The jury at an inquest into the 2011 death of an 18-year-old man who died of an overdose while in custody in Thunder Bay, Ont. has made more than two-dozen recommendations to prevent such deaths from happening in the future.

Cody Thompson-Hardy of Rocky Bay First Nation died in August 2011 after being transferred from the Thunder Bay District Jail to the Thunder Bay Regional Health Sciences Centre.

Based on evidence and testimony presented during the five-day inquest, which ended Friday, the jury determined his death was due to an accidental methadone overdose.

The jury returned after about four hours of deliberation on Friday with 27 recommendations aimed at the Ministry of Community Safety and Correctional Services, the Province of Ontario, the Thunder Bay Jail and the Office of the Chief Coroner.

Concerns raised about Indigenous inmates

The recommendations are not binding, but they're designed to raise awareness of gaps in service or other issues, and thereby prevent a death similar to Thompson-Hardy's from occurring again.

"I think the recommendations point to problems at the Thunder Bay Jail," said Emily Hill, one of the lawyers representing Thompson-Hardy's family. "The issue of over-representation of Aboriginal people in correctional facilities, and the treatment of Aboriginal people within correctional facilities, is well-known, and I think there was a real concern flagged in this inquest about the care that Aboriginal inmates can expect in facilities."

27 recommendations made

The recommendations include:

  • that the ministry train health care managers and staff to recognize signs of drug use and overdose, as well as on use of naloxone
  • the creation of an electronic health record system
  • that the Thunder Bay District Jail ensure Indigenous inmates have access to programming and private, one-on-one counselling
  • that the Thunder Bay District Jail provide young adult inmates with programs and services specific to them
  • that the province construct a new facility to replace the Thunder Bay District Jail, which would include an infirmary, counselling space, and separate housing for inmates who have been prescribed methadone

Hill said the recommendations will be sent to the relevant agencies or organizations, who each have one year to review the recommendations. They must then report back about whether they've accepted and will implement the recommendations or not.

The inquest was delayed for several years due to issues with Ontario's jury rolls, as well as an unrelated legal matter.

"It's been a very difficult process," Hill said. "I hope that having had it fully aired in the community, that that will allow the family some comfort."

Twenty people testified at the inquest, which began Monday, Oct. 16 and took place in Thunder Bay.

Cody Thompson-Hardy Inquest Final Verdict