Jury at inquest for 6 Hamilton jail inmates recommends safe drug supply plan, improving treatment access

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 inquest heard that on Sept. 7, 2018, an inmate in Sharp's dorm called a corrections officer for help. Staff found Sharp unresponsive. A resident in the dorm told the officer Sharp had been making a choking sound 15 minutes earlier. 

On March 21, 2019, Debien stopped breathing in his bed at night. The inquest heard that other inmates tried to revive him and did not call for help until nearly an hour later.

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.