Everyone knew Zlatko Sego needed help. Even Zlatko Sego.

Barely 24 hours after attacking his father, the 39-year-old sat in a room in the St. Joseph’s Health Centre psychiatric unit, speaking insightfully about his broken mind.

“I was very scared and I couldn’t do anything about it,” Sego told the doctor conducting a mental assessment on the afternoon of April 17, 2012. “I think the voices were controlling my body . . . There I was attacking my father in the room, punching him very violently.”

The previous morning, Sego, who suffered from paranoid schizophrenia, believed his father was an “evil Nazi” trying to kill him. The six-foot-four, 250-pound man repeatedly pounded his dad’s head with his bare fists, a beating that eventually ended the 79-year-old’s life. He then wandered around their High Park home breaking religious crosses and attacked his 69-year-old mother, the voices telling him she was a Neanderthal.

But his mind felt clear now, the voices were quiet, and reality was sinking in.

“I feel very bad about what act I did,” Sego told the doctor. “I think my sister hates me for that.”

“Would you do anything to hurt yourself?” the doctor asked. A hospital record from the previous day noted that a dazed Sego had admitted to thoughts of suicide by hanging in a garage.

“I might commit suicide,” he answered. “I feel I need a lot of help here.”

In two days’ time, a Toronto (Don) Jail correctional officer just starting his shift would deliver breakfast to Cell 4, segregation unit 1B, and find Sego hanging from the dingy room’s metal bunk bed, a sheet tied around his neck.

Despite hospital staff instructions that Toronto Police keep Sego under suicide watch.

Despite Toronto Police flagging him as emotionally disturbed and potentially suicidal on documents delivered to the Don jail.

Despite an Old City Hall Justice of the Peace writing “requires medical attention” on Sego’s court papers hours before he went to prison.

Despite the hospital providing him with a prescription for medication to ease his mind behind bars.

Despite the Don having a dedicated mental health wing, despite the jail practice that a nurse examine each new prisoner before bed, despite an alert on Sego’s inmate card stating he required mental-health care.

Despite it all, Sego — a mentally ill man with no criminal record — was the only new inmate not medically examined on the night of April 18. He was not provided with his prescribed medication. And he was not placed on suicide watch or even in the Don’s mental health section.

Despite it all, Sego succeeded in killing himself just 12 hours after arriving in prison for the first time in his life.

A coroner’s inquest is now examining the circumstances of Sego’s death. Testimony this week revealed an alarming confluence of events and errors that allowed Sego to slip past many of the checks intended to keep him safe.

Based on inquest testimony, health documents provided by the family and interviews, the Star has reconstructed Sego’s final days.

It is 4:30 a.m. on April 16, 2012, and Zlatko Sego can’t sleep, again.

Five months before, the effectiveness of his long-time antipsychotic drug Zyprexa wore off and he was switched to medication that gave him insomnia. He was getting three, maybe four hours of sleep a night.

Nada, his younger sister, is up too. An early riser, she usually leaves for her job as a social science teacher at Brebeuf College School at around 6 a.m. She tells her brother to fix himself a snack and try to go back to sleep.

Nada, 39, has lived with her brother, her father, Ivan, and her mother, Violet, her whole life, in part because of her brother’s disease, which struck when Zlatko was in his early 20s. Once a healthy, artistic young man studying graphic art at George Brown, Zlatko began to withdraw, began acting out of character.

At 21, he ran away from home and was picked up by police after trying to enter the house of a woman he wrongly claimed was his girlfriend, Nada says. He tried to attack his mother.

Nada was just 19 then, and she recalls watching him during a psychotic episode visibly shaking, staring intently at the ceiling.

“I could tell he was no longer the brother I knew,” she says.

The diagnosis — paranoid schizophrenia — was a blow for the family, which had no known history of the illness. But when the correct medication and dosage were found, life continued on as well as it could. The side effects of the drugs, including sleepiness and lethargy, made Zlatko unable to work or drive, and he went on disability.

