Inquest into inmate's death at EMDC results in 11 recommendations

After a five day inquest, jurors examining Michael Fall's death at Elgin-Middlesex Detention Centre say he died by accidental fentanyl overdose. The 47-year-old inmate was in custody at the south London, Ont. jail when he died on July 30, 2017. 

The coroner's jury said therapy for anyone witnessing a death is necessary and guards should carry naloxone

Crosses rest against a fence at London's Elgin-Middlesex Detention Centre. The jail has seen 15 deaths in the last decade, some of them from apparent opioid overdoses. (Hala Ghonaim/CBC)

After a five day inquest, jurors examining Michael Fall's death at the Elgin-Middlesex Detention Centre (EMDC) found he died by an accidental fentanyl overdose and are proposing 11 recommendations to improve safety for other inmates.

Fall, 47, was in custody at the south London, Ont. jail when he died on July 30, 2017.

Fifteen other 15 inmates have died at EMDC in the last decade but only four inquests have been held. Under the law, they are mandatory when an inmates dies in jail.

This one, which wrapped up Friday, saw the jury recommend correctional officers carry nalaxone kits at all times.

They also proposed that the province ensure therapy is available for correctional officers, nurses and inmates who witness a death.  

The jury said improved monitoring, such as synchronizing clocks on security cameras, and staff log books to record inmates found to be in possession of contraband drugs, could prevent further overdoses. 

(Paula Duhatschek/CBC)

Recommendations for the Minister of the Solicitor General:

  • Implement an electronic health record to improve monitoring of substance abuse and communication between health care providers. 
  • Review counselling services offer to correctional officers and nurses who witness death. 

Recommendations for EMDC:

  1. Implement a Direct Observation model in all units at EMDC.
  2. Reinforce a policy requiring correctional officers to regularly visit "living units during night shifts 
  3. Use a log sheet to inform correctional staff about inmates found in possession of contraband drugs or suspected to be under the influence. 
  4. Develop policy to ensure that a social worker, counsellor or other staff speak to inmates after witnessing a death, as soon as possible. Offer trauma- informed services to these inmates. 
  5. Assign correctional officers to living units in teams for at least six months at a time, instead of "rotating" schedules. 
  6. Increase the number of correctional officers on night shift to make sure at least one officer is on each unit at all times. 
  7. Put a policy in place so that nurses responding to emergencies have a radio and portable first aid kit. 
  8. Ensure that clocks on security cameras and monitors are synchronized. 
  9. Make sure correctional officers have a intranasal naloxone kit on them at all times.  

Another death

Earlier in the week, another jury overseeing the second trial of corrections officer Leslie Lonsbary could not reach a verdict on whether the guard had failed to provide the necessaries of life the night inmate Adam Kargus died.

Kargus was beaten to death by his cellmate Anthony George on Oct. 31, 2013. George pleaded guilty to second-degree murder in 2017 and is serving a life sentence with no chance of parole for 10 years