Windsor man overdosed in jail after being denied addiction meds, coroner's inquest hears

A Windsor father of two died from a fentanyl overdose at a local jail just days after being denied a prescription for a drug that treats opioid addiction, a coroner's inquest heard Monday. 

Joseph Gratton, who was 31 at the time of his death, had asked a nurse for suboxone eight days before jail staff found him unresponsive in his cell on the night of Oct. 29, 2019. 

Gratton was being held at the South West Detention Centre, a provincial jail on the city's outskirts, while awaiting court proceedings on robbery and assault charges. 

It's so far unclear why Gratton wasn't prescribed the medication. The nurse involved in the decision is set to appear as a witness Tuesday.

But on the first day of the coroner's inquest, the jury and other participants heard new details about the circumstances surrounding his death nearly six years ago at a jail that's been repeatedly criticized for overcrowding and understaffing. 

The inquest heard that there were several factors that might have delayed the medical response to the incident, including missing keys to quickly open the cell door where Gratton and his cell mate, Blake Carter, were found unconscious on the floor just after 11 p.m. 

The correctional officer who first made the discovery also had a "history of conflict" with Gratton that prompted a police investigation, inquest counsel Julian Roy said. She was working overtime that night, and normally wasn't assigned to his area.

Coroner's inquests, which look at the circumstances around a death, are mandatory under law when someone dies in custody from non-natural causes. It's not a trial, but a jury is responsible for establishing basic details about the death, and can also craft recommendations to prevent future ones. 

Roy extended his condolences to Gratton's mother — who is involved in the process — before delving into an overview of the case Monday morning. 

"You trusted he was safe in a difficult time in his life," he said. 

"I hope you will get some answers about what happened."

Gratton had "a fatal level of fentanyl" in his blood, according to a postmortem exam report shown at the inquest. He also had a plastic baggy in his rectum. Separate testing showed it contained fentanyl.