Fox Inquest: Coroner’s jury suggests ways of preventing similar deaths

Posted on June 29, 2026 by Ryan Dahlman

By Marcus Day

Maple Creek News

Okimaw Ohci Healing Lodge staff are being urged to carry 911 tools on them in the wake of last week’s Casandra Fox inquest.

A coroner’s jury made this recommendation after hearing two days of testimony related to the 2023 tragedy at the lodge, which is in a forested area in the Cypress Hills.

In a message to Correctional Service Canada (CSC), the jury said all workers should carry the 911 tool – a rapid-response device, which has a hooked, inward-facing blade that can cut through ligatures.

“In a situation where time is very important, running 30 seconds to one minute to get this tool could be life and death,” the jury said in its report.

There were two other recommendations to Correctional Service Canada, in the interests of avoiding similar deaths in the future:

Have an audit done of all the inside facilities for hanging and ligature points; and

Informal checks should be performed at a more random fashion

The “informal checks” refer to the counting of inmates, known as residents at the lodge.

The jury’s report also contained its findings. These were:

Name of deceased: Casandra Fox;

Date of death: January 18, 2023, 9.07pm;

Place of death: Okimaw Ohci Healing Lodge – Unit #2.1, Maple Creek;

Cause of death: Asphyxiation – hanging by a ligature around neck; and

By what means: Suicide

After the inquest, Fox’s family supported the recommendations.

David Fox, Casandra’s brother, said it looked as though long overdue change was about to happen, and that some “weird grey areas” would be filled in.

“I don’t see why staff wouldn’t carry a 911 tool,” he said.

It could be a lifesaver in emergencies, he added. If corrections officers carry CPR masks for emergencies, why not a 911 tool?

Backing calls for an audit of ligature points, the family believes lessons should have been learned from a suicide attempt that occurred before Casandra’s death – something that emerged during testimony at the inquest.

The circumstances had similarities, said David. Both took place in a closet.

“The only reason it didn’t work is that the person didn’t tie the ligature properly,” he said.

More random counting checks also makes a lot of sense, according to the family.

“People are so clever, and if they know when they are going to be checked, then they can get round it,” said David.

Extra security in residents’ units is another area that should be looked at, the family believes, particularly as there are knives in kitchens.

“There is always something you can do to improve safety,” said David. “There is always something you can do to make a difference.”

The inquest took place on Monday, June 15, and Tuesday, June 16 at Maple Creek’s Royal Canadian Legion Hall on Maple Street.

Nine witnesses gave evidence. According to testimony, 26-year-old Fox, a Sweetgrass First Nation woman, was discovered in her room (Unit #2.1) at the lodge after failing to appear for a count. She was unresponsive to life-saving measures by staff and emergency personnel.

The tragedy occurred about a month after she had entered the lodge, which is an institution for aboriginal female offenders that opened in 1995.

Under Saskatchewan’s Coroners Act, a public inquest is held when a resident or inmate dies in a correctional facility unless the death is determined to have resulted entirely from natural causes and is deemed non-preventable.

The Coroners Service says the role of the inquest is to determine who died, when and where the death occurred, and the medical cause and manner of death.

Coroner Timothy Hawryluk, K.C., a lawyer from Saskatoon, expressed hope that the hearing will find ways to prevent a similar tragedy happening again.

The jury, he said, would be able to make recommendations.

Robin Ritter, was counsel for the coroner, preparing, presenting, and examining evidence. Next to him sat Simone, Cassandra’s sister, and a friend.

In the public seating area behind were more members of the Fox family, including brothers David and Albert, and Casandra’s step-mother, Caroline Mosquito.

Appearing for the Federal Department of Justice, representing the healing lodge, were Julian Nahachewsky and Emily Arthur, counsel for Correctional Service Canada (CSC).

Jessie Buydens and Alyssa Gennrich, from the Elizabeth Fry Society of Saskatchewan, a non-profit advocacy group for women and gender-diverse adults who are criminalized or at risk of criminalization.

At the outset of the inquest, six jurors were selected and sworn in.

Const. Joshua Lee, from Maple Creek RCMP detachment, was the first witness.

He said he was on duty when the call came through in the evening about an incident at the healing lodge. When he arrived, Fox was on the ground on her back as CPR (Cardiopulmonary resuscitation) was performed.

Emergency Medical Services (EMS), from Consul, about 85 kilometres south of Maple Creek, also came and helped.

Asked about his own role, Const. Lee said he looked for signs of a fight, for evidence of weapon, whether there were any marks on Fox, and if she had left notes. He said he also took statements and a set of photographs.

Const. Joshua Lee, who attended the scene, concluded that Fox had died from suicide, using pyjama pants to create a ligature, which was attached to a shelving unit.

“There was no sign of life,” he said.

David Manley, an emergency medical responder from Consul with 32 years of experience, said the call to go to the healing lodge came through at 8.19pm.

