Jury makes recommendations for coroner’s inquest into 2016 death of incarcerated Orangeville woman

February 15, 2024   ·   0 Comments

By Paula Brown, Local Journalism Initiative Reporter

A coroner’s inquest examining the 2016 death of Terry Baker, an inmate at the Grand Valley Institution for Women in Kitchener, has concluded with more than 65 recommendations made by the jury. 

The inquest into the death of Baker, who was serving a life sentence for the first-degree murder, came to an end on Friday (Feb. 9) after three weeks of testimonies, in which the jury heard from approximately 18 witnesses. 

“I urge you to carefully consider the recommendations proposed. An important component of the inquest process is the ability to propose changes to policies, procedures and legislation, which if implemented, could prevent deaths in similar circumstances in the future. For each recommendation you’re considering, ask yourself, why should we make this recommendation or adopt a suggestion” said Dr. David Eden, the presiding officer of the Office of the Chief Coroner, to the jury.

The jury returned with a ruling that Baker’s death was a suicide by self-strangulation and provided a total of 67 recommendations to prevent similar deaths in prisons. 

Baker, who was 30 years old at the time of her death, died on July 6, 2016, after being found unresponsive in a segregation cell at the Grand Valley Institution for Women in Kitchener. Baker was found with a ligature around her neck made from a piece of her sweatshirt. She was transported to St. Mary’s General Hospital in Kitchener and later pronounced dead.

A coroner’s inquest to examine the events 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. 

Recommendations Made to Better Address Mental Health Care in Prisons 

In their first recommendation, the jury asked the Minister of Public Safety and the Commissioner of the Correctional Service Canada (CSC) to publicly acknowledge that its institutions are not an appropriate setting for people who have a severe form of mental health or are at risk of suicide and self-harm.

The jury added that behaviours of self-harm and suicide attempts should be treated first with a health-focused response rather than a security-directed response. 

Another recommendation from the jury included that the federal government create an independent oversight body to assess and evaluate the health care processes of people with serious mental health illnesses in federal corrections.

It was also recommended that there be adequate resources and 24/7 on-site mental health services for people in custody in place at all CSC facilities. 

The jury included a recommendation regarding the language used by staff engaging with individuals who are self-harming, specifically no longer referring to them as “instigators” and their behaviour as a “disciplinary problem” or “misconduct”. 

The jury also added that CSC’s health services sector should hire more qualified health care professionals, including psychotherapists, psychologists, and psychiatrists with first-hand experience managing individuals with borderline personality disorder. 

Why a Coroner’s Inquest is Mandatory 

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

“This is because persons in custody are deprived of their liberty,” said co-counsel, Kristin 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. 

During a coroner’s inquest, the role of a juror is not to make a finding of guilt or innocence but rather to hear the evidence from witnesses and provide recommendations to avoid similar deaths in institutions.  

History of Self-harm and Day Before Death

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 her participation in the 2002 murder of Orangeville teen Robbie McLennan.

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.” 

The jury was told on the first day of the inquest, 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 a 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.  


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

Baker 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. Another 16-year-old – never identified under the Youth Criminal Justice Act – was convicted of second-degree murder and sentenced to 18 months.

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