A five-person jury presented a coroner’s inquest into eight inmate deaths at the Hamilton Wentworth Detention Centre with 62 recommendations, on Friday night.
The verdict, based off of nearly six weeks of testimony, was carefully crafted over two days to include 15 recommendations in addition to counsel’s joint slate of 47.
The final submission includes measures aimed at strengthening communication, disrupting the flow of contraband drugs and improving access to healthcare for inmates.
“The healing process for my family and I definitely can truly begin,” said Glenroy Walton, whose 20-year-old son Julien died while in custody at the jail in 2015.
“I pray that this inquest makes sure that these individuals, these inmates … get rehabilitated,” he said.
Following the verdict, counsel to the coroner Karen Shea was optimistic.
“They’re clear, they’re realistic,” she said, referring to the recommendations. “I’m just hoping in the next few months we’re going to see more implementation.”
The jury learned before deliberating that two changes, now ensconced in their decision, are already in the works. One is an institutional security team that will look for contraband drugs and investigate gang activity at the jail. The second is an update to the institution’s opioid agonist therapy program to help manage addiction.
It seeks increase the level of access to Methadone and Suboxone, the latter listed as the preferred treatment.
From Walton’s perspective, one common thread that became evident during the inquest’s examination of the eight men’s deaths was the mental health and addiction issues in their lives.
Some of the recommendations are aimed at improving information sharing, training and healthcare access to address those concerns.
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- Opioid, mental health and suicide awareness training for jail employees who haven’t received it within the last six months
- Inmate assessment by a social worker within 48 hours of admission
- Inmate assessment by a doctor within 24 hours of admission
- Electronic health records to ensure accurate information at the point of admission
- Develop a standard prisoner information form with Hamilton police flagging recent reports of suicide risk/possession of contraband drugs
The jury has also put forward a thorough list of harm reduction measures from a security perspective.
“It was shocking that someone could be actually snorting a drug off of a table in a day room,” said Karen Shea, referring to video evidence. “Some of the things you just couldn’t imagine that could go on, but that’s where I think the real-time monitoring is really, really important,” she said.
The jury is calling for the introduction of a system within the next six months that will allow for active monitoring of security cameras posted in living units. It also recommends higher resolution monitors in segregation units.
“It’s not just in terms of controlling contraband, but it’s also an issue of safety and security for the inmates and for the correctional officers and healthcare staff,” said Shea.
A dedicated canine unit for searching cells and day rooms after an overdose, cell barriers to prevent ‘fishing’ lines from distributing contraband and increased use of the x-ray scanner after an overdose are just a few of the other changes put before the detention centre for consideration.
After reviewing the evidence on Louis Unllli, Trevor Burke, Stephen Neeson, David Gillan, Marty Tykoliz, Julien Walton and Peter McNelis, the jury advised seven of the deaths were from accidental overdose and one a suicide.
In the more recent deaths, the potent opioid Fentanyl appeared in toxicology reports. It has prompted this jury to respond to the impact of the opioid crisis inside the jail.
- Narcan at every guard station/admission/medical stations
- Code white kits for emergencies (e.g. overdose) on every floor of the HWDC
- Provide CPR to interested inmates
- Checking inmates who return from hospital after an overdose every 30 minutes
The verdict in its entirety has been applauded by the presiding coroner, Dr. Reuven Jhirad, counsel and family members, such as April Tykoliz. Her brother Marty died in 2014 from an overdose just hours after receiving naloxone for another.
She says the jury adopted all 30 of the recommendations she put forward. “So that feels really good,” she said, expressing relief.
There has been closure through this process, Tykoliz said, but stresses that she will be watching to see what the Ministry of Community Safety and Correctional Services does with the recommendations.
“I don’t feel like I could let go and I don’t feel that some of the families will let go, so I’m sure that we’re all hoping that these recommendations get taken seriously.”
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