Inquest for 6 Hamilton-Wentworth Detention Centre inmates to review 2018 recommendations

The coroner's inquest into the drug-related deaths of six men in custody at the Hamilton-Wentworth Detention Centre will revisit 2018 recommendations relating to eight other inmate deaths to determine what's been done to implement them, the inquest's lawyer said Monday on the first day of hearings.

Kristin Smith also told the jury that inquest officials have been in contact with the families of the six men, and that each was "loved and cherished."

Jason Archer, Paul Debien, Nathaniel Golden, Igor Petrovic, Christopher Sharp and Robert Soberal died between 2017 and 2021, either in the Ontario government jail or in hospital. Five of the men had been in the jail between five and 15 months, and one was there for under a day. 

"Losing a loved one is the most difficult thing most people experience in their lives," Smith said, noting that reliving those deaths through an inquest is an exceptional challenge. "We sincerely hope the process can answer some of their questions and bring them some manor of peace."

Opioid crisis to be highlighted at inquest

Smith said the inquest, which is expected to last until at least Dec. 13, will put a lot of focus on the opioid crisis and how to manage it within correctional facilities.

Six years ago, a coroner's jury overseeing the six-week inquest for the eight inmates heard testimony from dozens of witnesses who spoke of overcrowding, easy access to drugs, limited monitoring of inmates and little access to methadone for inmates with addictions. The jury's recommendations included limiting the number of inmates allowed in a cell, possible random searches of staff and having every guard carry naloxone.

The Hamilton-Wentworth Detention Centre, a maximum-security jail, houses people serving sentences of under two years or individuals awaiting trial or sentencing.

The virtual inquest is being broadcast publicly online, with Dr. John Carlisle as the presiding officer. Carlisle and his counsel, Smith and Julian Roy, work for the coroner's office.

Inquests for inmates are mandatory in Ontario under the Coroner's Act. Juries are tasked with answering five questions: who died, when, where, how and by what means (natural causes, accident, suicide, homicide or undetermined). They may make non-binding recommendations designed to prevent future deaths but aren't allowed to make findings of legal responsibility or blame. 

'As a society, we need to do better'  

The inquest that began Monday is scheduled to hear from witnesses including senior leaders at the jail, health-care workers, a physician with expertise in substance use disorder, a panel of Hamilton Public Health staff, and officials with the Ministry of the Solicitor General, which oversees corrections in the province. 

There are several parties to the inquest (people allowed to question witnesses), including the families of Sharp and Soberal, and lawyers representing the John Howard Society of Ontario and the Prison Harm Reduction Coalition.

As part of the morning proceedings, the jury heard statements from family members of some of the six men. In the afternoon, inquest counsel questioned Andrea Monteiro, a corrections consultant with diverse experience in the field.

Monteiro was provided with over 8,000 pages of documents, including health and corrections records, related to the inmates. She produced a report outlining the events leading up to and following the men's deaths that will inform the inquest. 

Monteiro answered questions about Archer, Petrovic and Sharp. She's scheduled to discuss Debien, Golden and Soberal on Tuesday. 

Here's a summary of what the jury heard about each man:

• Archer: The 30-year-old father, who had been on remand for 15 months, died on Aug. 21, 2017. Inmates had reported he was non-responsive in his cell. Monteiro's review found Archer was known to do drugs and records show he sought treatment but stopped taking methadone in jail after 10 months. It is unclear why. Archer had been disciplined for having contraband, including drug paraphernalia. Surveillance video appears to show him and other residents exchanging what might be drugs the day before he died. 

• Petrovic: The 29-year-old father died on Nov. 28, 2017. A corrections officer found him in his cell without vital signs. Petrovic experienced trauma growing up related to the war between Serbia and Croatia. One of his friends wrote a statement that was read by Smith. It said Petrovic and his girlfriend asked the friend to take care of their child while they sought help for their mental and physical health. The friend said Petrovic was "met with indifference at every level" and "as a society, we need to do better" when people ask for help. Petrovic's file showed he had intensive drug rehabilitation needs, Monteiro said. Petrovic was disciplined for various offences and spent around 200 days in segregation over seven months. Surveillance video from before he died appears to show him and another inmate using string to pass items between their cells. 

• Sharp: Called John by loved ones, the 53-year-old died on Sept. 7, 2018. He had dealt with addiction and was institutionalized throughout his life. His sister-in-law read her statement as well as one written by his mother that said he was a beloved uncle. Sharp's mother wrote she was not surprised to hear drugs killed her son, but she was shocked it happened in jail, where she thought he would be safe. She said her son was "respectful" and "loving," but dealt with attention deficit hyperactivity disorder (ADHD) and felt as if he never fit in because he was mixed race. His sister-in-law told the inquest that when he was sober, Sharp would help her and his brother with their children. However, she said, Sharp didn't have enough social support and kept turning back to drugs. She said he was a talented artist and helped inmates make greeting cards to send to loved ones. Monteiro said Sharp's file indicated several official complaints he made about his care. Health-care officials were seeing him for issues including nerve pain. Sharp had been in a cell with other inmates, one of whom said they heard him choking before he was found dead, but did not call for help. Officials found a mix of heroin and fentanyl in his cell. 

• Debien: The 34-year-old father of two died March 21, 2019. Inmates had found him unresponsive in his cell. He was known to have substance-use disorder. His sister told the inquest "he would do anything for anyone" and he loved spending time with his family. She said corrections workers told her he was "wonderful" and that she still decorates his grave around each anniversary of his death. 

• Golden: The 28-year-old father of three daughters died on Jan. 5, 2019, after reportedly telling a cellmate he had taken heroin while at court. 

• Soberal: The 46-year-old, who died on May 17, 2021, was close to his sister and the two protected each other, she told the inquest. She said he was adopted at age 3 and had trauma from living with a parent who couldn't take care of him. As a teenager, he started using drugs and getting into trouble. The family moved to Hamilton, where he got a job waterproofing basements. His sister said he was proud of his work, and was also an excellent guitarist, but found it hard to stay sober after his adopted mother died in 2017. The family shared a memory of driving through a blizzard to visit Soberal for Christmas when he was at a treatment facility in Guelph one year.