Jury makes mental health-based recommendations in Traigo Andretti inquest

Jury gives recommendations after inmate death Traigo Andretti was found dead in his cell after an apparent suicide.

The jury in the inquest into murderer Traigo Andretti’s death at the Regional Psychiatric Centre came up with four recommendations to help prevent a similar situation from happening, which include mandatory mental health training for all staff and better communication so staff understand inmates better.

The jury recommended there be better communication between mental health providers and correctional officers, for officers to rotate less frequently to different units and to increase the length of time an inmate spends in a mental health stability cell before moving them to a regular cell.

The recommendations come after two-and-a-half days of evidence from 13 witnesses. Inquests do not find criminal responsibility but determine who died, where and how. A jury can make recommendations to the Office of the Chief Coroner.

The jury determined Andretti, 40, died by suicide between 9:45 p.m. July 1 and 7 a.m. July 2 at RPC, which was during the time a correctional officer did hourly checks to confirm a “living breathing body” but failed to confirm Andretti was alive.

Andretti was found by a different officer around 7 a.m. the following morning with a slashed left wrist. All of the blood had drained into a makeshift basin of blankets and plastic bags underneath Andretti’s bed. The basin, and several suicide notes, could not be seen from the cell window and weren’t discovered until officers went into the cell. One witness testified the cell looked “pristine.”

Since Andretti’s death, policy changed at RPC that now sees managers do random reviews on how correctional officers do their checks on inmates.

Andretti was placed on maximum security unit at RPC after an emergency admission from his home facility of Stony Mountain because he was in danger of self-harm. The 13-bed unit is reserved for those with the most severe mental health issues. A psychiatrist testified Wednesday Andretti was determined to be a psychopath and had continuing suicidal thoughts and self-harmed.

Three days before Andretti died he was taken off additional monitoring.

He was serving time for the killing and dismembering of two women, one of whom was his wife.

Inquests are mandatory when someone does in custody in Saskatchewan unless the coroner believes the death was from natural causes and not preventable.

RPC is a secure federal prison and forensic psychiatric hospital. At the time of Andretti’s death there were 178 inmates at RPC.