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Corporal Shaun Collins hanged himself after being locked in a military cell.

Handout

Corporal Shaun Collins, a veteran of the Afghanistan war, had twice tried to take his life before he was locked in an Edmonton military cell for allegedly driving drunk and refusing to provide a breath sample.

He hanged himself not long after being placed in that darkened cell, as three military police members were in another room. Several safeguards that were supposed to help protect him failed, a provincial fatality inquiry into his suicide heard on Monday, the first day of testimony.

The bars on his cell door posed a hanging hazard and did not meet Canadian correctional standards. The video-monitoring system didn't work and hadn't for years. And his name was misspelled when it was entered into the military's security information database, a mistake that meant vital information on Cpl. Collins's fragile mental health wasn't turned up until after his suicide around 8:30 p.m. on March 9, 2011. Even one of the military's potentially life-saving equipment – a defibrillator – wasn't working properly, the inquiry before Justice Jody Moher was told at Edmonton provincial court.

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Ordered by the Alberta Justice Minister, such a public examination of a military death is a rarity in Canada. Scheduled to last four days and hear from 11 witnesses, the Alberta inquiry will offer a glimpse inside the sometimes secretive world of the Canadian Forces. The military holds its own death investigations called boards of inquiries. But they're not open to the public, and families usually only receive partially censored summary reports.

This is the first time a provincial fatality inquiry is being held in a soldier's death in Alberta. The judge's mandate is not to lay blame, but to determine the circumstances of Cpl. Collins's death and whether recommendations should be made to prevent other tragedies.

The young corporal is one of at least 62 soldiers and veterans who have killed themselves after returning from the gruelling Afghanistan mission, a continuing Globe and Mail investigation has found. Only 27 years old when he took his life, Cpl. Collins of the Princess Patricia's Canadian Light Infantry had been deployed to Afghanistan in 2006 and 2009, a period of intense fighting and bloodshed for the Canadians. He returned home from his last tour significantly changed, his social worker, Shaun Ali, testified Monday.

Mr. Ali began counselling Cpl. Collins in 2008, the year his sister's remains were found in a north Edmonton neighbourhood. He told the social worker that he was feeling stressed and bullied by his own military unit. He was also frustrated that no one had been arrested in his sister's killing, even though he thought he knew who killed her. (A first-degree murder charge was laid against a man known to his sister in 2013.)

Mr. Ali met with Cpl. Collins for about six sessions before his second deployment to Afghanistan. The next time Mr. Ali saw Cpl. Collins was in August, 2010, after another tough tour. His mental health had changed, Mr. Ali told the inquiry. Cpl. Collins was showing signs of depression and anxiety. He wasn't sleeping much and drinking more. He got angry quickly. He told the social worker about dangerous firefights and said he didn't like how a sergeant had treated him in Afghanistan. It appears he was also airlifted for psychiatric services while overseas.

Cpl. Collins was transferred to the Joint Personnel Support Unit (JPSU) the day he died. It's unclear from Monday's testimony whether he was diagnosed with post-traumatic stress disorder or another mental illness. His father, who was at the hearing, declined to speak with the media.

The JPSU, which is currently being reviewed by the military after a series of problems, offers programs and administrative support to those deemed unable to fulfill their regular duties for at least six months. The support unit is supposed to help these ill or wounded soldiers return to their military careers or train them for new civilian jobs and smooth their transition out of the Canadian Forces, but it has been chronically understaffed and under-resourced.

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Warrant Officer Dean Boyd, a military police officer, testified that he did not know of Cpl. Collins's suicidal history when his two corporals brought him into the military's guardhouse just before 7 p.m. on March 9, 2011. He said Cpl. Collins refused three times to provide a breath sample and attempted to strike one of the corporals with a phone. He was then taken to cell No. 1 and told he would remain locked up for the night unless he started co-operating.

WO Boyd, then a sergeant, said he could see Cpl. Collins pacing in his cell and could hear him yelling. Not long after, he saw the corporal standing still with his hands on the door's bars, his face pressed against the metal. The next time he checked on Cpl. Collins, he was slumped on the left side of the cell, with a hand-fashioned noose around his neck.

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