10/11/2012 04:23 EDT | Updated 12/11/2012 05:12 EST

Mother laments son who killed himself in jail cell: inquest recommends changes

CRANBROOK, B.C. - A coroner's jury has recommended body fluid samples taken from people who have been admitted to hospital for unnatural death or injury should be automatically stored for more than the current practice of seven days.

Jurors have spent the week hearing about the circumstances surrounding the death of Collan Kohalyk, who hanged himself in his jail cell after being arrested following a domestic violence call on Christmas Eve, 2010.

Kohalyk used his own T-shirt tied to the bars of his cell door. A guard noticed him standing with his back to the bars, but didn't physically check him immediately. The guard testified he was busy with other tasks while the incident occurred.

Kohalyk, 36, died 10 days later in hospital. Jurors heard he had been diagnosed with bipolar disorder and had a history of alcohol and drug abuse.

But pathologist Dr. Susan Tebbutt testified she wasn't able to determine what drugs were in Kohalyk's system because the blood and urine samples taken when he was admitted to hospital were automatically destroyed after seven days, the normal practice unless the RCMP has obtained a court order to retain them.

“These samples need to be treated differently,” Tebbutt said.

“I absolutely have a problem with that because I know we can't get those samples back. To me, we are losing valuable evidence and I think we can do better.”

Tebbutt said all she knows is that when Kohalyk was admitted, his samples tested positive for an unknown opioid. A more detailed toxicology test was never done before the sample was destroyed.

Tebbutt said the policy is in place because those samples are often not viable after seven days, except for toxicology tests. She recommended to the jury that these critical samples be frozen for at least a month to ensure they remain viable.

“This would give us the time that we need,” she said. “We know this is not an isolated incident.”

Jurors also recommended all clothing removed by prisoners should be taken from the cell immediately.

RCMP Const. Bob Archer was one of two officers who brought Kohalyk into the cell block that night.

Archer testified the man was agitated and combative as his clothes were being removed down to one layer, as is standard procedure.

“He was swearing, wanting to fight us,” Archer said. “All I can remember was him swearing.”

Archer said from the guard's room, he watched Kohalyk via camera as he removed his sweater and pants and rolled them into a ball to use as a pillow. Kohalyk refused to hand the clothing over and the officers and the jail guard concluded that entering the cell to demand the clothes would only aggravate the situation.

“Somebody would have gotten hurt,” Archer said. “He was very violent.”

But at 1:19 a.m., Kohalyk was seen standing with his back to the bars. A full view of him wasn't possible on the cell camera, and the guard continued on with his other duties.

But by the next check, minutes later, the guard realized Kohalyk was still in the same position. The guard and an RCMP officer then entered the cell and cut Chalk down.

After the juror's recommendations, Kohalyk's mother, Irene Kohalyk, said her son fell through the cracks when he was left unattended in the cell block.

“I think he was missed. He was able to do what he did because he disappeared off camera,” she said.

Half of the Cranbrook detachment cellblock was already under renovations to retrofit the barred cells to new steel and cinderblock when Kohalyk was arrested. Those renovations were a directive handed down Canada-wide.

After her son's death, the detachment made several swift changes including only using the old cells with low-risk prisoners and changing the camera angle to prevent blind spots.

“They have already made some changes, which is good,” Kohalyk said.

She said her son's life was much more than his death and his drug addiction. She earlier told the inquest he was a father of two who struggled repeatedly to get his life turned around.

“I want to put away the darkness and remember all the good,” she said. “I'm thankful to have had him for those 36 years.”

Inquest Counsel Rodrick Mackenzie said after the recommendations were announced that the coroner will now write letters to RCMP E Division and the provincial Minister of Health.

While the RCMP and Health Ministry are not bound to implement any recommendation made by a coroner's inquest, Mackenzie said they are bound by the public will to prevent another similar tragedy from happening.

(Cranbrook Daily Townsman)