The jury hearing testimony at a coroner’s inquest into the jail death of a mentally ill man is recommending giving prison staff better training in recognizing suicide signs, removing “anchor points” from cells, and exploring a province-wide electronic health records system that would give jails access to inmate medical records.

The five-day coroner’s inquest probed the circumstances behind the hanging death of Zlatko Sego in the now-closed Toronto (Don) Jail on April 19, 2012. Three days before, Sego, who suffered from paranoid schizophrenia, had fatally beaten his 79-year-old father in the family’s High Park home.

Related: The last days of Zlatko Sego, who took his life in the Don Jail

After roughly two hours of deliberations Tuesday, the five-member jury returned a list of five recommendations. In addition to improvements to training and the removal of “anchor points” where inmates could affix something to hang themselves with, they recommended that all new people being admitted to jail be seen by health-care staff before they’re sent to their cells.

The recommendation for an electronic health records system stems from inquest testimony about the lack of a centralized pharmaceutical database that would allow prison staff to get up-to-date information about an inmate’s prescriptions and needs. British Columbia’s system already allows for such access.

Linda Ogilvie, manager of corporate health at Ontario’s Ministry of Community Safety and Correctional Service, told the inquest last week that the inability of prison staff to access information about a prisoner’s medication means they must rely solely on inmates to come forward with information about which drugs they are taking.

At present, “If somebody doesn’t tell us they’re on medication, we have no way of knowing,” Ogilvie said.

The recommendations followed witness testimony that revealed numerous ways in which the correctional system did not properly care for Sego. He had been identified as a suicide risk by hospital staff and Toronto police, and a justice of the peace recommended that he be seen by medical staff one day prior to his suicide.

Among the inquest’s revelations:

Sego was the sole new Don Jail inmate on April 18, 2012, who did not see a nurse for medical attention.

Two prescriptions written for Sego on the day he was arrested were not delivered to the jail until after his death.

The Don’s mental health unit, staffed by a dedicated mental health nurse, was full the night Sego arrived.

The recommendations will now be sent to Ontario’s Ministry of Community Safety and Correctional Services. The ministry is not obligated to implement them.

Sego’s sister, Nada, was present every day of the inquest. Though pleased to see movement towards ensuring the circumstances surrounding her brother’s death are not repeated, she has doubts about the actual impact of the recommendations.

“Common sense would dictate that a lot of this could have been prevented,” she said. “The suggestions, of course, are fruitful, but I do keep in mind they are only suggestions. They’re not something that will be executed necessarily.”

Over the course of the inquest, jurors also heard about improvements in the care for mentally ill inmates made in the two years since Sego’s death. Ogilvie said that at the newly opened Toronto South Detention Centre, which now houses some of the offenders who would have been sent to the Don Jail, numerous changes have been made to increase inmate safety.

The jail was built so there are no anchor points in the cells. Any hooks present in rooms are constructed to collapse after more than roughly four pounds of weight is applied.

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Ogilvie said the layout of the new jail is designed so that new inmates being processed through the jail’s admissions and discharge unit are seen by a nurse prior to being sent to their cells.

It is also now mandatory for Toronto South jail staff to ask specifically about the inmate’s history of suicide and self-harm during processing, she said.

Additionally, staff are encouraged to run through a suicide checklist — a list of questions to determine if there is risk of self-harm — with already processed inmates who may have just received bad news, or are returning from a court date that produced what the inmate sees as a negative outcome.