Inquest for 6 inmates at Hamilton-Wentworth Detention Centre hears 5 of them died overnight

The inquest for six inmates at the Hamilton-Wentworth Detention Centre heard Tuesday that five of the men died overnight, one of several commonalities noted in testimony by a corrections consultant.

Andrea Monteiro addressed the jury on the second day of the Ontario coroner's hearings into the deaths of Jason Archer, Paul Debien, Nathaniel Golden, Igor Petrovic, Christopher Sharp and Robert Soberal. They all died of drug toxicity between 2017 and 2021, either in the Ontario government jail or in hospital.

The men, who were between ages 28 and 53, had lengthy criminal histories, Monteiro said, and five had notes on their files indicating they used drugs. Five of them were in the provincial jail for drug-related charges, with five on remand, meaning they were awaiting trial or sentencing. 

The inquest, which is mandatory under the Ontario Coroner's Act for people who die in custody, is expected to last about three weeks. Juries are tasked with answering five questions: who died, when, where, how and by what means (natural causes, accident, suicide, homicide or undetermined). They may make non-binding recommendations designed to prevent future deaths but aren't allowed to make findings of legal responsibility or blame. 

Monteiro began testifying on Monday, when lawyers for the coroner's office questioned the corrections consultant about a report the office hired her to prepare, outlining each man's stay at the detention centre and the circumstances of their deaths. Her report, drawn from over 8,000 pages of institutional documents, serves as a basis of facts for the jury.  

On Tuesday, Monteiro finished going through her report, then shared several common themes she identified through her review.

One theme was inconsistency in documentation. Monteiro said there was variability in how corrections used certain logs and in some cases, handwritten information was illegible.

When it came to corrections staff conducting checks on inmates, Monteiro said logs show rounds often being under one or two minutes. In some cases, she said, corrections officers recorded being unable to clearly see residents in their cells at night.

The public, virtual inquest is scheduled to hear from about 15 witnesses, including senior leaders at the jail, health-care workers, a physician with expertise in substance use disorder, a panel of Hamilton Public Health staff and officials with the Ministry of the Solicitor General, which oversees corrections in the province. 

There are several parties to the inquest (people allowed to question witnesses), including the families of Sharp and Soberal, and lawyers representing the John Howard Society of Ontario and the Prison Harm Reduction Coalition. The five jurors may also ask witnesses questions.

Vilko Zbogar, lawyer for the Prison Harm Reduction Coalition — a group of community organizations in the Hamilton-Niagara area that support drug users and prisoners — asked Monteiro several questions about naloxone administration.

Her review showed jail workers gave the drug, which works to reverse the effects of an opioid overdose, to at least four of the men when they found them in medical distress prior to their deaths. Zbogar pointed out it often took five to 10 minutes for staff to administer the drug.

On Tuesday, the inquest was also shown photos of the six men, some showing them as children or with family.

Here's some of what jurors have already heard about each man and images of each: