Hamilton woman still wants accountability after inquest into brother's 2017 death in jail

The sister of a 34-year-old man who died in the Hamilton-Wentworth Detention Centre in 2017 says the team who conducted the inquest was "fabulous," but she's frustrated she wasn't able to hold anyone accountable through the process.

Amy McKechnie, whose brother, Ryan McKechnie, died on June 29, 2017, said it was also a "kick in the face" that it took nearly eight years to hold the coroner's probe. 

Ryan accidentally died of combined fentanyl, methamphetamine and amphetamine intoxication, the inquest jury found in February. But coroner's inquests aren't tasked with assigning blame or make findings of guilt or innocence, something Amy found frustrating since she believes the jail could have taken steps to prevent his death.

"We're going to prevent future deaths hopefully, but what about my loved one?" Amy said in an interview with CBC Hamilton.

Amy believes jail staff erred in putting Ryan in a cell with another inmate after guards found contraband in the cell they were sharing. She said a body scan of the other inmate showed anomalies, suggesting he had ingested packages of drugs. The next morning, Ryan didn't wake up for breakfast and his cellmate called for help.

Amy said people who worked as corrections staff at the time testified at the inquest. She said one witness told the jury he would have done things differently looking back. None of the other workers said they'd change their actions, she said, adding she found that "disgusting."

Since Ryan was incarcerated, an inquest into his death was mandatory under Ontario's Coroners Act. During such procedures, lawyers for the coroner's and parties, including family members of the deceased, ask questions of witnesses — they can include eyewitnesses, experts, and institutional workers and officials. 

Inquest juries may make recommendations aimed at preventing future, similar deaths. The jury in Ryan's inquest issued 18, most of them focused on the Ministry of the Solicitor General, which oversees corrections. They include:

• Updating staff training concerning how to interpret body scans for contraband with the understanding that a negative scan is not a guarantee someone is free of contraband.
• Considering an audit of the efficacy of detecting contraband through current scan protocols.
• Funding trauma-informed supports for families following the death of a loved one in custody.
• Clarifying staff should identify signs of life when they routinely check on inmates.

In December, a weeks-long inquest for six men who died at the Hamilton jail between 2017 and 2021 led to 55 recommendations. They included 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. 

Ryan's death was originally going to be included in that inquest, Amy said, but it was held virtually and she pushed for an in-person proceeding, feeling it would be more "humane." On her request, Ryan's inquest was in person. The coroner's office held it in Toronto.

Amy said she followed the fall inquest and she attended one in 2018 that examined eight deaths at the detention centre between 2012 and 2016. It resulted in 65 recommendations, but close to half of them haven't been put into force, the fall inquest heard. Recommendations by inquest juries are non-binding — another thing Amy said she wishes would change.

I refuse to let my brother's death be in vain.- Amy McKechnie

For Amy, one of the key recommendations in Ryan's inquest is that the ministry fund support for families of inmates who die. She said she received little, if any, support after she learned through a friend that Ryan had died and then went to the jail to confirm it. 

In a brutal coincidence, she said, her dad died the same day.

"I don't think I ever grieved for them. I just kept on going."

In addition to support back then, Amy said, she would have appreciated financial assistance throughout the inquest.

She said she represented herself instead of hiring a lawyer because she couldn't afford one and had to pay for her own accommodations to stay in Toronto. 

On its website, the Office of the Chief Coroner says it offers two programs that can help families cover legal fees.

The office also works with police to provide support for families at the time of death, explain the investigation process and prepare them for an inquest, Stephanie Rea, a spokesperson for the coroner's office, said in an email.

Rea said the office also has a liaison to work with families and connect them to other support systems. 

"The inquest process can be a very challenging time for families, so we also permit them to rely upon the assistance of their familial or community supports during the hearing itself to the greatest extent possible, while still maintaining the necessary integrity of the inquest process." 

Amy said she also hopes the ministry and the Hamilton jail implement the recommendations around body scanners and checks. She said a more careful scan could have prevented her brother from getting drugs, and guards checking for signs of life at night may have learned Ryan needed help before it was too late. 

Call for better education, reintegration help for inmates

Going forward, Amy said, she also wants the ministry to implement better education and help for inmates so they can better reintegrate into society after their release.

"You can't just lock somebody into a cage, give them nothing and expect it to work," she said. 

Ryan wasn't just the negative stuff, she said, adding he was an "amazing" brother, "funny beyond funny" and "didn't deserve what he got."

Amy said she's also exploring other options to seek accountability for Ryan and other inmates whose family members died in the jail. 

"I refuse to let my brother's death be in vain."