'It's finally coming forward': Inquest into 8 jail deaths begins after years of delay

After years of delay, the inquest into the deaths of eight men who died while in custody at the Hamilton Wentworth Detention Centre is finally underway.

The inquest is taking place at the Hamilton Plaza Hotel and Conference Centre

Amy McKechnie, left, sat with April Tykoliz on day one of the inquest into the deaths of eight men who overdosed while in custody. (Flora Pan/CBC)

After years of delay, the inquest into the deaths of eight men who died while in custody at the Hamilton-Wentworth Detention Centre is finally underway.

It began Monday morning with family members of the men, all who died after drug overdoses at the the jail between 2012 and 2016, filling two rows at the Hamilton Plaza Hotel and Conference Centre.

"All of us here, myself included, and the parties withstanding, are here for one reason. We want to prevent similar deaths in the future," said coroner counsel, Karen Shea.

Family members sat quietly while Shea named each of the men and described the moments leading to their deaths. Louis Angelo Unelli, William Acheson, Stephen Conrad Neeson, David Michael Gillan, Trevor Ronald Burke, Julien Chavaun Walton, Marty Tykoliz and Peter Michael McNelis all died while in custody.

When Shea read out the name Marty Tykoliz, his picture came up on a monitor in the room. He died in 2014 after overdosing on powdered methadone. As Shea told the story of Marty's last few moments, his sister April watched in tears.

"I'm feeling relieved. It's finally coming forward," April Tykoliz said.

Marty Tykoliz was first sent to hospital for an overdose in spring 2014. He overdosed a second time the next day — and died in hospital.

Sitting with her was Amy McKechnie, a woman who said she lost her brother Ryan to a drug overdose in 2017.

McKechnie said she found April Tykoliz through reading about her brother in the newspapers.

"We've been each other rock, we've become soul sisters," McKechnie said.

"We've forged an unbreakable bond out of the death of our brothers, unfortunately. But it's them that brought us together, ultimately."

Marty Tykoliz (left) and his sister in better times. The 38-year-old Hamilton man died in hospital after a suspected overdose inside the Barton Street Jail Tuesday. (Facebook)

Monitoring inmates

Shea said the inquest will be looking into policies for delivering health care to inmates and monitoring inmates who have substance abuse issues, among others.

The goal, she said, is to find a balance between "both security concerns and treating it as a health care issue as well."

The first person to testify was Michael DuCheneau, the staff sergeant for operations at the detention centre. Shea went over the layout of the jail, policies for monitoring inmates and body search policies with DuCheneau for day one.

The morning was spent poring over the jail layout and policies for body searches, and also the location of cameras in the jail.

As it turns out, officers who do patrols do not have access to CCTV footage to do real-time monitoring.

DuCheneau said that only senior administrative staff and the security manager have access to that footage, and it's usually used for "post-incident" situations.

He explained they don't have real-time monitoring because of funding, privacy laws and also the fact that surveillance cameras do not pick up sound or smell.

He said the idea is for the officers to make their patrols and interact with inmates to find out what's going on, and to develop a rapport.

"If we just had the cameras, a lot of them would not make their tours, or we believe they would not make their tours," he said.

The inquest, which was originally called back in 2015, was repeatedly pushed back until it was officially set earlier this year for January of 2018. Then it was delayed yet again to April. (Adam Carter/CBC)

When inmates return from the hospital

Shea asked how inmates are monitored once they return from a health-care facility after a medical emergency.

Currently, the detention centre is supposed to be staffed around the clock with at least one medical staff member.

However, sometimes no one is available. This happens when a medical staffer is on sick leave, or no one is available to fill the shift.

How often inmates are checked also depends on information provided by hospital staff. There is a form that comes back with each person, and hospital staff are expected to fill it out so the detention centre health unit can monitor the inmate accordingly.

"That's what we expect. We don't always get that," DuCheneau said.

If there is no additional information, it'll be a "standard two-hour observation for head watch," DuCheneau said. That's when inmates are woken up to check for an "articulate response" to show that they are doing fine.

Shea pressed DuCheneau, asking if there has been changes in that procedure following the death of Marty Tykoliz, who overdosed only hours after he was sent to hospital for an overdose.

"Well, they still get checked every 20 minutes as part of security patrol," he responded.

However, he said the patrol officers will only look inside the cell to check for "signs of distress" and destructive behaviour.

"If we look inside a cell and they appear to be asleep … we will not wake them," DuCheneau said.

'The drug culture is rampant'

Egan said "it's astounding" that even with multiple people dying from a similar problem, there has been no change at the ministry.

From what he heard today, Egan said, nothing suggests inmates have an environment to rehabilitate in detention centres. And the lack of effort in creating that environment may be part of why Marty Tykoliz died.

"The drug culture is rampant," he said. "There's no real programs to assist them, and nobody keeping an eye on them to make sure they don't go astray."


Flora Pan


Flora Pan is a multimedia journalist based in southern Ontario. She currently works out of Windsor. You can reach her at flora.pan@cbc.ca or on Twitter @FloraTPan.