Thirteen years after Sherman Kirby Quisses’s death in the wake of an altercation with another inmate in Thunder Bay, Ont., an inquest jury has determined it was a homicide.

Quisses, 35, was a member of Neskantaga First Nation, a remote community in northwestern Ontario. Adam Capay, 19, was charged with first-degree murder.

But the charge was stayed after Capay spent more than four years in solitary confinement. The case drew national attention in 2016 when Renu Mandhane, chief of the Ontario Human Rights Commission, met Capay, who was being kept alone in his Thunder Bay Correctional Centre cell for 23 hours a day with the lights on.

Even though the murder charge was essentially dropped, under the Coroners Act, inquests are mandatory for anyone who dies in custody. The one probing Quisses’s death was held virtually, beginning on Feb. 24 and concluding on Friday.

According to his family, Quisses died days before he was meant to be released.

A four-person jury was tasked with answering several questions: identifying who died, when and where they died, their medical cause of death, and means of death — classified as either natural causes, accident, homicide, suicide or undetermined.

The jurors determined Quisses died by homicide — of hypoxic-ischemic encephalopathy caused by penetrating neck trauma — on June 4, 2012, at the Thunder Bay Regional Health Sciences Centre. 

The condition results from inadequate blood flow and oxygen delivery to the brain, according to the Canadian Journal of Ophthalmology.

CBC News reached out to the family of Quisses for comment on the outcome of the inquest, but did not receive a response by publication time.

Recommendations on mental health, cultural support

Inquest juries are prohibited from making any finding of legal responsibility or expressing any conclusion of law. Their role is not to assign or free someone from blame, or to state or imply any judgment.

However, they are able to make recommendations aimed at preventing similar deaths. 

All of the jury’s 24 recommendations were aimed at Ontario’s Ministry of the Solicitor General. They largely revolve around improving conditions at the existing Thunder Bay Correctional Centre and adding more health-care and cultural support at the new Thunder Bay Correctional Complex.

Construction on the 345-bed complex began in November 2022. The $1.2-billion project is intended to replace the existing jail and correctional centre, with a planned opening of 2026.

The inquest recommendations include hiring psychologists at the correctional centre, improving communications between staff and regularly reviewing the centre’s health-care unit.

The jury recommended a dedicated mental health unit be built at the new complex, and for there to be dedicated Indigenous cultural space for programming, ceremonies and celebrations.

There was also a large focus on increasing the number of Native Inmate Liaison Officers (NILO) available, and making sure NILOs and elders can meet the needs of Indigenous people in custody.

Jurors also made recommendations related to mental health education for staff, and Indigenous-specific training that focuses on culturally appropriate and trauma-informed care.

More consultations between the Ministry of the Solicitor General and political-territorial organizations that represent First Nations — such as Nishnawbe Aski Nation (NAN) — are also encouraged.

Security was another top priority, seen through recommendations to prohibit people in custody from hanging objects from bunk beds and to develop an action plan to locate inmates not present during bed checks.

While inquest recommendations are not legally binding, the Office of the Chief Coroner asks those who have received a recommendation to respond within six months and indicate whether the recommendations were implemented — and if not, why.

A list of all inquest verdicts and recommendations made in Ontario is updated regularly by the provincial government and can be found here.