A coroner’s inquest is calling for stronger suicide‑prevention measures in New Brunswick’s health‑care and correctional systems.
The inquest examined the death of Jean‑Martin Couture, who was found unresponsive in his cell before being taken to the Campbellton Regional Hospital.
He was later transferred to the Dr. Georges‑L.-Dumont University Hospital Centre, where he was pronounced dead on Sept. 25, 2025.
The Office of the Chief Coroner says the jury classified the death as a suicide.
The five‑member jury heard from 11 witnesses during the proceedings at the Campbellton courthouse, according to the coroner’s office.
Inquests do not assign blame or legal responsibility. They present evidence publicly and can lead to recommendations aimed at preventing similar deaths.
The jury recommended that Vitalite Health Network add a list of suicide‑risk factors and protective factors to its assessment documents within three months.
Jurors also said Vitalite should complete a new suicide‑risk assessment after any transfer between units or any event that could increase a person’s risk.
Another recommendation calls for the Dalhousie Regional Correctional Centre to replace any grab bars in high‑risk areas with anti‑suicide, or anti‑ligature, versions within six months.
The coroner’s office says the chief coroner will forward the recommendations to the appropriate agencies.
Their responses will be included in the chief coroner’s annual report for 2026.
