A three-day inquest into the death of 31-year-old Robert Wayne “Robbie” Slatten wrapped up Friday with recommendations aimed at preventing inmate deaths.

Slatten was found unresponsive in his cell at Fraser Regional Correctional Centre in Maple Ridge shortly before 7 p.m. on Oct. 19, 2010. It was determined he died of acute methadone intoxication.

The coroner’s jury heard that, on the morning of the day he died, Slatten stole his cellmate’s identification card and presented it to the nurse who was administering medication to inmates who were part of the methadone program.

The nurse, who was on her second day on the job, checked the card and gave Slatten the methadone meant for his cellmate.

Every 45 minutes officers looked through a window in his cell door. Each time, they saw him apparently sleeping.

Around 6:40 p.m., an inmate told the officers that Slatten was sick. When the officers went to Slatten’s cell, they found him unresponsive. He was declared dead shortly after 7 p.m.

The jury recommended six changes that include that correction officers should be more vigilant about checking on the well-being and level of consciousness of inmates in the hours following administration of methadone or any other narcotics.

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The other recommendations include:

• Log-book entries regarding inmate checks should be descriptive, with details on inmate position and chest or breathing movements, rather than the entry “visual check.”

• Correctional officers should help health-care staff correctly identify inmates before medication is dispensed.

• B.C. Corrections should train front-line staff to reinforce existing policy and procedures with respect to methadone and follow it up with careful on-site monitoring.

• B.C. Corrections should discontinue the practice of asking the RCMP to notify next of kin following an unexpected inmate death and implement a policy of delegating a specific staff member to perform this function in “an expeditious and compassionate manner.”

• Police should be required to conduct a comprehensive investigation into the unexpected death of any B.C. Corrections inmate, which includes interviewing all individuals who were directly involved.

The jurors classified Slatten’s death as “undetermined.” The other classifications available are accidental, homicide, natural, and suicide.

-Jennifer Saltman is with The Province