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Inquest investigates Westgate inmate’s sudden death

An inmate who died in prison had been put on suicide watch after attempting to take his own life, a jury heard.

An inquest into the death of Kevin Leroy Butterfield comes nearly eight years after he was found dead, at age 41, in his maximum-security cell at Westgate on October 8, 2015.

Mr Butterfield had been arrested for possession of a firearm at the start of the month. He was taken from prison, two days before he was found dead, to be treated in hospital for a razor wound on his wrist.

A senior nursing officer at Westgate described him “alert and orientated” on October 6 at King Edward VII Memorial Hospital after he was treated for the cut to his wrist, which required two stitches.

The statement described Mr Butterfield saying he had heard voices in his head and added that he had taken 12 painkiller tablets at about the time he cut his wrist.

After he was treated and assessed, Mr Butterfield’s vital signs were normal and he gave no indication he had further thoughts about self-harming.

He was returned to the prison. His cell was cleared out, an observation plan was put into effect and health services staff were given monitoring instructions.

The nursing officer’s witness statement reported seeing Mr Butterfield alive for the last time on the afternoon of October 7, in the prison’s segregation unit.

The officer described being called back to Westgate on October 8 after being informed Mr Butterfield had hanged himself.

The bulk of the evidence heard by the jury before magistrate Craig Attridge came from written statements.

It opened with an account from a police officer who was on duty at Hamilton Police Station on the evening of October 1 when Mr Butterfield was first brought into custody.

The custody officer described Mr Butterfield as “very co-operative” as he was booked into a cell at the station.

During a risk assessment, Mr Butterfield listed asthma and bronchitis as health issues — but the officer was told he had “never suffered mental health problems”.

Another police officer’s witness statement from October 2 described Mr Butterfield as being brought into custody with his wife.

His wife was released on bail, but Mr Butterfield was to remain in custody to attend the next session of plea court, at which he “appeared very upset”.

Mr Butterfield told the officer he “could not stay in the cell any longer because it was making him want to harm himself”.

Another officer’s statement told of Mr Butterfield being taken to the police medical room that evening to be assessed by a doctor.

Police came to the room when Mr Butterfield became “agitated”.

However, the doctor ruled he was fit to be detained.

Later in the evening, Mr Butterfield was found lying in his holding cell, conscious but with a T-shirt around his neck.

An on-call doctor was summoned. Officers reported that Mr Butterfield had begun banging his head against the cell wall.

The doctor advised that Mr Butterfield should be taken to the Mid-Atlantic Wellness Institute for assessment.

The officer’s statement added that Mr Butterfield had looked him in the eye when he was returned that night from MWI and said: “Sorry about earlier. I am feeling a lot better now.”

Another officer’s statement described how a syringe dropped from Mr Butterfield’s clothing as police took away garments that could be used to harm himself.

He denied any knowledge of the syringe.

A witness statement from the psychiatric registrar at MWI noted that Mr Butterfield was anxious to return to his family and had admitted he had last used heroin three days earlier.

A Westgate officer’s witness statement described finding Mr Butterfield in his cell, bleeding from a cut to his left wrist, on the evening of October 6.

Questioned by the officer, Mr Butterfield said: “They are going to take my children.”

An emergency room physician at KEMH gave a statement that Mr Butterfield was brought by ambulance to the hospital with cuts to his wrist inflicted by a razor.

Another police officer’s statement described being summoned to Westgate that evening after an attempted suicide at the prison.

Corrections staff told the officer that the matter was under internal investigation.

At about 3.20pm on October 8, the officer was again sent to Westgate after a sudden death was reported.

The officer arrived at about 4pm and was escorted to the cell where Mr Butterfield was lying unresponsive.

Evidence read out from a corrections psychiatrist’s statement said that Mr Butterfield had a “long history of substance dependence” and had tried to hang himself in the past.

The psychiatrist also wrote that Mr Butterfield “always had a problem with prison and being in confined areas”.

Another statement, from a forensic support officer trained in photographing crime scene evidence, told of being sent to Westgate at 3.15pm on October 8.

The officer photographed the cell where Mr Butterfield’s body lay on the floor.

Mr Butterfield was wearing black and white sneakers with the shoelaces missing.

There were pieces of black shoelaces on the floor next to his head and ligature marks visible on his neck.

The jury also heard from a new prison officer who had interacted with Mr Butterfield that day — his first day on duty in maximum security.

Mr Butterfield asked to have a shower after using the recreational area.

A call came for Mr Butterfield to be brought to the medical area of the prison and he asked for his sneakers to be retrieved from an office.

Asked why Mr Butterfield would not have had the shoes, the officer said it was “not a general rule” to be without them in the maximum security area.

Mr Butterfield was under observation at the time, which the officer said was “kind of normal” for inmates in maximum security.

Questioned by Mr Attridge, the officer said Mr Butterfield had been under a 30-minute suicide watch at the time.

The inquest continues.

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