REGINA — The second day of the coroner’s inquest into the death of Kalin Dean Holonics focussed mainly on illicit drugs inside prison walls.
The morning began with testimony from an expert in forensic pathology. Dr. Andreea Nistor performed the post-mortem autopsy on Holonics after he died in cells at the Regina Provincial Correctional Centre on July 9, 2020. A copy of her autopsy report was presented to jurors and entered in as an exhibit in the proceedings. Dr. Nistor’s report found minor bruises and cuts, but “nothing indicating he had been in a major altercation,” she said. What did pique Dr. Nistor’s interest was that Holonics’ lungs were very heavy and congested with fluid buildup, something consistent with drowning, heart failure, or narcotic use.
A further toxicology report ordered by Dr. Nistor revealed “multiple illicit drugs” in Holonics’ bloodstream, including fentanyl and gabapentin. She also discovered that cocaine had been used at some time prior and had been metabolized. Ultimately, Dr. Nistor called the cause of death a drug overdose.
During examination from Nicolas Brown - the lawyer present representing the Holonics family - Dr. Nistor recalled many drug overdoses occurring over the summer of 2020, explaining that from the start of the pandemic, daily autopsies for overdoses were occurring. From a line of questions around blood lividity, Dr. Nistor concluded that Holonics was likely deceased “a few hours” at the time he was discovered by corrections officers. At that point, a “Code Blue” was called and life-saving measures were attempted until EMS arrived, as per protocol within the institution.
Jill Thomson - a nurse for approximately 30 years with 20 of those spent working in corrections - was in the role of transcriber when the Code Blue was called, and reiterated that protocol.
“In the event that nobody is legally allowed to pronounce death, we try to do all interventions possible that would bring back life to a deceased individual,” she said, answering the question of why CPR was performed and Narcan delivered when those responding knew the man was deceased. “I would do everything that is available to me to bring someone back from death.”
The jury also heard from Giselher Reimer, who was the corrections officer on duty during the night shift before Holonics was discovered. A 16-year retired officer, Reimer noted the evening as quiet.
“To me, it was a normal regular night shift, he said, recalling the events of that evening to Coroner’s Counsel Robin Ritter. “Nothing untoward, nothing that would flag my radar or cause concern that something was amiss.”
During the evening shift, Riemer was the guard responsible for doing the night checks on inmates, which at that time occurred at midnight, 3 and 5 a.m. The frequency of those checks has since been increased to hourly during nighttime hours in the wake of Holonics’ death.
Brown provided video footage obtained from the CCTV camera during the night in question, queuing up the check times. In the video, Riemer is seen checking inmate cells, shining a flashlight into the ones without a light on. Each check took only a few seconds - more of a glance.
During his line of questions, Ritter asked Riemer what sorts of things he was trained to look for during cell checks. Riemer replied that he would look for signs of breathing, to see exposed skin, movement and signs of distress.
“I looked into the cell window, I was satisfied that everything was okay,” Riemer said.
One of the jury members asked Riemer what the size of the window on the door of each cell measured, and if they were difficult to see an inmate though. Riemer replied that the windows were approximately four by seven inches, and that “… sometimes it’s a challenge, especially if it’s scratched.”
A number of inmates who interacted with Holonics also provided statements, some from video interviews, who generally noted he was a well-liked person.
“I hope you guys find who brought it in, and I hope they go to jail for life,” said one inmate. “That was my best friend that they took.”
The inquest is expected to conclude Dec. 7 with jurors presenting recommendations to avoid future drug deaths in Saskatchewan jails
