Closing submissions leave 47 recommendations for jury at Barton jail inquest

A “real cultural shift” is needed to prevent future drug-related deaths at the Hamilton-Wentworth Detention Centre.

Those were the words of coroner’s counsel Karen Shea during closing submissions at the inquest into eight overdose deaths at the Barton Street jail between 2012 and 2016.

“In one way or the other, all eight of the deaths were preventable,” she said Wednesday, before taking the jury through a slate of 47 suggested recommendations, crafted by the parties with standing at the inquest.

The suggestions, aimed at preventing future deaths, touched on everything from improving security on admissions, to better supervision, to access to health care, recreation and other community services, to improving communication between police, health care and the jail.

After nearly six weeks of testimony, the deaths of Louis Unelli, William Acheson, Trevor Burke, Marty Tykoliz, Stephen Neeson, David Gillan, Julien Walton and Peter McNelis are now in the hands of the five-person jury.

“The heart of any inquest is the souls of those lost,” said the coroner, Dr. Reuven Jhirad.

The Ministry of Community Safety and Correctional Services said it supports about 70 per cent of the suggestions and will consider all the final recommendations from the jury.

“Jails are supposed to be about rehabilitation,” said Kevin Egan, lawyer for April Tykoliz, whose brother Marty died May 7, 2014. Instead the Barton jail is a “place where anything but corrections takes place.”

During the inquest the jury saw video footage of Tykoliz and his cellmate blatantly snorting drugs off a table inside the day room on his unit — but that wasn’t seen until after he overdosed, was revived, went to hospital and then back to jail again where he fatally overdosed.

Among the suggestions is that the ministry evaluate upgrading video technology to allow for real-time monitoring of inmates within six months.

“He deserved better,” Egan said, adding Tykoliz was no angel but he was also let down by “a system bound to fail.”

Several notable changes have already taken place at the jail, including the addition of overnight nursing, and the use of full-body scanners on admissions.

Shea recommended the ministry confirm the scanners are working well and then expand their use, including mandating inmates in the area where an overdose took place are quickly strip-searched and scanned.

These inmate searches would be co-ordinated with faster cell searches by the promised Institutional Security Team, expected at the Barton jail within six months.

In addition to the jointly-recommended 47 suggestions, Egan called for jail staff to be randomly searched and be restricted from bringing personal items inside the jail.

In the midst of the inquest, the ministry announced it had updated a controversial policy that had limited inmate access to opioid withdrawal treatment.

On Wednesday, Shea recommended the jail ensure that policy is followed, and that suboxone — a safer medication similar to methadone — become the preferred treatment.

Vilko Zbogar, lawyer for Prisoners HIV/AIDS Support Action Network (PASAN), which had participatory rights in the inquest, urged the jury to go further.

“We can’t think small, change has to be transformational,” he said.

Chief among his suggested recommendations was access to the opioid antidote naloxone.

The inquest has heard that correctional officers are being trained and will have access to “strategically placed” nasal spray.

But Zbogar recommended all correctional officers be required to carry the medication and it be placed in cells for inmate access.

Shea pointed to the fact that some witnesses testified concern that inmates could use the spray container nefariously, including to hide drugs.

Instead, she recommended willing inmates be offered CPR training.