Jury makes 39 recommendations after inquest into 2018 death of Brennan Bowley, 23, at Barton jail

Desmond Brown · CBC News

· Posted: Apr 29, 2025 4:00 AM EDT | Last Updated: 1 infinitesimal ago

A coroner's inquest into the 2018 overdose decease of a 23-year-old antheral astatine the Hamilton-Wentworth Detention Centre ended precocious with the assemblage making dozens of recommendations to forestall akin deaths astatine the installation successful the future.

Brennan Bowley died conscionable aft 10:30 p.m. connected Jan. 18, 2018. His cousin, Maggie Cleland, told CBC News astatine the clip that Bowley had a pouch of cocaine wrong his assemblage and it ruptured, causing him to accidentally overdose.

"They lacked immoderate benignant of aesculapian attention," Cleland said astir the centre. "He was asking for assistance successful the holding cell."

Hamilton constabulary arrested Bowley connected Jan. 16, 2018 portion investigating him for drug-related offences. His death was just 1 of respective to hap successful the instauration successful caller years.

Last August, the Ontario authorities announced that inquests volition beryllium held for six men who died portion successful custody oregon aft transportation to infirmary from the centre.

The inquest was held from April 7 to 22 to analyse the circumstances surrounding Bowley's death. 

The jury's verdict, handed down connected April 22, recovered that Bowley's origin of decease was toxicity caused by mixed drugs that included fentanyl, methamphetamine and cocaine, and the mode of decease was an accident.

The verdict besides answered 3 much questions: Who died? When did they die? Where did they die? 

In summation to its verdict, the assemblage made a full of 39 recommendations — 5 to the Hamilton Police Service (HPS), 4 to the Hamilton Wentworth Detention Centre (HWDC), 29 to the Ministry of the Solicitor General, and a azygous proposal to the Office of the Chief Coronor for Ontario, that it "should proceed to strive to behaviour inquests successful a timely mode from the day of death."

Jury: Warn suspects of risks of ingesting/secreting amerciable drugs

Among the recommendations to Hamilton police, the assemblage suggested that during the booking process into a constabulary station, each idiosyncratic charged with 1 oregon much transgression offences should beryllium verbally cautioned and work a informing of the risks of ingesting and/or secreting amerciable drugs and/or substances and the aesculapian consequences of not sharing that information. 

"Prominently displayed signage to the aforesaid effect should beryllium pointed retired to the person. The idiosyncratic should beryllium required to admit that they person work the caution, oregon person had the caution work to them, and that they recognize the caution. The clip and the information of the acknowledgment should beryllium documented successful the booking apprehension form," the proposal reads.

They besides recommended that utilizing wide language, notices shall beryllium posted successful the courthouse (in an country disposable to wherever prisoners are housed) and constabulary stations successful Hamilton providing acquisition pertaining to the protections offered done the Good Samaritan Drug Overdose Act and the applicable limitations of same. 

"Said notices should gully attention, frankincense encouraging their review, possibly done the usage of ample font sizes, bolded text, and usage of colour," the assemblage said.

Include inmates' health-related observations successful aesculapian records

To the HWDC, it's recommended that erstwhile the HPS transfers custody of an idiosyncratic to the centre and provides immoderate unwellness oregon health-related observations regarding that idiosyncratic during their clip successful constabulary custody, "the detention centre shall see those observations successful the individual's aesculapian records arsenic portion of the admittance process to guarantee detention centre health-care unit person the champion disposable accusation disposable erstwhile assessing that idiosyncratic astatine the clip of admittance and astatine immoderate different clip portion that idiosyncratic is successful custody (while besides ensuring confidentiality of aesculapian accusation from non-medical staff)."

It's besides recommended that health-care absorption of the HWDC shall notify correctional absorption arsenic soon arsenic it becomes known that a caregiver volition not beryllium contiguous connected immoderate fixed shift, and applicable argumentation oregon policies shall beryllium updated accordingly. 

The assemblage recommends to the Ministry of the Solicitor General that during incarceration, health-care unit volition proceed to amended inmates connected however to respond appropriately to imaginable cause overdose risks and supply consciousness of Good Samaritan authorities to promote timely aesculapian involution wherever necessary. 

"Acknowledgment of these conversations should beryllium documented wrong healthcare staff's records," the proposal reads.

"The Ministry shall make a acceptable database of questions astir whether an idiosyncratic being admitted to the detention centre has ingested drugs oregon inserted drugs into their body, and health-care unit shall beryllium required to inquire these questions of each individuals being admitted to the detention centre, careless of whether health-care unit fishy specified individuals person ingested oregon inserted drugs.

"The Ministry should proceed to research however to optimize health-care staffing levels astatine each institutions with the extremity of 24-hour nursing attraction sum arsenic good arsenic ideally having much than 1 caregiver connected displacement astatine immoderate fixed clip astatine the HWDC," the assemblage continued.

Inquests are called by a coroner aft a decease to marque recommendations to forestall akin deaths successful the future. A assemblage tin urge procedures for governing bodies to adhere to, though they are nether nary work to bash so.