Inquest into death in Niagara jail tells province to improve conditions for inmate mental health and drug use

A recent coroner's inquest into the 2018 overdose death of a man in a Thorold, Ont., jail resulted in 17 recommendations to prevent it to prevent similar deaths from happening in the future.

Those recommendations include better tracking and assessing inmates' mental health and assessing the risk of having drug traffickers and users living together in jail. 

The inquest into Jordan Case's death started Jan. 20 and was held virtually. It followed another in the fall that examined five men's drug-related deaths at the Niagara Detention Centre (NDC). That inquest ended with the jury making 66 recommendations aimed at preventing future deaths.

Case's death was initially going to be included in the larger inquest but was examined separately for scheduling reasons. 

Case was 22 when he was readmitted to the NDC after an arrest for property crimes and probation breaches, according to an agreed statement of facts created for the inquest. Case had been imprisoned at the jail five times between September 2015 and August 2018 for other charges including assault.

Upon admission to the jail on Sept. 21, 2018, Case told a nurse he had attention deficit hyperactivity disorder, smoked meth daily and had been hospitalized for a heroin overdose, the inquest learned.

A doctor referred him to be assessed for opioid agonist therapy, a medical treatment for people dependent on opioids that works to suppress cravings and withdrawal, according to the agreed statement of facts. Case requested and declined treatment repeatedly throughout his time in jail. 

Case was in his cell about 23 hours a day with another inmate.

Death related to drugs but manner 'undetermined'

On Nov. 27, 2018, Jordan went to court for an appearance. When he returned, security staff scanned him and did not find contraband. 

Three days later, corrections officers responded to Case's cell when he set off a fire alarm. He said he wanted to be moved to a different cell so he could be by himself. He wasn't moved. Officers said Case did not seem suicidal or intoxicated.

Around 9 a.m. the following morning, an officer found Case in his cell unresponsive and called for help. Paramedics pronounced Case dead about 20 minutes later.

Officers did not find contraband in Case's cell, but they did on his cellmate. When asked what happened, the cellmate told an officer "it was not his fault that he couldn't handle it," but refused to elaborate, the agreed statement of facts reads.

Jury recommends tracking, training and risk assessments

Inquest jurors answer a series of factual questions about how a person died. They may find the death to be natural causes, accident, homicide, suicide or undetermined.

In this inquest, the jury found Case died due to the "acute toxic effects of fentanyl and cocaine," but the manner of his death was "undetermined."

Jurors may decide to make recommendations aimed at preventing future deaths. They do not assign blame or legal responsibility and the recommendations are non-binding. 

The jury directed its recommendations to the Ministry of the Solicitor General, which oversees jails, and NDC, on Feb. 3.

They include:

• Regularly auditing the system used to track offenders to ensure it is up-to-date.

• Correctional staff to consider speaking with a person in custody, who asked to be moved from a shared cell, to determine the reasons for their request.

• Exploring opportunities to "work collaboratively with families and local and provincial agencies to enhance rehabilitation and reintegration efforts."

• Thoroughly assessing the risk of housing known drug traffickers with known drug addicts before doing so.

• If a daily mental health check finds someone's mental health worsened, consider conducting an in-depth assessment.

• Provide and hold compulsory training for correctional staff on dealing with people in crisis, including individuals with mental health issues and those at risk of suicide.

• Recruit more social work staff to ensure there is enough weekend coverage at NDC.