On Oct. 18, Mr. Pickering was rushed to Peebles Hospital from HMP, where he was pronounced dead the following morning. The cause of his death is still unknown.

At the time, Acting Superintendent Leslie McMaster was “off island,” according to Mr. Gregg’s testimony, and he was left in charge of the prison.

Mr. Gregg also testified that some necessary procedures were not followed on the day of the death, but their omission was not mentioned in a final report that he presented to Mr. McMaster when he returned to take over the case three days after Mr. Pickering’s death.

After being notified that Mr. Pickering had been rushed to the hospital at around 9 a.m., Mr. Gregg testified, he got to the prison about a half hour later to send a security team to be present at the hospital with the prisoner.

Mr. Gregg agreed that ensuring the prisoner’s medical file went with him to the hospital — which it didn’t — would have been “very important,” but he testified that he didn’t check to see if the prisoner’s records had travelled with him.

He also said he didn’t call the prison nurse or doctor.

After checking Mr. Pickering’s cell at about 9:40 a.m. to see what might have caused him to collapse, Mr. Gregg testified, he learned that the prisoner’s cellmate was present at the time. He neglected to speak with him — though, in retrospect, doing so would have been “very important,” he conceded.

Asked by Crown Counsel Valston Graham why he overlooked these steps, then left them out of a written report, Mr. Gregg answered, “No special reason.

“For instance, sometimes an incident happens at the prison and you don’t think it’s that serious. … Some things might be overlooked.”

Continuing, he testified that he also did not check the prison’s surveillance cameras, or follow up with investigations after learning of the inmate’s death later that night.

Mr. Gregg further testified that he returned to the hospital at about 9 p.m., because an officer there called and said Mr. Pickering had died.

He then spoke to a doctor who said, “She contacted [the] inmate’s mother and reported the death,” he testified.

Asked by the Crown counsel if he checked to see if anyone had been notified, he answered, “No, sir.”

“I knew it was a fault, but the doctor said she already called,” he continued.

In his report, Mr. Gregg testified that he found all seven officers on the scene had “complied” with proper procedures, but he left his own inconsistencies out.

Asked by Coroner Valerie Stephens if he ever found the case to be serious, he responded, “It was serious when he died.”

The full story appears in the Nov. 19, 2009 issue.