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Coroner’s inquest into 2016 death of Grand Valley Institution for Women inmate underway

January 25, 2024   ·   0 Comments

By Paula Brown 

A coroner’s inquest examining the 2016 death of Terry Baker, an inmate at the Grand Valley Institution for Women in Kitchener, is underway. 

Baker, who was 30 years old at the time of her death, was serving a life sentence after pleading guilty to her part in the 2002 murder of 16-year-old Orangeville teen Robbie McLennan. 

Baker was convicted of first-degree murder in 2006 and handed a life sentence without the eligibility of parole for 10 years. Her then 20-year-old boyfriend, William Bronson Penasse, also pleaded guilty to first-degree murder in 2005 and was sentenced to life in prison without the eligibility for parole until 2030. Another 16-year-old – never identified under the Youth Criminal Justice Act – was convicted of second-degree murder and sentenced to 18 months. 

A coroner’s inquest to examine the event surrounding her death was announced in 2017 by then regional supervising coroner, Dr. David Eden, and was delayed due to the pandemic and receiving documents from Corrections Canada. 

A coroner’s inquest is mandatory under the Coroner’s Act. 

History of Self-Harm Behind Bars

Co-counsel Kristin Smith shared details about Terry Baker’s life prior to incarceration and the decline of her mental health while behind bars. 

Baker experienced many challenges as a young person, including substance use issues that started when she was 13 years old, bullying, sexual assault, and self-harm. Before incarceration, she left her adopted family and lived with acquaintances or at shelters. 

Baker was diagnosed with borderline personality disorder, also known as BPD, and had low-level cognitive function consistent with fetal alcohol spectrum disorder. 

She received psychiatric treatments and was prescribed several psychotropic medications, including anti-depressants, mood stabilizers, antipsychotics, anti-anxiety medication and medication for ADHD. 

She reportedly felt remorse and guilt over participation in the murder. 

During her time in custody, Baker experienced deteriorating mental health. The jury heard she tried multiple times to kill or seriously harm herself by swallowing batteries, drinking cleaning products with bleach, cutting herself with a razor, banging her head, and tying ligatures around her neck. 

Baker was repeatedly put into isolation under suicide watch, placed in restraints and had her possessions limited or taken away. Correctional staff were recommended not to give attention to her self-harming behaviours so it “doesn’t get reinforced.” 

Days Leading up to Baker’s Death 

Baker spent more than a decade at the Grand Valley Institution for Women in Kitchener, with intermittent stints at the Institut national de psychiatric legale Philippe-Pinel in Montreal and the Regional Psychiatric Centre in Saskatoon. 

The inquest was told that about 10 days before Baker’s death, she had become upset after a visit from her mother. When she made threats to kill a staff member, Baker was placed in a segregation cell. 

On June 27, she was found unresponsive on the floor of her cell in the segregation unit with a ligature around her neck. Correctional staff performed life-saving measures, and Baker began breathing on her own again. The jury was told that she was moved from the segregation cell into an interview room, where she tried to bang her head against the wall. Baker was placed on a high suicide watch and kept in restraints for approximately 20 hours, during which time she continued to attempt to bang her head. 

On June 29, Baker’s status was changed from high to moderate suicide watch with constant observation by camera. She was continually observed on camera by correctional officers over the Canada Day long weekend. 

The following Monday (July 4), staff met to discuss whether she should stay in segregation. It was ultimately decided to remove her from segregation the next day. She was also taken off modified suicide watch, and her status was changed to mental health monitoring, with staff checking every 30 minutes. She was no longer being observed by correctional officers, but cameras were still recording the activity in her cell. 

On July 4, shortly after 8:30 p.m., an officer saw Baker lying on her back on the cell floor. Baker had a ligature tied around her tied around her neck and wasn’t breathing. 

Baker was transferred to hospital and died two days later, on July 6, after being removed from life support.  

Ashely Smith Similarities

Baker’s death at the Grand Valley Institution for Women occurred nine years after another inmate, Ashley Smith, died while in custody. 

The 19-year-old died after tying a ligature around her neck while under direct camera observation from correction staff, who were told not to intervene. 

Smith’s inquest led jurors to provide 104 recommendations to Correctional Service Canada (CSC) to address similar issues being explored in Baker’s inquest. 

“Ms. Smith’s death shone a bright light on CSC shortcomings in balancing the requirements for operational security and to provide every inmate with essential mental health care.” 

Recommendations

The inquest is expected to span three weeks, during which the jury will hear from approximately 18 witnesses. 

Inquests are mandatory by law whenever a prisoner dies from non-natural causes while in custody. 

“This is because persons in custody are deprived of their liberty,” said Smith. “They are under the control of the state and it is the state that is responsible for keeping them safe.” 

“As a society, it is up to us to ensure that non-natural deaths in correctional institutions are not covered up, overlooked or ignored,” she added. 

Dr. David Eden, the presiding officer of the Office of the Chief Coroner, explained what the jury’s role will be over the three weeks while they hear from witnesses and are presented with evidence from Baker’s death. 

The jurors will not be making a finding of guilt or innocence during the inquest; instead, they will be looking at the facts surrounding Baker’s death and will come up with recommendations to help prevent similar deaths from happening in the future. 

The inquest is being conducted by video conference. Members of the public who wish to view the proceedings can do so live via – firstclassfacilitation.ca/office-of-the-chief-coroner/inquest-into-the-death-of-terry-baker/.

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