62 recommendations in Barton jail inquest
Hearing exposed rampant drug use, health-care barriers, miscommunication
The jury at an inquest into eight drug overdose deaths at the Hamilton-Wentworth Detention Centre has made 62 sweeping recommendations to transform health care, security and inmate rights at the Barton Street jail.
The five-person jury, which began deliberations Wednesday afternoon and finalized the recommendations shortly after 7 p.m. Friday, went above and beyond the slate of 47 suggested recommendations laid out by the coroner’s counsel, calling for a number of significant changes.
These include limiting two inmates per cell, considering random searches of correctional staff, and tracking all overdoses and times staff administer the opioid overdose antidote naloxone.
Coroner Dr. Reuven Jhirad commended the jury’s work as “inspiring.”
“I think you have profoundly helped change what our specialty can be,” he said.
For the families there, many who had come to lean on each other throughout the six weeks, the verdict was both overwhelming and a relief.
For many, the inquest was the first time they learned details of what happened to their loved ones.
Louis Unelli, William Acheson, Trevor Burke, Marty Tykoliz, Stephen Neeson, David Gillan, Julien Walton and Peter McNelis all died of drug overdoses while inmates at the jail between 2012 and 2016.
All were accidental, save for Gillan who died by suicide.
“I’m so relieved. I’m so happy. Four years is a very long time,” said April Tykoliz, whose brother Marty died in 2014.
All of the 30 recommendations she and her lawyer and inmate advocate, Kevin Egan, had suggested were adopted by “the best jury ever,” she said.
“I have a sense of closure now ... we can rest, we can go home.”
Glenroy Walton, whose son Julien was the youngest of the men who died — just 20 — also expressed relief and hope that the jail would become a place where mentally ill inmates get help and where rehabilitation is a goal.
“Now it is time to make sure that these recommendations are implemented, that no other family has to go through what we’ve gone through,” he said.
Their recommendations are optional, but the Ministry of Community Safety and Correctional Services has promised to seriously consider all of them. And the families say they’ll be watching.
The six-week inquest revealed rampant drug use in the Hamilton-Wentworth Detention Centre, limited health care and consistent missed communications between correctional and medical staff and police.
The recommendations spanned all aspects of corrections, including stricter admission, better searches, faster access to health care and better communication between corrections and police.
Some of the other recommendations included:
• Real-time monitoring of inmates by surveillance cameras and better quality security cameras in segregation; • Prompter searches of units after a suspected overdose that includes strip-searching and scanning all inmates;
• Increased access to canine searches;
• Automatic administering of naloxone and calling of an ambulance when someone presents with overdose symptoms;
• Inmates returning from hospital after an overdose should be checked, ideally by health care staff, every half-hour;
• Transfer of health-care staff working at the jail from the Ministry of Community Safety and Correctional Services to the Ministry of Health and LongTerm Care;
• Equipping all correctional officers with naloxone; • Create a prisoner admission form or checklist to make sure all relevant information about an inmates drug use is obtained on admission;
• Explore the creation of electronic logs;
• Consider weekly case management meetings about inmates between health-care and correctional staff;
• Reinstate four dedicated recreation staff and reopen the gymnasium to inmates.
A number of changes have already happened at the jail since these deaths, including the addition of full-body X-ray scanners used on admission that show contraband hidden in body cavities.
Yet drugs, including deadly fentanyl, continue to get inside and inmates continue to die.
The Ministry of Community Safety and Correctional Services has already promised the Barton Street jail will be getting a designated search team — Institutional Search Team (IST).
It has also updated policies on addictions treatment, including a controversial one that previously limited new inmates from access to methadone unless they already had a prescription.
The jury also recommended suboxone, another opioid medication with less risk than methadone, become the preferred withdrawal treatment.
Coroner’s counsel, Crown attorney Karen Shea — a force who kept the inquest on track — called the recommendations “amazing” and showed the jury “was listening.”
Shea believes in the power of inquests to make change, and called the process “invaluable.”
She admitted to being concerned in beginning that by including eight deaths they would lose sight of some, but that didn’t happen.
“In the end, having watched the families come together and being here, even when it wasn’t evidence about their loved one, that, I think is what really made it work,” Shea said.
I’m so relieved. I’m so happy. Four years is a very long time. APRIL TYKOLIZ
Sister of inmate Marty Tykoliz