Jury in coroner's inquest recommends 66 changes to prevent future deaths at Niagara Detention Centre

The coroner's inquest into the deaths of five men at the Niagara Detention Centre (NDC) ended with the jury making 66 recommendations aimed at preventing future deaths. 

Timothy Anderson, Murray Balogh, David Cowe, Michael Croft and Jahrell Lungs all died of drug-related causes between 2018 and 2022. Because they were incarcerated, inquests into their deaths are mandatory. 

The non-binding recommendations are addressed to Ontario's Ministry of the Solicitor General, which oversees the province's correctional services, and the NDC. They include adopting harm-reduction principles, implementing 24-hour nursing services, abandoning zero-tolerance policies for drug use, continuously monitoring patients at risk of overdosing, and increasing access to naloxone, which can reverse the effects of opioid overdoses.

"The ministry thanks the Coroner's Jury for their recommendations," spokesperson Brent Ross told CBC Hamilton in an email. He did not address any specific recommendations, saying officials will review and respond to them "within the required six-month response period."

For about three weeks, the inquest, which the Ontario chief coroner's office held virtually, heard from workers and managers at the jail, as well as medical experts. Each witness answered questions from lawyers who work for the coroner, then from those representing the solicitor general's ministry, the Prison Harm Reduction Coalition, and two doctors, who served as witnesses. The Prison Harm Reduction Coalition represents Niagara community organizations advocating for the incarcerated and also those who use drugs.  

Members of Anderson's and Balogh's families were party to the inquest and could ask questions through its lawyers.

Afterwards, jurors answered a series of factual questions about how the men died. On the causes of death, their verdict mirrored an agreed statement of facts read at the start of the inquest. It found that Cowe died of drug poisoning and the rest of the men due to drug toxicity. All the deaths were accidental, the jury found.

Inquest juries are encouraged, but not required, to make recommendations. The Ontario chief coroner's office says on its website that it follows up with recipients within six months to indicate if recommendations were implemented, and if not, why.

Recommendations include all-day nursing services

Many of the recommendations reflect topics discussed in detail during the inquest.

For example, one was to implement and recruit for 24-hour nursing services at NDC. Patrick Sproat, deputy superintendent of the facility in Thorold, Ont., told the inquest that not having 24-hour health-care staffing can lead to delays in accessing inmates' health records.

Sproat also answered several questions about possibly adopting "Good Samaritan principles," through which inmates could share information about drug use in the facility without fear of punishment.

Generally, Sproat said, NDC security staff do not want people to get in trouble for trying to help. However, in some cases, they must report or act on incidents, and there can be negative consequences for inmates.

Along those lines, the jury said the ministry should abandon zero-tolerance policies for drug use.

Jury says ministry should consider making naloxone available in cells

Pending 24-hour nursing staff implementation, the jury recommended a roster of on-call nurses. They also suggested that correctional staff could check on inmates readmitted from hospital after an overdose or suspected overdose every 20 minutes until a health-care worker could do so. 

Lungs died of drug toxicity at the NDC, following a hospital visit due to a suspected overdose. He had refused treatment at the hospital, and was not reassessed at the detention centre once he was readmitted.

Jurors also recommended the ministry and institution study the "feasibility and benefits" of directly providing naloxone spray for people in custody, including within locked cells.