Jury makes 39 recommendations after inquest into 2018 death of Brennan Bowley, 23, at Barton jail

A coroner's inquest into the 2018 overdose death of a 23-year-old man at the Hamilton-Wentworth Detention Centre ended recently with the jury making dozens of recommendations to prevent similar deaths at the facility in the future.

Brennan Bowley died just after 10:30 p.m. on Jan. 18, 2018. His cousin, Maggie Cleland, told CBC News at the time that Bowley had a pouch of cocaine inside his body and it ruptured, causing him to accidentally overdose.

"They lacked any kind of medical attention," Cleland said about the centre. "He was asking for help in the holding cell."

Hamilton police arrested Bowley on Jan. 16, 2018 while investigating him for drug-related offences. His death was just one of several to happen in the institution in recent years.

Last August, the Ontario government announced that inquests will be held for six men who died while in custody or after transfer to hospital from the centre.

The inquest was held from April 7 to 22 to examine the circumstances surrounding Bowley's death. 

The jury's verdict, handed down on April 22, found that Bowley's cause of death was toxicity caused by mixed drugs that included fentanyl, methamphetamine and cocaine, and the manner of death was an accident.

The verdict also answered three more questions: Who died? When did they die? Where did they die? 

In addition to its verdict, the jury made a total of 39 recommendations — five to the Hamilton Police Service (HPS), four to the Hamilton Wentworth Detention Centre (HWDC), 29 to the Ministry of the Solicitor General, and a single recommendation to the Office of the Chief Coronor for Ontario, that it "should continue to strive to conduct inquests in a timely manner from the date of death."

Jury: Warn suspects of risks of ingesting/secreting illegal drugs

Among the recommendations to Hamilton police, the jury suggested that during the booking process into a police station, every individual charged with one or more criminal offences should be verbally cautioned and read a warning of the risks of ingesting and/or secreting illegal drugs and/or substances and the medical consequences of not sharing that information. 

"Prominently displayed signage to the same effect should be pointed out to the person. The person should be required to acknowledge that they have read the caution, or have had the caution read to them, and that they understand the caution. The time and the fact of the acknowledgment should be documented in the booking arrest form," the recommendation reads.

They also recommended that utilizing clear language, notices shall be posted in the courthouse (in an area visible to where prisoners are housed) and police stations in Hamilton providing education pertaining to the protections offered through the Good Samaritan Drug Overdose Act and the relevant limitations of same. 

"Said notices should draw attention, thus encouraging their review, perhaps through the use of large font sizes, bolded text, and use of colour," the jury said.

Include inmates' health-related observations in medical records

To the HWDC, it's recommended that when the HPS transfers custody of an individual to the centre and provides any illness or health-related observations regarding that individual during their time in police custody, "the detention centre shall include those observations in the individual's medical records as part of the admission process to ensure detention centre health-care staff have the best available information available when assessing that individual at the time of admission and at any other time while that individual is in custody (while also ensuring confidentiality of medical information from non-medical staff)."

It's also recommended that health-care management of the HWDC shall notify correctional management as soon as it becomes known that a nurse will not be present on any given shift, and applicable policy or policies shall be updated accordingly. 

The jury recommends to the Ministry of the Solicitor General that during incarceration, health-care staff will continue to educate inmates on how to respond appropriately to potential drug overdose risks and provide awareness of Good Samaritan legislation to encourage timely medical intervention where necessary. 

"Acknowledgment of these conversations should be documented within healthcare staff's records," the recommendation reads.

"The Ministry shall develop a set list of questions about whether an individual being admitted to the detention centre has ingested drugs or inserted drugs into their body, and health-care staff shall be required to ask these questions of all individuals being admitted to the detention centre, regardless of whether health-care staff suspect such individuals have ingested or inserted drugs.

"The Ministry should continue to explore how to optimize health-care staffing levels at all institutions with the goal of 24-hour nursing care coverage as well as ideally having more than one nurse on shift at any given time at the HWDC," the jury continued.

Inquests are called by a coroner after a death to make recommendations to prevent similar deaths in the future. A jury can recommend procedures for governing bodies to adhere to, though they are under no obligation to do so.