Inquest Ends With 10 Jury Recommendations

In a brief statement to the Press the family of Jeremy Sabourin said taking part in the coroner’s inquest was worth it especially if it prevented a similar tragedy.

Their son the 40 year old Jeremy had passed away on October 7, 2021 in Moose Jaw Police Service (MJPS) holding cells from a self inflicted gun wound.

The three day inquest had shown a series of errors, omissions and failure to follow protocol lead to Sabourin being able to smuggle a small gun into the holding cells and then turn the weapon on himself.

To prevent a similar death in the future the inquest’s jury of 1 man and 4 women provided 10 recommendations.

The Jury’s recommendations were:

  • the RCMP and the Moose Jaw Police Service shall require all new members to be familiar with policies and all members will review policies on an annual basis and document their completion.

  • the RCMP and the Moose Jaw Police Service include annual testing and qualifications of their members on physical and wand-use testing with testing being conducted by an external police agency

  • The RCMP have a minimum of two wands available at each detachment to search with

  • The RCMP modify the C-13 form so it provides more space for more information to be written on the document and clearly indicate which fields are mandatory before they transfer prisoners to another agency

  • The RCMP and the Moose Jaw Police Service provide their members with annual mental health and suicide crisis training

  • The Moose Jaw Police Service ensure their members complete all applicable forms when prisoners coming into their custody

  • The Moose Jaw Police Service modify their custody intake form to include a space for non-responsiveness

  • The RCMP shall review their search procedures and the disadvantaged position used by the RCMP to determine if it is effective and in line with best practices in policing

  • The RCMP and Moose Jaw Police Service shall format a policy audit with audits conducted once a year

  • The RCMP and the Moose Jaw Police Service shall consider that all breach involving the search of a prisoner is a serious matter and engage disciplinary processes where appropriate.

Following the jury’s recommendations presiding coroner Blaine Beaven said he would like to add a recommendation as allowed under the Coroner’s Act.

“The Coroner’s Act permits the presiding coroner over an inquest to provide recommendations as well…it’s not something coroners do often it is something that was only added to law a few years ago,” Beaven said.

He is the recommendations made by the jury were “very thoughtful and very thorough.”

Beaven said his recommendation was “to supplement what they have. It does not tread on what they have written.”

“All Saskatchewan police services shall review and where necessary modify the wording of the jury recommendations so they apply to their police service.”

Beaven said he was expanding the jury’s recommendations because prisoners are in custody at various police services and agencies across the province on a daily basis.

“This incident could have happened at any of them.”

With that the inquest was adjourned.

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