At the time, he and a colleague were already on the road responding to another call. They were at Fox’s side by 9.02 pm.

Ritter asked Manley whether the EMS crew would benefit from a LUCAS machine, which is a mechanical device used to deliver automated chest compressions during cardiac arrest. By maintaining optimal rates and depths, it reportedly eliminates rescuer fatigue.

“It would be handy, especially in our remote location,” Manley said.

One of the jurors asked how much a LUCAS machine would cost, but Manley said he did not know.

Juli Schultz, a corrections officer at the lodge, said the facility can accommodate 59 to 60 residents, although at the time of Fox’s death it was “under-populated”.

To promote a positive atmosphere, the term “inmate” was not used. Women were referred to as residents, and corrections officers wore civilian clothes, not uniforms.

Fox had been at the lodge about a month before her death, said Schultz, and was a “very quiet, very nice girl”, who never caused problems.

Asked whether she had looked at Fox’s file, Schultz said there had been no reason to do so.

“I am not sure whether she had problems of mental health or drugs. Nobody briefed me on her having a mental health issue.”

Schultz said formal counting of residents took place four times a day – at 7.30am, 3.45pm, 8pm, and 10pm. There were also informal counts to avoid predictability.

When Fox did not show up at 8.15pm, Schultz went to her unit with another officer, Rebecca Jones, who opened the door and yelled for a “911 tool”, a 3-4 inches long piece of equipment used by first responders for cutting seatbelts or fabric. In this case, it was needed to cut ligature.

Ritter asked Schultz whether she believed corrections officers should carry “911 tools”.

“Yes,” she replied.

After Fox was found in her room, Schultz said she ran as fast as she could to get a “911 tool”, going upstairs and down a hallway. In the rush, she picked up two “911” tools. Returning, she found Rebecca Jones holding up Fox.

Compression began immediately after the ligature was cut, and the corrections manager was called to provide help.

Schultz said she used a defibrillator, whose prompts told her to deliver harder compressions. For 30 minutes, she performed CPR.

“It got very tired. It was very strenuous.”

Dr. Andreea Nistor, a forensic pathologist, performed an external and internal examination of Fox.

Giving testimony via phone, Dr. Nistor said the markings on Fox’s neck were consistent with hanging by ligature, and internal injuries and fractures were associated with attempts at resuscitation.

According to a toxicology report, there was no alcohol or illicit substances in Fox’s blood.

Ritter asked her: “What do you believe was the medical cause of death?”

She replied: “Asphyxiation due to hanging by ligature around the neck.”

The coroner asked how quickly death results.

Dr. Nistor said there was a four to five-minute window before irreversible brain damage and death.

Tia Getz, a corrections officer, spoke about video camera footage of Fox on the day she died.

She said Fox was last seen on camera at 16.58 (4.58pm) entering her living unit.

Earlier, she had been seen leaving the phone room, sitting and talking with fellow residents, and appeared to be upset.

Ritter, after consultation with Simone, asked Getz: “Why didn’t anyone talk to her if she was upset?”

“I don’t know,” Getz replied.

Getz, who said she did not know Fox, testified that she observed the video footage a week after January 18.

One of the jurors asked Getz how long Fox was in the phone room.

“Not very long,” she said.

Hawryluk asked Getz about residents’ access to phones.

Getz said residents had access to three phones between 4pm and 10pm and could could only call those on a pre-approved list.

Rachel Parker, Kikawinaw or director at the lodge (The word Kikawinaw is translated to “mother” in the Cree language), said that staff had acted in a timely fashion and followed procedure after Fox was found hanging from a ligature.

She did not see how the situation could have been foreseen.

Ritter asked whether any policy changes had resulted from the incident. “No,” she replied.

Asked about 911 tools, Parker said there was no current legal authority for staff to carry them.

Ritter questioned her about training for suicide and self-harm cases.

Parker said all staff were up-to-date with training.

“Is one day every two years enough?” asked Ritter.

Parker believed the training was sufficient.

Emily Arthur, counsel for Correctional Service Canada (CSC), handed out documents to the coroner, jurors, Ritter and the Elizabeth Fry Society of Saskatchewan representatives. Each document related to mental health, and showed the checks carried on every resident arriving at the lodge.

One of them was a suicide risk checklist that was completed within 24 hours of a resident’s arrival. Fox arrived at the lodge on December 22, 2022.

Another document was a physical and mental assessment of residents.

In response to Arthur, Parker said a mental health triage was carried out on every new lodge arrival.

In his closing comments, coroner Hawryluk reminded the jury that the inquest was not a trial, and was not deciding on guilt or innocence.

He said any recommendations must be lawful, practical and implementable.

After about two hours of deliberations, the jury returned with their findings and recommendation.

Before closing the inquest, Hawryluk thanked those in attendance, beginning with family members who had sat through two days of testimony.

He later shook their hands, expressing hope that the hearing provided an element of closure.