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.
Report sites inconsistent documentation, short inmate checks
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.
Naloxone given to at least 4 inmates in distress
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:
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Archer: The 30-year-old father, who had been on remand for drug charges for 15 months, died on Aug. 21, 2017. Inmates had reported he was non-responsive in his cell. Monteiro’s review found Archer was known to do drugs and records show he sought treatment but stopped taking methadone in jail after 10 months. It is unclear why. Archer had been disciplined for having contraband, including drug paraphernalia. Surveillance video appears to show him and other residents exchanging what might be drugs the day before he died. On the morning of Aug. 21, Archer’s cellmates called for help. Guards responded to find Archer unresponsive. Paramedics declared him to be dead later that morning. A post-mortem report identified drug toxicity to be the cause of his death.
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Petrovic: The 29-year-old father died on Nov. 28, 2017. He had been in the detention centre for over seven months on remand for drug charges. Petrovic experienced trauma growing up related to the war between Serbia and Croatia. One of his friends wrote a statement that was read by Smith. It said Petrovic and his girlfriend asked the friend to take care of their child while they sought help for their mental and physical health. The friend said Petrovic was “met with indifference at every level” and “as a society, we need to do better” when people ask for help. Petrovic’s file showed he had intensive drug rehabilitation needs, Monteiro said. Petrovic was disciplined for various offences and spent around 200 days in segregation over seven months. Surveillance video from the evening before he died appears to show him and another inmate using string to pass items between their cells. The next morning, a correctional officer found him unresponsive in his cell. Paramedics took him to hospital, where he was declared dead the next day. A post-mortem report said drug toxicity killed him.
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Sharp: Called John by loved ones, the 53-year-old died on Sept. 7, 2018. He had dealt with addiction and was institutionalized throughout his life. His sister-in-law read her statement as well as one written by his mother that said he was a beloved uncle. Sharp’s mother wrote she was not surprised to hear drugs killed her son, but she was shocked it happened in jail, where she thought he would be safe. She said her son was “respectful” and “loving,” but dealt with attention deficit hyperactivity disorder (ADHD) and felt as if he never fit in because he was mixed race. His sister-in-law told the inquest that when he was sober, Sharp would help her and his brother with their children. However, she said, Sharp didn’t have enough social support and kept turning back to drugs. She said he was a talented artist and helped inmates make greeting cards to send to loved ones. Sharp had been in jail for close to five months on remand for drug charges. Monteiro said Sharp’s file indicated several official complaints he made about his care. Health-care officials were seeing him for issues including nerve pain. On the day he died, Sharp had been in a cell with other inmates, one of whom said they heard him choking 15 minutes before he was found unresponsive, but did not call for help. Paramedics declared him dead soon after. Officials found a mix of heroin and fentanyl in his cell. Sharp’s post-mortem examination found fentanyl toxicity killed him.
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Golden: The 28-year-old father of three daughters died on Jan. 5, 2019, after reportedly telling a cellmate he had taken heroin while at court. He had been on remand for about 11 months on robbery charges. He did not have substance abuse noted on his offender record but had a record of misconduct in prison, including some related to drugs. On the day before he died, surveillance showed him passing objects to other inmates. Monteiro said it would be fair to interpret that as him smuggling contraband. After Golden died, his cellmate said he had taken at least one substance in the cell, was sweating and complained of a headache. There is no documentation of the cellmate reporting that. On the morning of Jan. 5, 2019 the cellmate called for help after finding Golden unresponsive. Paramedics declared him dead later that day and a post-mortem found the cause of death to be fentanyl toxicity.
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Debien: The 34-year-old father of two died March 21, 2019. He had been in the detention centre for about 14 months, serving a sentence for drug charges. His sister told the inquest “he would do anything for anyone” and he loved spending time with his family. She said corrections workers told her he was “wonderful” and that she still decorates his grave around each anniversary of his death. Debien was known to have suffered childhood trauma stemming from significant burns. He had been receiving treatment for substance abuse and was scheduled to start a treatment program in jail four days after he died. Monteiro’s review found that inmates reported seeing he needed help the night he died, attempting CPR and putting him back into bed. It was about 50 minutes before they called for help. Paramedics declared him dead later that night, and a sergeant found drugs in his cell. A post-mortem report lists his death as being due to drug toxicity.
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Soberal: The 46-year-old, who died on May 17, 2021, was close to his sister and the two protected each other, she told the inquest. She said he was adopted at age 3 and had trauma from living with a parent who couldn’t take care of him. As a teenager, he started using drugs and getting into trouble. The family moved to Hamilton, where he got a job waterproofing basements. His sister said he was proud of his work, and was also an excellent guitarist, but found it hard to stay sober after his adopted mother died in 2017. The family shared a memory of driving through a blizzard to visit Soberal for Christmas when he was at a treatment facility in Guelph one year. Soberal had been in the detention centre for under 24 hours on remand for drug charges when he died. His record noted mental health and substance abuse issues, and flagged him as being at risk for suicide. When he entered the jail, a health screening found he had symptoms of COVID-19 and opioid withdrawal. An officer found him unresponsive in his cell the next morning and paramedics declared him dead. A post-mortem found he died of drug toxicity.
On Tuesday afternoon, inquest lawyer Kristin Smith questioned Michael Viera, a senior official at the detention centre who worked as a corrections officer for 14 years prior to working in supervisory and management roles. Viera is currently deputy superintendent of administration.
The inquest is scheduled to hear from Wayne McKoy, the detention centre’s deputy superintendent of programs, on Wednesday.