Ministry of the
Solicitor General

OCC Inquest - HWDC

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: Louis Unelli, William Acheson, Trevor Burke, Martin Tykoliz, Stephen Neeson, David Gillan, Julien Walton, Peter McNelis
Held at: Hamilton, ON
From the: 9th of April, 2018
To the: 18th of May, 2018
By: Dr. Reuven Jhirad, Coroner for Ontario
having been duly sworn/affiremed, have inquired into and determined the following:

Surname: Unelli
Given name(s): Louis
Age: 40
Date and time of death: March 17, 2012 at 1 p.m.
Place of death: 165 Barton Street East, Hamilton, Ontario
Cause of death: Combined drug toxicity (oxycodone, hydromorphone and lorazepam)
By what means: Accident

Surname: Acheson
Given name(s): William
Age: 42
Date and time of death: September 12, 2012 at 8:14 a.m.
Place of death: 165 Barton Street East, Hamilton, Ontario
Cause of death: Heroin poisoning
By what means: Accident

Surname: Burke
Given name(s): Trevor
Age: 38
Date and time of death: March 25, 2014 at 5:15 a.m.
Place of death: 237 Barton Street East, Hamilton, Ontario
Cause of death: Combined drug toxicity (methadone, hydromorphone and bupropion)
By what means: Accident

Surname: Tykoliz
Given name(s): Martin
Age: 38
Date and time of death: May 7, 2014 at 2:05 a.m.
Place of death: 3237 Barton Street East, Hamilton, Ontario
Cause of death: Acute methadone toxicity
By what means: Accident

Surname: Neeson
Given name(s): Stephen
Age: 44
Date and time of death: February 15, 2015 at 9:56 a.m.
Place of death: 165 Barton Street East, Hamilton, Ontario
Cause of death: Combined drug toxicity (hydromorphone, gabapentin and topiramate)
By what means: Accident

Surname: Gillan
Given name(s): David
Age: 46
Date and time of death: May 19, 2015 at 8:27 a.m.
Place of death: 165 Barton Street East, Hamilton, Ontario
Cause of death: Combined drug toxicity (fentanyl, zopiclone and bupropion)
By what means: Suicide

Surname: Walton
Given name(s): Julien
Age: 20
Date and time of death: October 2, 2015 at 1:51 a.m.
Place of death: 237 Barton Street East, Hamilton, Ontario
Cause of death: Combined drug toxicity (fentanyl, lorazepam and zopilcone)
By what means: Accident

Surname: McNelis
Given name(s): Peter
Age: 47
Date and time of death: March 13, 2016 at 2:35 p.m.
Place of death: 165 Barton Street East, Hamilton, Ontario
Cause of death: Combined drug toxicity (cocaine, methamphetamine and fentanyl)
By what means: Accident

(original signed by Foreman and Jurors)


This verdict was received on the 18th of May, 2018
Coroner’s Name: Dr. Reuven Jhirad
(original signed by Coroner)


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


Inquest into the deaths of:

Louis Unelli, William Acheson, Trevor Burke, Martin Tykoliz, Stephen Neeson, David Gillan, Julien Walton and Peter Mcnelis


Jury Recommendations

Table of Contents

Harm Reduction from a Security Perspective


Harm Reduction from a Health Care/Health Promotion Perspective


Harm Reduction from a Security Perspective

  1. Admission Procedures

To: The Ministry of Community Safety and Correctional Services and the Hamilton-Wentworth Detention Centre:

  1. In order to ensure that all searches of inmates on admission are conducted in compliance with ministry policy, weekly audits must be conducted of Admission and Discharge search records.  In those cases where there is no record of a search of an inmate or the records are not in compliance with ministry policy, an unscheduled search of living units of the involved inmates should take place.  
  2. In order to reduce the risk posed by individuals who commit criminal offences to gain access to the detention centre for the purpose of introduction and distribution of contraband, at the time of admission, review previous placements and, where a request is made for a different placement with no apparent change in circumstances, report the request to the in-charge officer and, where feasible, place the inmate in a dry cell for observation.
  3. In order to ensure that screening for contraband is optimized through use of the Whole Body X-Ray Security Scanning System, within 3 months of this verdict:
    1. conduct a survey of correctional staff currently trained in the use of the device to determine if valid concerns exist regarding its operation and/or if additional training is required; and
    2. confirm that installed software is up-to-date.     
  4. In order to enhance screening capabilities and detection of contraband drugs at admission, explore the feasibility of increased use of the canine unit in the admission area, and the availability of other technology for drug screening.

