14 Hamilton jail inmates have died from overdoses since 2012 but Ontario change is slow, inquest hears

The Ontario government has had six years to follow through on dozens of recommendations from a coroner’s inquest to prevent inmates from dying of drug overdoses at the Hamilton-Wentworth Detention Centre. 

But close to half of the recommendations haven’t been put into force, the jury in a current inquest heard during closing submissions Tuesday, after over three weeks of proceedings. Corrections officers, for example, still don’t carry nasal naloxone — a medicine that quickly reverses an opioid overdose. 

The first inquest, for eight men in custody at the provincially run jail who died between 2012 and 2016, resulted in 62 recommendations; the current inquest, which began Nov. 25, is for six men who died under similar circumstances between 2017 and 2021. 

“Six deaths over six years brought us back to Hamilton-Wentworth, and once again we grappled with the same set of issues as before — from the opioid crisis, to response, to access of the incarcerated, to lifesaving drugs and programs,” Jerry Wu, counsel for the John Howard Society of Canada, told the jury. 

The John Howard Society was among parties with standing at the inquest, along with prison reform advocacy groups and the families of two of the men who died of drug toxicity — Robert Soberal and Christopher Johnny Sharp. 

“Actions needed to be taken yesterday,” Tracy Sharp, Johnny’s sister-in-law, told the jury. “It’s almost an insult to the families and juries who spent their time and energy on inquests into this matter. We need something of substance to be done.” 

Inquests are mandatory under the Ontario Coroner’s Act for people who die in custody. Among their work, jurors may make non-binding recommendations to prevent future deaths.

In this case, inquest counsel presented a range of recommendations to jurors — 27 of them were from the 2018 inquest but not implemented. 

The other men at the centre of the current inquest are Jason Archer, Paul Debien, Nathaniel Golden and Igor Petrovic. They were between ages 28 and 53, and overdosed on substances overnight. 

Jail faces budget, staffing constraints: ministry lawyer

The jail issued misconduct notices — a disciplinary action — for possessing contraband to most of the men after they overdosed and died, and some of those notices were never withdrawn or dismissed, said inquest counsel Kristin Smith. 

“This practice needs to stop,” she said. “All staff need to understand a misconduct [notice] should never in any circumstance be written related to the circumstances of [the inmate’s own] death.” 

Smith also urged jurors to recommend that the jail ensure inmates are allowed to have nasal spray naloxone in their cells.

In most cases, the men’s cellmates were the first to raise the alarm about a suspected overdose, but had to wait up to 10 minutes for staff to administer it, Smith said. 

Rob Sidhu, lawyer for the Ministry of the Solicitor General, said providing health care in the corrections system with strict security is a “challenging scenario” that staff were trying their best to achieve. 

The guards work hard to develop a rapport with the people incarcerated there and nurses offer a “high standard” of care, Sidhu said. Those who work at a higher management level are also “engaged” with front-line staff. 

He urged the jury to consider that financial and staffing resources at provincially run detention centres are “finite” and if “strict timelines” to fulfilling the recommendations make sense. 

“Avoid taking an overly prescriptive approach,” Sidhu said. “People can be trusted to use their judgment and do the right thing.” 

Inmates offered addiction treatments

Among the recommendations the ministry has implemented is offering inmates opioid agnostic treatment, which involves taking prescription drugs like methadone or suboxone to prevent withdrawal symptoms and reduce cravings. 

“That’s a landmark achievement,” Vilko Zbogar, who represents the Prison Harm Reduction Coalition, said during closing arguments.

But much more needs to be accomplished to prevent future overdose deaths, he said. 

Recommendations from 2018 that have not completed by the province or the jail include:

• Not allowing more than two inmates to a cell.
• Inspecting all items provided to inmates to ensure contraband is not transferred.
• Conducting a full search of jail for other contraband after overdose occurs.
• Conducting a review with all parties involved after the death of an inmate from a drug overdose. Those parties could be physicians, nurses, guards and managers. 
• Transferring responsibility of public health programs in correctional facilities from the Ministry of Community Safety and Correctional Services to the Ministry of Health. 
• Equipping all corrections officers with naloxone. 
• Holding weekly meetings between corrections and health-care staff regarding needs of all inmates. 
• Doctor assessments of all inmates within 24 hours of admission.
• Providing CPR training to interested inmates.
• Stopping disciplinary actions against cellmates who report suspected overdoses, which would be similar to the Good Samaritan Act. The law offers immunity for simple possession charges to people reporting overdoes in the outside community.