Hamilton
The coroner’s inquest into the deaths of six men who were incarcerated at the Hamilton-Wentworth Detention Centre ended Thursday with the jury making about 60 recommendations, including to help inmates with substance use issues.
Weeks-long inquest for men who died 2017-2021 led to about 60 recommendations
Justin Chandler · CBC News
· Posted: Dec 13, 2024 11:36 AM EST | Last Updated: 5 hours ago
Igor Petrovic, Christopher Sharp, Robert Soberal, Paul Debien, Nathaniel Golden and Jason Archer, clockwise from top left, all died of drug toxicity between 2017 and 2021, either in the Hamilton-Wentworth Detention Centre or in hospital. A coroner’s jury released about 60 recommendations on Thursday with the aim of preventing similar deaths. (Submitted by Office of the Chief Coroner)The coroner’s inquest into the deaths of six men who were incarcerated at the Hamilton-Wentworth Detention Centre ended Thursday with the jury making about 60 recommendations, including to help inmates with substance use issues.
The recommendations, aimed at preventing similar deaths, include developing a plan to offer a safe drug supply within the institution, ensuring inmates won’t be penalized for reporting overdoses, and improving access to treatment for substance use disorder.
Jason Archer, Paul Debien, Nathaniel Golden, Igor Petrovic, Christopher Johnny Sharp and Robert Soberal all died of drug toxicity between 2017 and 2021. They ranged in age from 28 to 53.
“We hope that the inquest will have provided some answers … and may add to just a little bit of closure,” said Dr. John Carlisle, who oversaw the inquest that began Nov. 25 and works for the office of the chief coroner.
Several of the six men’s families addressed the inquest early on, sharing stories about those inmates’ struggles with addiction and mental health.
Jurors were tasked with answering factual questions about each man’s death, including when, where and how they died. The jury determined all died accidentally.
Inquest juries do not have to, but are encouraged to, issue recommendations.
In 2018, a similar inquest examining eight deaths at the detention centre, also known as the Barton jail, resulted in 65 recommendations, but close to half of the them haven’t been put into force.
Inquests into the deaths of people who were in custody are mandatory in Ontario.
Many of the recommendations at the inquest that ended Thursday stemmed from topics described at length in the hearings.
For example, ensuring people who report drug use and overdoses are not penalized relates to what are referred to as Good Samaritan policies, which came up several times.
The Hamilton-Wentworth Detention Centre is a provincially run jail. (Bobby Hristova/CBC)After Sharp died in 2018, his cellmate reported hearing him choking 15 minutes before he was found unresponsive, but he did not call for help. The inquest heard that in some cases, inmates could be penalized if an investigation into drug use found drugs in their cells.
Good Samaritan policies also were brought up during another, recent inquest, into five deaths at the Niagara Detention Centre.
Other recommendations released Thursday include:
Providing treatment for opioid addiction to new inmates within four hours of admittance if they’re at risk of withdrawal. Improving supports for people with attention deficit hyperactivity disorder (ADHD). Prioritizing the administration of naloxone, which can reduce the effects of an overdose, when an inmate is found unresponsive. Doing more to prevent people from passing contraband from cell to cell. Improve information sharing between security and health-care staff at the jail. ABOUT THE AUTHOR
Justin Chandler is a CBC News reporter in Hamilton. He has a special interest in how public policy affects people, and he loves a quirky human-interest story. Justin covered current affairs in Hamilton and Niagara for TVO, and has worked on a variety of CBC teams and programs, including As It Happens, Day 6 and CBC Music. He co-hosted Radio Free Krypton on Met Radio. You can email story ideas to justin.chandler(at)cbc(dot)ca.
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