Nada completed a teaching degree, ultimately becoming the family bread winner and, alongside her mother, caregiver to her brother and her aging father. The months leading up to the attack were a particularly challenging time at home: Ivan’s health was rapidly deteriorating, and he was requiring more and more help with daily living. The family began discussing placing Ivan in a home.

Zlatko, too, helped out with his father when he could, sometimes accompanying him in a cab to his various appointments. On April 16, it was his turn to take his father to a 9 a.m. appointment. On her way out the door that morning, Nada told him not to forget.

But just moments after she left, Zlatko began beating his father.

Downstairs, Violet has just woken up and she encounters her son as he comes down the stairs. He begins pounding on her, breaking her wrist and thumb as she raises her arms in defense.

Then, at 6:30 a.m., Zlatko calls police.

“(Patient) says he called 911 after he had an argument with his parents and felt homicidal towards them,” reads a hospital report written that day. “Said he had a psychotic episode and needed to be in a hospital.”

Zlatko is arrested under the provincial Mental Health Act, which gives police powers to apprehend someone who, due to a mental health issue, is a danger to himself or others. By 8:10 a.m., he is being examined at St. Joseph’s, the doctor ruling he is suffering from a mental disorder that “will likely result in serious bodily harm to himself” or another person.

Just as she is beginning her first-period class at 9 a.m., Nada is paged by the school office. Her mother is on the phone, her voice shaking.

“Zlatko just had a relapse,” Violet tells Nada. “You need to get here right now.”

Nada rushes to St. Joseph’s, where her entire family has been admitted — Zlatko in the mental health crisis unit, Violet in the fracture clinic and Ivan in the ER.

Her father is the first she sees. He lies on a gurney, one eyelid open and the other closed, a massive purple bruise on his forehead. When Nada asks what happened, his speech is garbled. He is soon transferred to Toronto Western Hospital for more tests and treatment.

When she is told she cannot presently speak to her brother, she finds her battered mother, with her right arm in a cast and extremely stressed. As soon as Violet is cleared to leave the hospital, Nada takes her home. Both women are reeling.

At 4 p.m., the phone rings. Nada is both relieved and upset to hear Zlatko’s voice. Though she knows the disease is to blame, she struggles to control her anger toward him.

“I was asking him what happened?” she says.

“He kept telling me on the phone — and this was out of character — ‘I love you. I love you. I love you.’ ”

Police return to the Sego residence on the morning of April 17. The home on Glenlake Ave. has become a crime scene.

Ivan has been declared brain dead and is being kept on life support only until Nada and Violet can say goodbye. His imminent death means Zlatko will be charged with second-degree murder. For the attack on his mother, he will be charged with assault causing bodily harm.

Zlatko has spent the night at St. Joseph’s. Medical staff monitoring him in the morning note he has been walking back and forth in his room. That afternoon, he is in taken for a psychiatric assessment.

There, Zlatko tells the doctor that the voices inside his head have been getting louder for months. In the two weeks before the attack, he has gone through what he calls a bout of “vicious paranoia.”

According to the doctor’s notes and hospital documentation, as Zlatko and the doctor are discussing whether he might harm himself, two Toronto police officers interrupt. They lead Zlatko away in handcuffs.

“Would not let me speak further to the patient or to explain why they’re here,” the doctor notes in a rushed scrawl.

(As the inquest is ongoing, spokesperson Mark Pugash said Toronto police could not comment on the doctor’s suggestion police barged in).

“Patient is on ‘suicide alert’ while in police custody,” reads the final line in the hospital record, which shows Zlatko being discharged at 3:45 p.m.

From there, Zlatko is taken to 11 Division police station, near Davenport and St. Clair, where he is booked.

According to inquest testimony by Toronto Police Det. Ryan Miller, the lead investigator of Zlatko’s death, officers performing a strip search find a prescription for two medications. Miller told the inquest he did not recall which medications.

