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Thunder Bay, Ontario: Adam Capay is brought into the Ontario Court of Justice on June 6, 2012.Jeff Labine

Four years before Adam Capay landed in an acrylic-glass-lined segregation cell at Thunder Bay Jail, another inmate died in the same isolation cell – a death directly related to his brutal confines.

Jail staff at the time insisted that the cells had to be renovated or replaced, but they remained in service with only a few improvements to the air conditioning, ventilation and plumbing fixtures until the Capay case came to light last month.

In October, Ontario Premier Kathleen Wynne called the plight of Mr. Capay, a 23-year-old inmate who has spent more than four years in solitary confinement awaiting trial, "extremely disturbing." Her government set about searching for other inmates languishing in the same conditions: acrylic-glass cell, no natural light, 24-hour artificial illumination, limited access to mental health support.

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But revelations about the Thunder Bay segregation cells should have come as no surprise to her government. As part of an ongoing investigation, The Globe and Mail has learned that multiple coroner's inquests have warned the government about unsafe conditions in Thunder Bay's segregation cells and the state of general disrepair at the 90-year-old building.

The most recent warnings came this spring during a coroner's inquest into Christopher Coaster, who died in the sweltering summer of 2008 – he was housed in the same cell that would one day hold Mr. Capay.

"It was horrible," said Robert McKenzie, a jail sergeant at the time. "He dehydrated to death and boiled to death in there."

Mr. Coaster was a great father, skilled musician and expert furniture-maker, according to family testimony at the inquest in June.

He was also a chronic alcoholic.

On July 30, 2008, he embarked on a bender at his sister's house in Geraldton, Ont., about 300 kilometres northeast of Thunder Bay. His heavy drinking coincided with his nephew's birthday and his sister Wendy asked him to stop. When he refused, she called the police, who arrested him for breaching a bail condition prohibiting the consumption of alcohol.

The next day, correctional officers admitted him to Thunder Bay Jail, an austere Neo-Gothic structure that has been a candidate for replacement since a riot tore through the facility in 1977.

Screening found that Mr. Coaster was going through extreme symptoms of alcohol withdrawal. Staff placed him in segregation cell 11(2), a roughly 9-foot-by-8-foot space with three solid steel walls and a front wall made up of steel bars covered with acrylic glass.

Like segregation cells in any jail, those in Thunder Bay have a sad history.

In 2003, an inmate named Steven Voss hanged himself from a metal bar in one of the segregation cells. A subsequent coroner's inquest implored the jail to eliminate all such "suspension points," which management accomplished by lining the segregation cells with Lexan, or some other variety of acrylic glass.

"That Lexan was just put on there by our own maintenance people," said Mr. McKenzie. "It was put on with little metal straps, like the kind used to affix copper plumbing pipes to the rafters in your home."

By the time Mr. Coaster arrived in the cell, on July 31, 2008, the acrylic glass had been scratched by dozens of previous inmates.

Mr. Coaster "kept yelling about wolves, to be careful of the white wolf," Renee Perrier, who was managing the segregation unit at the time, said during the inquest. "There was something wrong. I knew it's not normal…But in the pit of your gut, [I felt] he needed to get out. He needed to be brought to the hospital."

Medical staff didn't agree with her assessment, and Mr. Coaster remained in place.

It was a hot week in Thunder Bay, with temperatures reaching upwards of 26 Celsius. Much of the jail, including the two-cell segregation unit, lacked air conditioning. With the acrylic glass preventing air to circulate, the heat Mr. Coaster experienced in the cell was far worse.

"It was disgusting, absolutely disgusting," said Ms. Perrier of the heat.

On the morning of Aug. 3, 2008, correctional officer Blair Penney was posted outside an adjacent segregation cell to observe a suicidal inmate. He had a clear view of Mr. Coaster as well.

"[It was] hot as hell. I was very uncomfortable," he said at the inquest. "Officers were allowed to have a small fan in the area. Nothing for the inmates, though."

Mr. Penney testified that he and many other officers had raised concerns about cell conditions, especially the heat, but nothing changed. "As far as I remember, there were no holes drilled for circulation," he said. "At the time, it was solid Plexiglas with a small hole cut out to slide meals into."

That morning, Mr. Coaster's behaviour deteriorated. He began hitting his cell walls and laughing maniacally.

"His arms were bruised from banging against the wall," said Ms. Perrier. "I don't remember him taking any liquid or food."

Around 10:30 a.m., Mr. Coaster lay down and seemed to be sleeping.

When Mr. Penney left the unit for lunch, "It appeared to me that his chest was moving and I thought I saw his foot move."

A sergeant walking by the cell around noon noticed Mr. Coaster's lack of movement and began banging on the glass. "We tried to get a response from Mr. Coaster by calling his name, clapping our hands, doing anything we could to rouse him," said George Kasper. "We didn't get any response."

They entered the cell and found Mr. Coaster's limbs stiff and his skin cold. He was long dead. The official cause of death was delirium tremens, a state of extreme mental and physical excitement that can arise from alcohol withdrawal with potentially fatal side-effects: abnormal heartbeat, tremors and seizures.

That was eight years and five corrections ministers ago.

At the inquest, the extreme cell conditions and dehydration suffered by Mr. Coaster arising from the heat were identified as contributing factors. Immediately following the death of Mr. Coaster, the province upgraded the jail's ventilation and air conditioning systems, but the inquest jury insisted further upgrades were needed. They recommended the province replace Thunder Bay Jail with a building featuring adequate segregation cells to "meet the needs of the present and anticipated population of the jail."

It's not the first time the recommendation has come up in regards to the Thunder Bay Jail. In January, another inquest into the deaths of two inmates who overdosed on methadone at the prison called for the same thing: a new jail with adequate segregation cells.

Last month, Thunder Bay city council came to the same conclusion, sending a formal request to province for a new jail.

This month, the province hired outgoing federal prisons ombudsman Howard Sapers to head an external review of segregation procedures and, since Mr. Capay's story went public, has started overhauling Thunder Bay's segregation cells.

"In recent weeks at the Thunder Bay Jail, the ministry is in the process of installing solid doors with large windows top and bottom, lighting upgrades are under way including dimming features and TVs are being installed in segregation areas," said spokesman Andrew Morrison.

At the Coaster inquest, the most telling testimony regarding the need for new infrastructure came from a surprising source.

"The cells are not appropriate for all purposes – the seg cells, that is," said the jail's acting superintendent Deb McKay.

When asked how the cells could be improved, she struggled for an answer. "Well, there are many different options that are out there today and our building is so old that it doesn't meet the modern standards, so I can't really tell you exactly what, but it, it would be something not – something less disciplinary."

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