The jury at a coroner's inquest into the death of a mentally ill inmate at Ottawa's jail has made sweeping recommendations aimed at preventing a similar incident from happening in the future.

Cleve Geddes, 30, died on Feb. 17, 2017, two days after he was found hanging in his segregated cell at the Ottawa-Carleton Detention Centre (OCDC), prompting the province to launch the inquest.

Geddes, whose friends and family called him Cas, had struggled with schizophrenia for about a decade when he was arrested in Killaloe, Ont., in January 2017.

A judge had initially ordered him to undergo a 30-day psychiatric assessment, but there were no beds available.

Geddes was instead sent to OCDC, where he was placed in solitary confinement — a decision his sister, Sigrid Geddes, has condemned as "complete torture."

"He was sleeping on a concrete bed, he had a single blanket and it was five degrees below the regular temperature in the jail and he told guards he was cold," said lawyer Paul Champ, who represented the family at the inquest, on Monday.

"The only human contact he had during the day was a hatch through his cell door. It was inhumane"

Lawyer Paul Champ represented the family of Cleve Geddes at the inquest. (Laurie Fagan/CBC)

After hearing from dozens of witnesses over nine days, the five-person jury made sweeping recommendations directed at OCDC, Ontario Provincial Police (OPP), the Ontario Court of Justice, the Ministry of Community Safety and Correctional Services, the Royal Ottawa Health Care Group, Ontario's attorney general and the Ontario government.

The jury called on OCDC to avoid placing inmates on suicide watch in segregation, in accordance with the ministry's suicide prevention policy, and called on the province to follow through on a bill that would end that practice.

The bill has been given royal assent, but hasn't yet been proclaimed.

"It's sad that they hadn't made those changes before," said Champ.

"But we now have a law that requires them to do it, and we just need the current government to follow through on that."

The jury called for an end to the practice of psychiatric assessments being carried out through a hatch in the jail cell door, and for changes to the jail's phone system so inmates can call out to cell phones, not just land lines.

Geddes's family complained they were unable to receive calls from him because no family member had a land line.

Specialized unit at OCDC

The jury also called for a specialized mental health unit at OCDC as soon as possible, staffed by employees trained to deal with mentally ill inmates.

The jury recommended OPP ensure every uniformed member gets regular training on how to respond to mentally ill subjects, including de-escalation techniques.

The jury recommended inmates awaiting psychiatric assessment should return to court within seven days to make judges aware, and to present another opportunity to find an open hospital bed.

The Royal should evaluate the suicide potential of inmates awaiting a court-ordered assessment, and then draw up a prioritized list of patients, the jury said.

Irene Mathias, a volunteer with the group Mothers Offering Mutual Support, echoed the jury's call for a specialized unit for mentally ill inmates at OCDC, first proposed in 2016. (Laurie Fagan/CBC )

Irene Mathias, a volunteer with an group called Mothers Offering Mutual Support (MOMS), said she's pleased the jury tackled what she called "system flaws that warehouse and incarcerate mentally ill people."

Mathias says inmates and their families have waited too long to see a law stopping the mentally ill from being put in segregation.

"It really sets out a principled framework that allows [the correctional system] to become humane and move into this century," she said.

Mathias also echoed the call for a specialized unit at OCDC, a recommendation first made by a task force in 2016.

"They need to get off their asses and build that thing," she said.

"In the year or more that the plans for the unit have been sitting there, how many people like Mr. Geddes have had to endure segregation cells?"