Sawa inquest produces 23 recommendations

Fewer inmates allowed out of cells at one time, more frequent cell checks and additional video monitoring are among 23 recommendations following the inquest into the death of a Port Colborne man while in the Thorold detention centre. 

46 year old Kelvin Sawa died in hospital 2011 after being beaten and terrorized by fellow inmates on the protective custody range. 

Video evidence showed Sawa being spat on, kicked and hit in a common area after a beating in the shower. 

Inmates forced Sawa back to his cell and given a noose made of a bed sheets and told to use it. 

Guards found Sawa and he was taken to hospital where he died in August of 2011.

An autopsy found the cause of death was multiple organ failure due to hanging.

There was also evidence presented that a corrections officer sparked the attack by telling an inmate that Sawa was charged with sexual assault of a minor.

The inquest lasted 8 days with more than a dozen witnesses offering evidence.