OCC Inquest - Coaster 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Coaster
Given Name(s): Christopher Dennis
Age: 29

Held at: Thunder Bay, Ontario
From: June 8
To: June 10, 2016
By: Dr. Michael Wilson, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Christopher Dennis Coaster
Date and time of death: August 3, 2008 at 12:30 p.m.
Place of death: Thunder Bay Jail
Cause of death: Delirium tremens
By what means: Natural

(Original signed by: Foreperson and Jurors)


The verdict was received on June 10, 2016
Coroner's name: Dr. Michael Wilson
(Original signed by coroner)


We, the jury, wish to make the following recommendations:


Inquest into the death of:

Christopher Dennis Coaster


Jury Recommendations

To the Ministry of Community Safety and Correctional Services (‘the ministry’):

  1. The ministry shall build a new facility to replace the Thunder Bay Jail. The design and construction should address:
    1. Fostering the health of inmates
    2. Eliminating overcrowding of inmates
    3. Adopting the best design to provide in house medical care to inmates from intake assessment to appropriate continuing monitoring and provision of medical care to inmates within the jail.
    4. Having enough medical observation beds and medical segregation cells to meet the needs of the present and anticipated population of the jail.
  2. The ministry implement an electronic medical record system to:
    1. Facilitate continuity of care through improved communications among professionals and enable safe clinical decision making
    2. Improve the ability to monitor health status, including substance use disorders and outcomes over time
    3. Enhance appropriate utilization of services, including health-related programs
    4. Collect data for future resource program planning, research or education
    5. Conduct quality of care reviews
    6. Develop an alert and notification system to ensure compliance with provincial standards of care (e.g. CIWA-Ar scoring thresholds)
  3. Explore with CAMH the revision to the present CIWA-Ar screening tool to include language that:
    1. Scores between 10-20 require consultation with a physician directly or through the Ontario Telehealth Network
    2. scores of 20 or greater require automatic inmate transfer to the hospital
  4. Ensure that the training for Health care staff includes both the Provincial Orientation Manual and case studies such as the one involving Mr. Coaster to personalize and illustrate the importance of adhering to Provincial Standards. Regular and timely review of all coroner inquest recommendations that relate to deaths in correctional facilities as a source of continuing education

To the Thunder Bay Jail:

  1. Review the duties of nurses, correctional officers, and operational managers to identify gaps in the health care needs of inmates and address any that may exist. For example, the use of medical observation forms by correctional officers to assist in health care decision making and regular debriefing between medical staff and correction officers.
  2. Management of the Thunder Bay Jail should review both the health care and correctional officer staffing levels to ensure compliance with Provincial Standards. For example, the ability of nurses to administer the CIWA-Ar assessment tool and conduct re-assessments every 1-2 hours or as required.  Management shall request additional staff from the Ministry if and as required.
  3. That all staff receive additional and ongoing training on alcohol withdrawal and Delirium Tremens ('DTs') conditions in the inmate populations.
    1. In particular the medical (nursing and contract physician) staff be trained on the proper utilization of Alcohol Withdrawal Assessment tools (CIWA-Ar, and the Management of Alcohol Withdrawal Policy and Procedures)
    2. All non-medical staff receive awareness training on signs and symptoms of alcohol withdrawal and DTs.
  4. Explore additional options for the management of dehydration in inmates experiencing symptoms of alcohol withdrawal.
  5. Until an adequate infirmary is made available all inmates being assessed with the  CIWA-Ar  form with scores between 10-20 require a one to one correctional officer watch.