Jury makes 23 recommendations after inquest into deaths of 7 Maplehurst inmates

The jury serving on the coroner's inquest into the deaths of seven men from drug overdoses while they were in custody at Maplehurst Correctional Complex has made 23 recommendations to prevent future inmate overdoses, including making naloxone kits available to inmates and providing more training for corrections staff.

The men died from accidental drug overdoses either at Maplehurst in Milton, Ont. or after transfer to a local hospital between June 2017 and October 2019.

The jury provided the verdict and recommendations on Friday after hearing from more than 25 witnesses, including correctional officers, jail medical staff, and managers, over a two-week period. 

The inquest also heard families' statements, including from the mother of one of the inmates, who said her son needed help for his addictions. 

The jury is proposing that the Ontario Ministry of the Solicitor General implement 23 recommendations.

The recommendations include increasing access to primary care providers at Maplehurst, providing newly admitted inmates with information on addiction treatment and services at the jail, and equipping correctional officers with naloxone kits while they are on duty.

The other recommendations include:

• Develop and implement an analysis to address correctional staffing shortages at Maplehurst.
• Make naloxone kits available to inmates and educate inmates on recognizing the signs and symptoms of overdose, safe administration of naloxone, and the importance of alerting staff to a potential overdose. 
• Provide naloxone training videos on the televisions in the living units. 
• Monitoring fire doors between the wings of the living units to prevent the passing of contraband between the units.
• Provide training to officers and health care staff on how to respond to a potential opioid overdose on an annual basis.
• Conduct random reviews on a quarterly basis of CCTV footage to audit the quality of correctional officers' security patrols.
• Assign additional officers to the module unit during daytime hours to assist in monitoring the screens. 
• Develop a preliminary summary at the forefront of the electronic medical record for each patient.
• Explore the feasibility of conducting routine drug testing as part of the intake procedure for admission. 

WATCH | Video shows Maplehurst guards strip-searching and zip-tying inmates: 

Ontario inmates zip-tied, strip-searched in court video; jail under investigation

1 month ago

Duration 1:57

CBC News has obtained court videos appearing to show jail guards in tactical gear strip-searching and zip-tying inmates in their underwear at Maplehurst Correctional Complex — actions now under investigation by the Ontario Ombudsman.

CBC has reached out the Ontario government asking for a response to the recommendations.

In Ontario, inquests into deaths while in custody are mandatory under the Coroners Act.

Maplehurst Correctional Complex holds about 1,500 inmates in medium and maximum security.

On Wednesday, Ontario's ombudsman said he was alarmed by the "growing state of crisis" in provincial jails, saying that urgent reform is needed.

He also said he has launched an investigation into the province's response to a two-day incident at Maplehurst in December 2023, in which "many inmates were so poorly treated that they have had the charges against them reduced or even dismissed by judges." In that incident, inmates were ordered to strip to their underwear and to sit facing a wall with their wrists zip-tied.