Skye Martin's mother wishes some details of her daughter's death were public

Natasha Martin says she was left "broken" and on a search for answers after her daughter died behind bars in a women's jail last spring.

Some of those answers have now been compiled in a report completed on the deaths of four adults in Newfoundland and Labrador's correctionalsystem since 2017. It was released to the public this week, but with 31 pages removed.

Despite being called "Deaths in Custody Review," there was no information on how the inmates died.

"Some of the circumstances surrounding what happened to Skye should have been in the report," her mother told CBC News on Thursday."To fix something, you have to know what was broken."

She should have been taken back to theWaterfordHospital.- Natasha Martin

Skye Martin died on April 20, 2018, while in segregation at the Newfoundland and Labrador Correctional Centre for Women in Clarenville.

She was alone in a cell at lunch time, unsupervised after having several self-harm incidents in the days before her death. Police said she choked on a sandwich, a detailthat does appear in the unredacted version of the report provided to the families.

A witness told CBC News that Martin was banging on the door of her cell before she died, prompting guards to run down the hall towards her. Minutes later, an ambulance arrived and paramedics began working on her. She was pronounced dead at the local hospital at 3:30 p.m.

Why was Skye Martin in jail?

Natasha Martin believes her daughter shouldn't have been locked upin a correctional facility after two self-harm attemptsearlier in the week.

"She should have been taken back to the Waterford Hospital," Martin said.

"She was discharged from the Waterford and sent to Clarenville. So they were aware that she had a mental illness. When she was showing these signs, the Monday, there was an incident where she was taken out of the prison and brought to the hospital and brought back to the prison.

"Tuesday, there was another incident where she was taken out of the prison to the Clarenville hospital, seen by a doctor and sent back to Clarenville. Why, why? There was two opportunities there for somebody to recognize there was mental health issues, but nothing was done."

Changes to health care caused distress, mom believes

Martin said her daughter's mental health care changed after she left the psychiatric hospital in St. John's.

"Skye left the Waterford with a diagnosis. Bipolar. And a list of medications. Those medications were changed, altered while she was in Clarenville. The change in the medication went hand-in-hand with the increase in her mental health distress. One was reduced and the other one escalated."

[Dr. Craig] said he may have seen patient release documentation once or twice in his career.- Death in Custody Review

The report found communication between doctors at the Waterfordand medical staff in the prisonhas been lacking for decades.

According to prison doctors, there is little or no documentation sent to them after a patient is transferred from the Waterfordto the correctional system.

Duringthe review process, Dr. David Craig, the primary psychiatrist in the province's jails for more than 20 years, said he "may have seen patient release documentation once or twice during his career."

Nurse practitioners in the correctional systemtold the review staff there is "limited documentation" provided to them from the hospital, aside from a note with a list of medications and follow up appointments.

This section of the review was disputed by Dr. Nizar Ladha, a forensic psychiatrist at the Waterford, who said there is a discharge letter sent to the jail superintendent for each patient transferred to a correctional centre, which states his or herdiagnosis and treatment plan.

The superintendent denied ever seeing discharge letters.

Whether a lack of communication led to changes in her daughter's health care, Natasha Martin didn'tsay.

But when asked if those changes led to her death,she tooka second to exhale.

"She was well enough to leave the Waterford and a month later a month later I was saying goodbye to my child," she said.

"I'm broken. Heartbroken. When I lost Skye, I had so many questions."

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