Jeremy Phillips, 33, was murdered in November 2010 by convicted serial killer Michael Wayne McGray two years ago, and a coroner's inquest this week ended with jurors making a series of recommendations aimed at improving prison safety to prevent similar incidents in the future.
Phillips and McGray were housed together at the Mountain Institute medium-security prison in Agassiz, B.C., after McGray was transferred there from a maximum-security facility. McGray, who pleaded guilty to first-degree murder in Phillips' death, was previously convicted of six murders and once claimed to have killed a total of 16 people in Canada and the U.S.
The inquest heard testimony from another inmate who said Phillips was worried about his cellmate, though prison officials insisted a thorough assessment determined it was safe to put the pair together.
Guards didn't notice Phillips was dead until McGray told them. A guard told the inquest it was difficult to see into the cell's window with his flashlight.
The coroner's jury recommended multiple murderers be kept in single accommodations, unless there is evidence that shows it is both "safe and practical" to put such inmates in shared spaces.
The jury recommended wardens be allowed to disregard wait lists for single-cell accommodations to ensure dangerous offenders are moved to their own cells.
The jury said prison staff should be told "all information" about inmates before transfers are approved, and said a series of recommendations from the Mountain Institute's own internal investigation into Phillips' death should be implemented across the country.
Jurors also recommended the Correctional Service of Canada look into technology to monitor inmates' body heat and review its policy regarding flashlight intensity.
Less than 24 hours after Phillips' murder, McGray, then 45, confessed to police, admitting that he tied up Phillips using strips of bed sheets, shoved a thick sock down his throat and strangled him for five minutes.
He said it was Phillips who dreamed up the scenario, a fake hostage taking in which McGray would tie him up with bed sheets because he believed it would get him out of his cell and into a medical infirmary.
During his rambling confession, McGray described himself as a psychopath and blamed federal corrections officials for moving him into a medium-security prison. While McGray had applied for the transfer to a lower-security facility, he had previously refused the move twice after learning he would be double-bunked.
He was on a wait list for his own cell when he committed the murder, which he told police was an inevitable consequence of his mental health issues that stirred fantasies of stacking bodies.
Prison officials conducted a number of assessments to determine whether McGray could live in the medium-security prison. One gave him a score that put him in the medium-security range — but just barely. At the time, they hadn't received information that McGray had, in fact, beaten another inmate recently.
Both the Correctional Service of Canada and the federal public safety ministry issued statements Wednesday that said corrections officials were reviewing the recommendations,
"While CSC (Correctional Service of Canada) has implemented significant changes to its operational procedures following the death of Mr. Phillips, CSC welcomes the recommendations that the jury has offered," the correctional service's statement said.
"CSC takes the death of an inmate very seriously. The loss of life is a tragedy at any time. The safety and security of all Canadians, including staff and offenders inside institutions, is always the paramount consideration for CSC."
The correctional service said about 19 per cent — or 2,780 — of its inmates were double bunked as of Oct. 7. The statement also noted double bunking "is a normal practice used by many Western countries."
The agency did not have any figures indicating how many multiple murderers are currently sharing cells with other inmates.
Tim Veresh of the John Howard Society said ifinmates share accommodation, the Correctional Service of Canada already has procedures to determine whether they pose a risk to their cellmate, and it appears they weren't followed in this case.
"The checks and balances are put in for a reason, and I would say that the Correctional Service of Canada does a great job in not making errors, but that wasn't the case in this instance," said Veresh.
The inquest heard five guards were disciplined after Phillips died because they failed to realize he was lying dead in his cell for hours. They didn't notice Phillips was dead until McGray himself alerted them to the body.
The inquest heard there are currently 14 multiple murderers incarcerated at Mountain Institute, one of three medium-security prisons in B.C.
Brenda Lamm, an assistant warden, said among 260 cells, 60 per cent of accommodations are shared.
Some 92 per cent of prisoners are serving sentences for a violent offence, like murder, aggravated assault or rape, while 30 per cent are being held on "indeterminate" sentences.
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