Hospital documents show that just prior to Zlatko’s arrest, a doctor wrote him a prescription for Seroquel, a drug often used to treat severe mental disorders, including schizophrenia. “For agitation,” the doctor noted.

His file also shows Zlatko was on two medications at the time of the attack: risperidone, an antipsychotic, and lorazepam, which treats anxiety.

At the station, an officer runs through a health checklist with Zlatko, during which time he admits to having harboured suicidal thoughts in the past. On the prisoner information form — which documents pertinent health information — the officer checks off the boxes next to “potentially violent and suicidal” and “emotionally disturbed person.”

That night, as Zlatko sits in an 11 Division holding room, an unmarked police car picks up Nada and Violet from a friend’s home in Brampton, where they are staying.

Brought into 11 Division for questioning, mother and daughter testify to Zlatko’s devotion to his parents when healthy, to the hideous hold the disease can have on him, to his innocence.

“We told them we put no responsibility on him for doing what he did,” Nada says.

She and her mother leave as soon as the interviews are done, she says, unaware that Zlatko is in the station.

As sometimes occurs when an accused has court in the morning, Millar says, Zlatko spends the night at the station.

Just before 8 a.m. the next day, Zlatko is brought to Old City Hall for a show cause hearing, held so the Crown can demonstrate reasons why the accused should be held in custody until trial.

Appearing before Justice of the Peace Leslie Anne Kirke, Zlatko looks disoriented, his white prisoner’s sweater torn at the left shoulder. He is remanded to the Don Jail, with a note written on the side of the court record: medical attention is required.

Don Jail nurse Angela Kroher looks at her list of new inmates to examine. At 25, it is roughly double the night shift average.

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The sole nurse working in the jail’s admission and discharge unit — known as the A and D — on the night of April 18, 2012, she knows there is no way she can get off at 10:30 p.m. It would be overtime, again.

Before its closure in December, 2013, the Don was a remand jail, a prison where a person facing charges went before getting bail or while awaiting trial. So the population was in constant flux. The average length of stay was one week.

Each day, as many as 70 inmates could cycle through the A and D. The unit consisted of six holding cells where inmates were housed together, their restraints removed. As time ticked by inside, volume and tensions rose.

At the usually overcrowded jail, it could take hours for new inmates to check in. Offenders would have to be processed in the jail’s internal database, have their possessions catalogued and be examined by a nurse who, among other things, would ask about mental health challenges..

Inmates would also be placed in a cell. Within the five-storey building, cells were divided by classification. There was general population, the medical range for patients with physical issues (broken legs, diabetes, those coming off drugs), special needs for patients with mental health challenges and served by a mental health nurse, and segregation, often for inmates who could be harmed by others because of their alleged offences (usually involving children).

Segregation was also where inmates placed on suicide watch would be held. Those inmates would be clothed in a one-piece, fire- and tear-proof uniform, called a “baby doll.” They would be given a mattress made of the same material and fed finger food so they would not need utensils.

Inmates in general population were checked on every 30 minutes, those in segregation and special needs every 20 minutes, and those on suicide watch, every 10.

There was no exact science to cell assignment. Typically, it was the supervisor, the A and D sergeant, who placed an inmate on suicide watch.

It is 8:30 p.m. when Sego arrives at the jail, as correctional officer Donovan Ellis is nearing the end of his shift. It’s not clear what caused a delay in transporting Sego from court to prison.

As the A and D “booker” that night, Ellis is the first to speak to Sego. As he processes him, Ellis notes that Sego’s warrant flags him as violent, with suicidal tendencies.

At the inquest, Ellis said he could not recall if the paperwork filled out at 11 Division stating Sego was emotionally disturbed and was a suicide risk had arrived that night. Human error meant it sometimes arrived the next day, he said.

Ellis then goes through a suicide checklist, asking Sego if he’s suicidal or has tried to kill himself in the past six months. He denies both. Ellis documents that Sego is not crying and does not appear to be in emotional distress.

