OCC Inquest - Fagan and Pierre 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Names of the deceased: Ronald Fagan, Jacy Pierre
Held at: Thunder Bay, ON
From: January 18th
To: January 27th, 2016
By: Dr. Michael Wilson, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Fagan
Given Name(s): Ronald
Age: 21
Date and time of death: September 27, 2007 at 07:43 hours
Place of death: Thunder Bay Jail
Cause of death: Methadone toxicity
By what means: Accident

Surname: Pierre
Given Name(s): Jacy
Age: 27
Date and time of death: October 27, 2007 at 13:48 hours
Place of death: Thunder Bay Jail
Cause of death: Methadone toxicity
By what means: Accident

(Original signed by: Foreperson and Jurors)


The verdict was received on the 27th of January, 2016
Coroner's name: Dr. Michael Wilson
(Original signed by coroner)


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


Inquest into the deaths of:

Ronald Fagan and Jacy Pierre


Jury Recommendations

Joint Submission Jury Recommendations

To the Ministry of Community Safety and Correctional Services:

  1. The ministry shall build a new facility to replace the Thunder Bay Jail (TBJ). The design and constructions should address:
    1. fostering the physical and mental health of inmates
    2. meeting the programming needs of inmates
    3. eliminating overcrowding of inmates
    4. adopting the best design to prevent and address movement of contraband
    5. having enough segregation cells to meet the needs of the jail
    6. ability to better meet the needs of First Nations/Métis/Inuit inmates, including access to indoor/outdoor space for ceremonies.
  2. Ensure that each First Nations/Métis/Inuit inmate be asked to self-identify their community of origin, and; explore sharing this information with researchers and First Nations/Métis/Inuit communities.
  3. The ministry implement an electronic health record 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
  4. The ministry continue to reduce the incidence of contraband (drugs) entering provincial jails through using modern available technology such as body scanners and Drugloos. The Ministry prioritize the TBJ to receive new technology as soon as possible.
  5. Within the next 12 months, review the use of the Jail Screening Assessment Tool (JSAT) and consider adding additional validated questions regarding substance abuse or the utilization of a new assessment tool. If any changes are made or a new assessment tool is introduced, this information will be publicly available.
  6. The ministry shall:
    1. collect data and evaluate research to identify and determine best practices for providing services such as addiction and mental health programming to inmates in provincial remand institutions
    2. ensure this research considers but is not limited to such factors as the unique needs of First Nations/Métis/Inuit inmates, brief interventions and the challenges of providing services in remand environments
    3. consider a pilot project to implement any new assessments, programming, or other services identified
    4. make available the result of the research and pilot project to the public.
  7. Adopt the excerpts of the Clause inquest jury recommendations as outlined in Exhibit #22 as part of these inquest recommendations, and attached as Appendix “A”.

To the Thunder Bay Jail:

  1. Facilitate regular and frequent access to the TBJ by a canine (K9) unit (preferably a passive K9 unit), where such unit is reasonably available.
  2. Increase correctional staffing levels to enable inmates to have regular access to private counseling with Native Inmate Liaison Officers (NILOs), chaplains, elders and others.
  3. Review the roles of nurses, mental health nurses, social workers, and NILOs to identify gaps and areas that overlap. Following this review, eliminate overlap and increase staffing levels to ensure that counseling is given first priority.
  4. Use best efforts to ensure that TBJ always has a minimum of one NILO and that there are facilities to ensure that inmates have ongoing access to that person including a private space to speak with them.
  5. Ensure appropriate staffing levels and physical space such that Ministry and community-based support programs (including but not limited to Alcoholics Anonymous, Narcotics Anonymous, Canadian Mental Health Association, John Howard Society, First Nations/Métis/Inuit traditional counselors and Elders, and Ministry core programs) can be made available for remanded inmates at the TBJ.
  6. The TBJ shall request any inmate discharge summary from any health facility where the inmate consents.
  7. Provide additional mandatory training for all staff (including management) about the unique circumstances of First Nations/Métis/Inuit inmates and best practices for supervision of First Nations/Métis/Inuit inmates.
  8. Explore the feasibility of using the JSAT mental health assessment as part of the admissions process for all inmates.

To the Office of the Chief Coroner:

  1. If after a post-mortem of an inmate the Supervising Regional Coroner receives information about a possible threat to the health of other inmates, that information should be communicated to the superintendent of the appropriate institution.