Jury makes 38 recommendations during inquest into Indigenous woman's death while in custody

WARNING: This story contains references to suicide.

A jury of four has made 38 recommendations in the coroner's inquest examining the jail death of Delilah Blair, including recognition that inmates phoning loved ones shouldn't be viewed as a privilege.

Blair died by hanging as an inmate at the South West Detention Centre (SWDC) in Windsor, Ont., on May 21, 2017. She was in the mental health unit.

The jury heard Blair, a 30-year-old mother of four, made at least two written requests to speak with her mother, Selina McIntyre, in the weeks before her death. McIntyre lived more than 4,000 kilometres away in Hay River, N.W.T., in the weeks before her daughter's death. Blair was an Indigenous woman of Cree ancestry with an Inuit upbringing.

Those requests weren't fulfilled and McIntyre testified the first time she even knew her daughter was in jail was when someone called to say she was dead.

"My daughter was going to tell me something and I'll never hear those words from her. It seemed to be she was silenced for some reason," McIntyre previously told CBC News.

WATCH | Delilah Blair's mother speaks about daughter's death:

The jury has recommended the Ministry of the Solicitor General, which oversees jails, to update policies so an inmate's access to a phone is not considered a privilege. In addition, any inmate who cannot reach a family member using a jail-issued calling card should be given priority access to a separate phone in order to be able to call family, the jury found.

Kate Forget, co-counsel to the coroner and legal counsel with the Indigenous Justice Division of the Ministry of the Attorney General, stressed the importance of the issue during closing submissions on Thursday.

"Knowing that she made this request while she was located in a female mental health unit by today's standards would be considered segregation," Forget said.

"[It] makes this all the more heartbreaking."

The jury heard none of the several jail staff who testified at the inquest knew Blair was an Indigenous woman.

There also wasn't any Indigenous programming being offered to inmates in the female mental health unit, no access to spiritual elders or knowledge keepers and at the time, the institution didn't have a Native Inmate Liaison Officer (NILO).

Many witnesses who testified, including some correctional staff, said they acknowledged the needs of Indigenous peoples, particularly women in custody, are unique when considering a deep connection to culture.