“He just looked like the average normal inmate,” he said. “There was nothing that raised any flags for me.”

Around this time, Sego is taken to have his possessions catalogued. It would have been at this stage that his prescription would be taken, scanned, and passed along to medical staff.

But an officer marks “no property” on Sego’s declaration. By this time, the prescription is gone.

Some around 9 or 10 p.m., floor supervisor Lawton Calendar places Sego in a segregation room. He has noted that Sego has mental health challenges — a murder charge as a first criminal offence is alarming in itself — and he wanted to place Sego in the “special needs” unit.

But it is full tonight, as was often the case in the Don’s last two years operating. There were 36 beds, but it was not unusual to have 50 or 60 inmates who required them.

Still, Calender wanted to personally observe Sego’s mental state, so he accompanied him to the cell. Sego engaged him in conversation, the men discussing soccer and the Croatian origin of Sego’s name. Calendar notes Sego is not withdrawn and is making eye contact.

“To me, he was all there, not in any distress,” he said.

Sometime before midnight, nurse Kroher checks her list again. She has examined 24 inmates. There is one left: Sego. She approaches Calendar and learns he has already been taken to a cell.

Calendar considers. It is late, and the jail is on nighttime lockdown. Any prisoner removed from a cell at this hour can cause a disturbance for an entire cellblock.

He opts to leave Sego in his cell, and Sego’s name is placed on a list for the doctor to see in the morning.

Calendar is not concerned that the inmate had not received medical attention tonight.

“I figured he’d be seen first in the morning.”

Dressed in his orange prison jumpsuit, Sego sits on the bottom bunk, his hands to his side. It is 9:10 a.m. on April 19.

Correctional officer Bruce Chin has just started his shift and is making his first patrol of the cells in segregation area 1B. When he arrives at cell 4 — a dingy, eight-by-eight-foot room with a paint-chipped metal bunk bed — Sego inquires about breakfast. He is hungry.

Sego’s voice is steady, neither high or low, and he does not show any signs of distress. The officer leaves to get breakfast.

When he returns to the room at 9:25 a.m., Zlatko is strung up from the top rung of the bunk bed, a bed sheet tied around his neck. Chin calls out to his partner — “he’s hanging.”

A medical alert immediately sounds throughout the jail, prompting correctional officers and medical staff to descend on the tiny room.

Among the first to arrive is a correctional officer trained in the use of a 911 knife, a hook-shaped blade sharp only on the inside edge, so it can slice through a ligature without cutting skin.

He and Chin hold Sego up, trying to relieve the pressure on his neck, and begin cutting him loose. Sego is placed on his back. He is not breathing. He has no pulse.

Nursing staff begin CPR, then the fire department takes over. A defibrillator is brought to the room, but never used — the machine kept advising not to shock him.

By 10:15 a.m., Zlatko is declared dead.

Two hours later, as Nada and Violet are about to leave the house to visit Zlatko in jail, the Toronto police arrive. They are told to sit down.

“It was a complete nightmare. I was living a nightmare,” Nada said of hearing of her brother’s death.

“I remember telling the police: ‘this sounds like negligence. Where was the monitoring?’”

She began immediately began comforting Violet, who was in pieces. Zlatko’s death, Nada says, “was the beginning of the end for her.”

She died of cancer in March, 2013. In the span of one year, Nada’s entire family was gone.

There is no reliable way to ensure no one kills himself in jail. Even inmates on suicide watch at the Don found ways.

Some have attempted to strangle themselves in the arm sleeves of their “baby doll” uniforms. They have banged their heads on the walls, or jumped off the toilet and hit the ground, hard.

Asked by a juror at the inquest if he could have done anything differently to save Sego, Calender replied that it was difficult to say.

Some inmates will admit to thoughts of harming themselves if they are asked. Others, he said, will keep quiet if they are “hell-bent” on it.

In situations like Sego’s, Calendar said, “it’s hard — because he showed no signs.”