Inquest calls for safe supply, better access to addictions treatment at Hamilton-Wentworth Detention Centre

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 to prevent future, similar deaths.

Recommendations include developing a plan to offer a safe drug supply within the institution, ensuring inmates will not 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 from 28 to 53-years-old. 

"We hope that the inquest will have provided some answers … and may add to just a little bit of closure," Dr. John Carlisle, who oversaw the inquest and works for the office of the chief coroner, said.

Several of the men's families addressed the inquest early on, sharing stories about their 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 issue recommendations but are encouraged to. Their recommendations are not legally binding.

In 2018, a similar inquest examining eight deaths at the Hamilton jail resulted in 65 recommendations, but close to half of the recommendations haven't been put into force. Inquests into the deaths of inmates are mandatory in Ontario.

Many of the recommendations stemmed from topics described at length in the inquest. 

For example, ensuring people who report drug use and overdoses are not penalized, relates to so-called Good Samaritan policies, which came up several times.

After Sharp died in 2018, his cellmate reported hearing him choking 15 minutes before he was found unresponsive, but 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 cell. 

Good Samaritan policies also came up during the recent inquest into five deaths at the Niagara Detention Centre.

Other recommendations included:

• 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) 

• Prioritize 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 healthcare staff in the jail