Man who died in prison had been taken off suicide watch
A prison inmate downgraded from suicide watch insisted he had “a lot to live for” only hours before he was found dead in his cell.
An inquest held in Magistrates’ Court into the sudden death of Kevin Butterfield in Westgate nearly eight years ago heard that the 41-year-old had seemed his usual self on October 8, 2015.
Stewart Richardson, the prison officer checking on Mr Butterfield in his cell at the time, told the jury: “I was the last person to talk to him and the first person to find him.”
He added that working in Westgate became easier when staff built a rapport with inmates.
He said he had come to know Mr Butterfield because he was on remand at the prison “quite often”.
“Me and him used to talk at times,” he said. “We used to have a good rapport.”
In their final exchange, Mr Butterfield asked the officer where he was going.
Mr Richardson said he was leaving the maximum security wing to fetch a copy of the newspaper for one of the inmates upstairs ― a task that he told Craig Attridge, the coroner, probably took him ten to 15 minutes.
He recalled Mr Butterfield’s final words to him were: “When you get back, come see me.”
Mr Richardson added: “Ten, 15 minutes, that’s all it took.
“Sometimes you wonder if there’s anything else you could have said, that it would have been different.”
The officer described coming back downstairs at about 2.45pm from dropping off the newspaper.
From the stairs, he could see Mr Butterfield in the corner of his cell.
A “string” was tied to the lever of the door.
He said he was unable to push the door open with Mr Butterfield against it and got no answer when he called out to the inmate.
A colleague helped get the door open and they discovered Mr Butterfield on the floor with “no expression” and black string looped around his neck.
The officers struggled to break the string from Mr Butterfield’s throat. The testifying staff member told the court the string appeared to be shoelaces from the inmate’s sneakers.
At the opening day of the inquest on Tuesday, jurors heard that Mr Butterfield had been arrested on October 1, allegedly after police found a firearm in his home.
Mr Butterfield, who had been incarcerated before, struggled with addiction.
When he was In custody at Hamilton Police Station, he grew agitated about being separated from his family ― but an on-call doctor who examined him deemed him fit to be held by police.
However, he was assessed at the Mid-Atlantic Wellness Centre later that night after police found him in his holding cell with a shirt tied around his neck.
Mr Butterfield had been moved to Westgate by the time he was brought to hospital by ambulance on October 6 after using a razor to cut his left wrist.
The wound was treated at King Edward VII Memorial Hospital and Mr Butterfield was returned to Westgate the next day.
He was initially held in a segregated unit and monitored under a suicide watch.
By the morning of October 8, Mr Butterfield has been transferred to the maximum security cells, where prison officer Carlton Williams recalled bringing him to the medical area of the prison for another assessment.
“He appeared lively. He was neither up nor down. He didn’t appear to be overly bothered about anything,” he said.
Mr Williams recalled bringing Mr Butterfield back to maximum security after his medical assessment. “He was speaking up a little more,” he told the court.
Mr Butterfield told the officer that he wanted staff at the maximum security unit to be informed that his observation had been reduced to the minimum.
The officer responded that he did not take orders from nursing staff or from inmates and that Mr Butterfield’s level of observation would be adjusted “when it comes down the pipeline”.
A nursing officer from Westgate was asked about Mr Butterfield’s assessment in the medical area.
She said staff had been briefed on the inmate’s self-inflicted wrist injury and his subsequent placement on suicide watch.
Asked about his demeanour, she told the court: “I recall him saying ‘I am not that type of person. That’s not me ― I have a lot to live for.’”
The court heard that at 2.50pm, a medical emergency was sounded in the maximum security area.
The nursing officer described seeing Mr Butterfield on the floor of his cell with officers administering CPR.
Mr Butterfield was unresponsive and his pallor was “grey”.
She checked his pulse and continued CPR until the medical team arrived.
Asked if she was surprised to get the call after medical staff had elected to reduce Mr Butterfield’s observation schedule, she replied: “Yes.”
She added: “In the beginning, when he first came in, he was a bit upset.
“But as the days went by, from the way he was speaking, from the short interactions, nothing seemed wrong.”
The on-call doctor who examined Mr Butterfield told the court he had been pronounced dead just before 4pm, citing the possible cause as asphyxia or strangulation.
Philip Downie, now Acting Commissioner of Corrections, said he was serving as chief officer at Westgate at the time of Mr Butterfield’s death.
He added that he had met Mr Butterfield while he was in custody on “several occasions”.
Mr Downie explained that prisoners on suicide watch were typically held in the segregated unit and under constant observation, with their clothing limited to a smock.
“Mr Butterfield was on suicide watch and segregated,” he said.
“But once he moved to general population, he was not on suicide watch.”
Prisoners on suicide watch would have an officer outside their cell and checking on them every 15 minutes.
The court heard that inmates were placed on observation for a variety of reasons but that those on downgraded observation would be permitted to wear their regular prison uniform, including sneakers.
Mr Butterfield had been moved to hourly observation.
Mr Downie added that he had spoken with Mr Butterfield the day before his death when the inmate was returned to Westgate from hospital after being treated for the wound to his wrist.
“I asked him what had happened. He said child and family services were trying to take his children.
“I said I thought that what he was doing to himself was not helping his children.”
The inquest concludes today.
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