Inquest exposed inmate health-care failures in Ontario jails that staff, advocates say are widespread

A recently concluded coroner’s inquest into the death of a Wiikwemkoong First Nation man at the Sudbury Jail has drawn attention to what advocates and correctional officers say are long-standing, Ontario-wide failures in correctional health care.

Sara-Jane Berghammer, CEO of the John Howard Society of Sudbury, said she wasn’t surprised by nurses' testimony about staffing shortages and lack of overnight medical coverage at the jail.

“My initial thoughts are, no, I’m not surprised. This is stuff that’s been happening for as long as I can remember,” Berghammer said. “An inmate’s health is not governed by the Ministry of Health. It’s governed by corrections, and corrections [and] their mandate is care and control. It’s not health.”

Berghammer said her organization regularly hears from inmates and families saying people aren’t receiving medication they were prescribed before entering custody.

“We sometimes get phone calls from inmates themselves or from family members saying, ‘Can you please help me? My son isn’t receiving medication that he should be inside.’”

The inquest examined a 2021 case involving 44-year-old Justin Alexander Trudeau, who died five days after arriving at the Sudbury Jail to serve a 30-day sentence. A post-mortem found he died of pneumonia and blood poisoning caused by an antibiotic-resistant bacterial infection.

After hearing testimony from medical experts, correctional staff and health-care workers, the jury issued 13 recommendations aimed at preventing similar deaths. 

Jurors urged the Ministry of the Solicitor General and the Sudbury Jail to improve health-care staffing, including by adding overnight nursing coverage and reviewing doctor and nurse practitioner availability. 

They also called for better communication between guards and nurses during shift changes, clearer observation standards for inmates in segregation, and upgrades to cell doors and windows to allow officers to better monitor people in distress.

Other recommendations focused on improving infection control and medical monitoring.

The jury said inmates showing signs of bacterial or viral infection should be more closely observed and that staff should receive training to recognize symptoms of septic shock. Other recommendations include moving forward with electronic medical records, hiring a pharmacist or pharmacy technician to free up nurses’ time, and offering cultural awareness and trauma-informed training for staff working with Indigenous inmates and people with substance use disorders.

Berghammer said the same recommendations resurface after every inquest, yet little changes.

“For a number of years, I’ve been following inquests and it’s just incredibly heartbreaking because the recommendations from inquests are often the same,” she said. “The outcomes are the same, but there’s no pressure to actually improve the conditions for people inside or implement some of these recommendations.”

The government is not legally bound to implement inquest recommendations.