Inquest into death in Niagara jail tells province to improve conditions for inmate mental health and drug use

Justin Chandler · CBC News

· Posted: Mar 05, 2025 4:00 AM EST | Last Updated: March 5

A caller coroner's inquest into the 2018 overdose decease of a antheral successful a Thorold, Ont., jail resulted successful 17 recommendations to forestall it to prevent similar deaths from happening in the future.

Those recommendations see amended tracking and assessing inmates' intelligence wellness and assessing the risk of having cause traffickers and users surviving unneurotic successful jail. 

The inquest into Jordan Case's death started Jan. 20 and was held virtually. It followed different successful the autumn that examined 5 men's drug-related deaths astatine the Niagara Detention Centre (NDC). That inquest ended with the assemblage making 66 recommendations aimed astatine preventing aboriginal deaths.

Case's decease was initially going to beryllium included successful the larger inquest but was examined separately for scheduling reasons. 

Case was 22 erstwhile helium was readmitted to the NDC aft an apprehension for spot crimes and probation breaches, according to an agreed connection of facts created for the inquest. Case had been imprisoned astatine the jailhouse 5 times betwixt September 2015 and August 2018 for other charges including assault.

Upon admittance to the jailhouse connected Sept. 21, 2018, Case told a caregiver helium had attraction shortage hyperactivity disorder, smoked meth regular and had been hospitalized for a heroin overdose, the inquest learned.

A doc referred him to be assessed for opioid agonist therapy, a aesculapian attraction for radical babelike connected opioids that works to suppress cravings and withdrawal, according to the agreed connection of facts. Case requested and declined attraction repeatedly passim his clip successful jail. 

Case was successful his compartment astir 23 hours a time with different inmate.

Death related to drugs but manner 'undetermined'

On Nov. 27, 2018, Jordan went to tribunal for an appearance. When helium returned, information unit scanned him and did not find contraband. 

Three days later, corrections officers responded to Case's compartment erstwhile helium acceptable disconnected a occurrence alarm. He said helium wanted to beryllium moved to a antithetic compartment truthful helium could beryllium by himself. He wasn't moved. Officers said Case did not look suicidal oregon intoxicated.

Around 9 a.m. the pursuing morning, an serviceman recovered Case successful his compartment unresponsive and called for help. Paramedics pronounced Case dormant astir 20 minutes later.

Officers did not find contraband successful Case's cell, but they did connected his cellmate. When asked what happened, the cellmate told an serviceman "it was not his responsibility that helium couldn't grip it," but refused to elaborate, the agreed connection of facts reads.

Jury recommends tracking, grooming and hazard assessments

Inquest jurors reply a bid of factual questions astir however a idiosyncratic died. They whitethorn find the decease to beryllium earthy causes, accident, homicide, termination oregon undetermined.

In this inquest, the assemblage recovered Case died owed to the "acute toxic effects of fentanyl and cocaine," but the manner of his death was "undetermined."

Jurors whitethorn determine to marque recommendations aimed astatine preventing aboriginal deaths. They bash not delegate blasted oregon ineligible work and the recommendations are non-binding. 

The assemblage directed its recommendations to the Ministry of the Solicitor General, which oversees jails, and NDC, connected Feb. 3.

They include:

• Regularly auditing the strategy utilized to way offenders to guarantee it is up-to-date.

• Correctional unit to see speaking with a idiosyncratic successful custody, who asked to beryllium moved from a shared cell, to find the reasons for their request.

• Exploring opportunities to "work collaboratively with families and section and provincial agencies to heighten rehabilitation and reintegration efforts."

• Thoroughly assessing the hazard of lodging known cause traffickers with known cause addicts earlier doing so.

• If a regular intelligence wellness cheque finds someone's intelligence wellness worsened, see conducting an in-depth assessment.

• Provide and clasp compulsory grooming for correctional unit connected dealing with radical successful crisis, including individuals with intelligence wellness issues and those astatine hazard of suicide.

• Recruit much societal enactment unit to guarantee determination is capable play sum astatine NDC.