Federal correctional investigator Howard Sapers said Wednesday that corrections staff did not "make any attempts to save human life."

He also found that officials at Warkworth Institution, 180 kilometres northeast of Toronto, failed to probe complaints of staff racism made by workers and inmates.

Blackwind, a 52-year-old aboriginal, was serving a 17-year manslaughter sentence for the beating death of his common-law wife, Kathleen Hart.

Sapers' report concludes Blackwind was left alone, locked in his cell and largely unmonitored for 30 minutes after pressing an emergency alarm. He had sliced into an artery in his left arm with an undisclosed object.

Four prison staff directly involved were suspended without pay for 10 to 20 days. But the report says the correctional service was less than satisfactory in its response to the incident - and it's not the first time.

"Yet again we find that the correctional service falls short in its legal mandate to preserve life and quickly act on recommendations related to inmate deaths," Sapers wrote.

"We will continue to see tragic deaths like this until the Correctional Service implements corrective action in all its institutions to improve mental health services, address the program needs of inmates and improve staff responsiveness to emergency situations."

Sapers doesn't name Blackwind or the prison in his report because of privacy restrictions. But the dates and details match public accounts of Blackwind's death and an imminent coroner's inquest.

Sapers stressed that the correctional service is required by law to provide a safe environment for all inmates and staff. More support for prisoners with mental health issues, for example, is still badly needed, he said.

His findings "continue a well-documented pattern" of in-custody deaths from multiple sources, he said.

"What is perhaps the most disturbing to me is that this isn't isolated, and that the problems have been documented and known to the correctional service for a period of time.

"I think there's many, many issues involved. Resources are certainly a big issue: making sure you have the right people with the right training and preparation."

Sapers also reported inaccurate communications between investigators probing Blackwind's death on Oct. 3, 2006. And he cited excessive investigative delays.

Fixing systemic problems will take more than just money, Sapers said. "It's making sure the resources that are available are used on priority areas."

It was known that Blackwind, who was moved to an aboriginal section of the prison shortly before he died, was increasingly agitated.

His grim death ended a hardscrabble life that began with beatings at the hands of alcoholic parents who sometimes used him as a bartender growing up near Portage la Prairie, Man.

Court heard that Blackwind's almost lifelong battle with booze started with sips of his stepfather's beer at the age of eight. He was sent to a residential school in Brandon, Man., and wound up in reform school for car theft by the age of 14.

He would go on to rack up 37 convictions over 30 years, a steady and often brutal crime spree that ceased only when he was already behind bars.

Sapers was particularly concerned that the results of an initial fact-finding report that cited staff failures to provide first aid weren't included in a separate report on the incident to senior corrections officials. He cites procedural failings rather than any kind of coverup, and says the correctional service has agreed to revamp its practices in favour of "a much more open and transparent process."

The investigator recommends that the correctional service:

-Videotape responses to medical emergencies.

-Offer a "diversity awareness-sensitivity program" to all staff.

-Share all information related to death and serious injury with police in a timely manner.

-Develop policy on handling discrimination complaints made by staff or during an investigation.

The service says it will respond fully to the recommendations and is now investigating the allegations of discrimination at Warkworth.

Hart died at age 35 on Nov. 1, 1998, in an alley near Toronto's Eaton Centre where she and Blackwind, who were homeless, often bunked down on a hot-air grate. She was clubbed to death with a heavy piece of scaffolding while she was either asleep or unconscious.

Blackwind's alcoholic rages had put Hart in the hospital twice before - including the time he slit her throat as she slept. She always refused to press charges.

Blackwind had previously pleaded guilty to manslaughter for choking to death another lover in 1976. He served most of a 10-year sentence.