Inquest jury rules prisoner deaths accidental, methadone not intentionally fatal

THUNDER BAY – A jury has determined the deaths of both Ronald Fagan and Jacy Pierre while in custody at the district jail were accidental.

The jury at the coroner’s inquest into the deaths of Fagan and Pierre returned with their verdict Wednesday morning, concluding the use of methadone was not intentionally fatal.

The five-member jury also accepted the 16 joint suggested recommendations from Crown co-counsels Dan Mitchell and Nicole Stortini, lawyer representing the families Emily Hill and Ministry of Community Safety and Correctional Services lawyer Norm Feaver.

Those recommendations include building a replacement to the Thunder Bay District Jail, where both Fagan and Pierre fatally overdosed on methadone.

Fagan, 21, was found dead in his cell on the morning of Sept. 27, 2007 and Pierre was found unresponsive one month later on Oct. 27, 2007, later dying at the Thunder Bay Regional Health Sciences Centre.

Other recommendations addressed to the ministry include asking Aboriginal inmates to self-identify their community of origin, implementing an electronic health record, taking measures to reduce contraband entering jails and adopting recommendations from the Clause inquest in Hamilton.

A number of recommendations were also addressed specifically to the district jail, which include facilitating regular and frequent K9 unit access to the facility, increasing correctional staffing levels to enable inmates to have regular access to private counselling and reviewing the roles of nurses, mental health nurses, social workers and Native Inmate Liaison Officers to eliminate overlap and increasing staffing levels to bridge gaps.

But while the families support the recommendations, they still see more work to do.

In particular, the grandmother of Jacy Pierre took issue with the lack of Aboriginal representation on the jury, which was composed of five women.

“The jury recommendations are good for the whole system but we’re looking at our own way, that we use our own Anishinabek way to treat people who have hurt others and hurt our own society as a whole,” Marlene Pierre said.

Some of the jury’s recommendations focus on Aboriginal inmates, such as ensuring each First Nations inmate be asked to self-identify their community of origin, using best efforts to have at least one Native Inmate Liaison Officer at the district jail at all times and requiring all staff at the jail to undergo mandatory training about how to supervise Aboriginal inmates.

Pierre said those are only the beginning steps and would like to see a criminal justice system that has more solutions tailored to indigenous people.

“We have to take our men and women out of jails and provide alternatives to jails,” she said.

“We want the provincial government to look at camps where judges will the opportunity to sentence inmates to places that are representative of our teachings, our influence and our ways of treating people who want to change.”

The recommendations:

To the Ministry of Community Safety and Correctional Services

1. The Ministry shall build a new facility to replace the Thunder Bay Jail (TBJ). The design and construction should address:

• fostering the physical and mental health of inmates
• meeting the programming needs of inmates
• eliminating overcrowding of inmates
• adopting the best design to prevent and address movement of contraband
• having enough segregation cells to meet the needs of the jail
• ability to meet the needs of First Nations/Metis/Inuit inmates, including access to indoor/outdoor space for ceremonies

2. Ensure that each First Nations/Metis/Inuit inmate be asked to self-identify their community of origin and explore sharing this information with researchers and First Nations/Metis/Inuit communities
3. The Ministry implement an electronic health record to:

• facilitate continuity of care through improved communications among professionals and enable safe clinical decision making
• improve the ability to monitor health status, including substance use disorders and outcomes over time
• enhance appropriate utilization of services, including health-related programs
• collect data for future resource program planning, research or education
• conduct quality of care reviews

4. The Ministry continue to reduce the incidence of contraband (drugs) entering provincial jails through using modern available technology such as body scanners and Drugloos. The Ministry prioritize the TBJ to receive new technology as soon as possible.
5. Within the next 12 months, review the use of the Jail Screening Assessment Tool (JSAT) and consider adding additional validated questions regarding substance abuse or the utilization of a new assessment tool. If any changes are made or a new assessment tool is introduced, this information will be publicly available.
6. The Ministry shall:

• collect data and evaluate research to identify and determine best practices for providing services such as addiction and mental health programming to inmates in provincial remand institutions
• ensure this research considers but is not limited to such factors as the unique needs of First Nations/Metis/Inuit inmates, brief interventions and the challenges of providing services in remand environments.
• consider a pilot project to implement any new assessments, programming or other services identified
• make available the result of the research and pilot project to the public

7. Adopt the excerpts of the Clause inquest jury recommendations as outlined in Exhibit #22 as part of these inquest recommendations

To the Thunder Bay Jail

8. Facilitate regular and frequent access to the TBJ by a canine (K9) unit (preferrably a passive K9 unit) where such unit is reasonably available.
9. Increase correctional staffing levels to enable inmates to have regular access to private counselling with Native Inmate Liaison Offiers (NILOs), chaplains, elders, etc.
10. Review the role of nurses, mental health nurses, social workers and NILOs to identify gaps and areas that overlap. Following this review, eliminate overlap and increase staffing levels to ensure that counselling is given first priority.
11. Use best efforts to ensure TBJ always has a minimum of one NILO and that there are facilities to ensure that inmates have ongoing access to that person including a private space to speak with them.
12. Ensure appropriate staffing levels and physical space such that the Ministry and community-based support programs can be made available for remanded inmates at the TBJ.
13. The TBJ shall request any inmate discharge summary from any health facility where the inmate consents.
14. Provide additional mandatory training for all staff (including management) about the unique circumstances of First Nations/Metis/Inuit inmates and best practices for all supervisors of First Nations/Metis/Inuit inmates.
15. Explore the feasibility of using the JSAT mental health assessment as part of the admissions process for all inmates.

To the Office of the Chief Coroner

16. If after a post-mortem of an inmate the Supervising Regional Coroner receives information about a possible threat to the health of other inmates, that information should be communicated to the superintendent of the appropriate institution.