A five-person jury at the coroner’s inquest into the death of 55-year-old Mario Hamel has made a number of recommendations on how to prevent similar incidents in the future.

Hamel used his shirt to hang himself while in the custody of London police in November 2010.

Clearly intoxicated, he had been picked up for liquor law violations just hours earlier, so he could sober up in a cell at police headquarters.

The inquest has heard that police records showing Hamel was checked every 20 minutes by police cadets as required were inaccurate.

Video evidence shows that he removed his shirt just before 3 a.m., and was lying lifeless on the floor ten minutes later. His body wasn’t found until over an hour afterwards, just after 4 a.m.

London police implemented a number of changes after the incident including an electronic system for checking cells that requires cadets to touch a wand to multiple points in a cell’s area to ensure no one is missed.

But Wednesday, after only three days of testimony and deliberation, the jury delivered eight additional recommendations.

Some of the suggested changes include:

  • better communication with inmates when they’re being booked on what charges mean
  • cell choice made by a senior officer, not a cadet
  • 24 hour monitoring of video surveillance of inmates
  • light and/or sound alarms if an inmate’s cell is not checked

But Roseena Baksh, Hamel’s wife, says justice hasn’t been served, “I lost my husband, I lost my happiness, I lost my life, I lost everything.”

While Ontario’s Special Investigations Unit cleared London officers of wrongdoing in 2011, Baksh thinks the cadet, now a constable, who forgot to check on Hamel should face punishment.