail instructions for post-treatment care and possible follow up.

“The discharge summary is a critical piece,” she said. “It could be detailed.”

One point of clarification brought forward by coroner William Davern referred to the dictated doctor notes, which were interpreted to suggest Bellegarde’s condition after release from the emergency unit ought to be monitored by RPCC, to return for further care if required.

“From my perspective, every word means something,” Thomson said after reviewing the document. “We have a choice on what words we wish to use.”

Next to testify was Maurice Munro, the Deputy Director of Operations at RPCC. After his review of policy and the investigation, Munro was confident in the protocol followed and couldn’t see where anything was done incorrectly or even where possible changes could be made in admitting Bellegarde to the facility.

Ritter asked Munro about the feasibility of having a policy of placing inmates that have recently visited a hospital (24-48 hours) placed directly to the medical care portion of RPCC for observation. Munro agreed that was a suggestion that could be considered, “but operationally, it could be an issue.”

The jury deliberated for over three hours, and presented the following seven recommendations:

To the Minister of Corrections, Policing and Public Safety

  • Detailed report that is generated at the time of an atypical incident, report will be accessible alongside inmate (physically or otherwise) at all pertinent locations and to be reviewed by anyone interacting with the inmate, employees of ministry to sign oath of confidentiality to maintain inmate's right to privacy while ensuring safety;
  • To ensure appropriate feedback from employees, staff must be given appropriate time to review proposed policy changes;
  • Adding a position of Policy Analyst be reconsidered to ensure proper review of policies;
  • That inmates coming from hospital exhibiting alcohol withdrawal symptoms be placed in medical cells or designated withdrawal cells that have more frequent cell checks by corrections officers.

To the Regina Provincial Correctional Centre

  • That the alcohol assessment scoring guideline form (CIWA) be updated to a portrait layout instead of landscape to allow for ease of use, that there be no blanks beside the number scale but a detailed description to aid assessments;
  • An additional policy that if an inmate is exhibiting distress, all intake forms regarding physical health should be reviewed to discover a health baseline to correctly compare. Re-evaluation by nurse if necessary;

To Saskatchewan Health Authority

  • That a Discharge Summary for persons in custody be clear and concise. Any follow up needs or therapies must be explicitly stated to avoid misinterpretation by other healthcare professionals accessing health reports.

Davern concluded the inquest with heartfelt words for Darlene Bellegarde, the aunt of Vance Bellegarde, who represented the family throughout the proceedings.

“Words are not adequate. I’m very sorry for your loss,” he said. “I know how hard it is to come here and sit through this. You’ve shown great courage.”

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