To: The Hamilton-Wentworth Detention Centre

  1.  To ensure human dignity, health and safety of inmates, there should no more than two inmates per cell.
  2.  Explore the feasibility of establishing inmate to correctional officer ratio guidelines.

To: The Hamilton-Wentworth Detention Centre and the Hamilton Police Service

  1. In order to ensure that all available sources of information, including NICHE, are reviewed at the time of booking prisoners into custody and that information is made available to the Hamilton-Wentworth Detention Centre at the time of transfer of custody, within 3 months of this verdict, designate a liaison officer or officers from the Hamilton Police Service to meet with representatives of the detention centre with a view to:
    1. developing a standard Prisoner Information or Custody Report which includes information relating to any recent reports of suicide risk or possession of contraband and other information as reflected in the Ontario Provincial Police LE204 Form;
    2. exploring other means of information sharing with respect to reducing risks associated with the introduction of contraband into the detention centre. 

To: The Hamilton-Wentworth Detention Centre and the Ontario Provincial Police

  1. In order to ensure that all available information relating to suspicion of possession of contraband is provided to the Hamilton-Wentworth Detention Centre at the time of transfer of custody, ensure that, in all instances, a copy of the LE204 and LE205 is provided to the correctional officer to whom custody is transferred.

To: The Hamilton-Wentworth Detention Centre

  1. In order to ensure that all relevant information relating to risk of possession of contraband is obtained at admission, within 6 months of this verdict, develop a Prisoner Admission Form or checklist that confirms the following:
    1. where applicable, receipt of complete Prisoner Information or Custody Reports from transferring police agency;
    2. check of  OTIS management risk relating to history of possession of contraband upon admission to correctional institutions

  1. Search, Surveillance and Security procedures

To: The Hamilton-Wentworth Detention Centre

  1. In order to detect high risk situations that involve the presence or use of contraband, within 6 months’ time of this verdict, evaluate the feasibility of upgrading video monitoring capability within the facility to reflect more modern and comprehensive coverage, including:
    1. real-time monitoring of all living units, including cameras with capabilities to capture all   areas of the day room;
    2. improved monitors with higher resolution in the segregation unit to allow a clear picture of activity within cells with real-time monitoring; and
    3. live-feed monitors to be located in staff stations.
  2. In order to enhance searches of the institution and to develop expertise in the area of searches, within 3 months of this verdict, develop terms of reference for a dedicated Institutional Security Team and, within 6 months of this verdict, have the resources and staff in place to fully implement this search strategy.
  3. In order to ensure that contraband is not distributed between inmates through “fishing”, explore the feasibility of vertical pins or another barrier at the bottom of cell and range doors to prevent transfer of contraband between cells and living units.
  4. In order to ensure that contraband is not inadvertently transferred between inmates by correctional staff, all items should be inspected before they are provided to inmates.
  5. In order to increase the likelihood that all contraband is located and removed from a living unit after an inmate has experienced a suspected overdose and to ensure documentation that reflects a thorough search:
    1. all cellmates of the inmate should be immediately removed from the cell and strip searched before placement in another cell that is not occupied by other inmates;
    2. the cell of the inmate should be sealed pending a search of the cell that includes a search of the toilet, the vents and, where feasible a search by the canine unit:
    3. within 6 hours of the suspected overdose, all cells of the living unit and the day room should be subject to a search that includes, where feasible, a search by the canine unit;
    4. within 6 hours of the suspected overdose, all inmates of the living unit should be subject to a strip search and scanning with the Whole Body X-Ray Security Scanning System;
    5. the search subsequent to the suspected overdose should be documented on a dedicated form, “Critical Incident Search Record” that will include a record of the following:
      1. names of inmates searched and individual results for search of each inmate
      2. individual results for search of each cell
      3. results from search of all other areas of the living unit
  6. In order to reduce the risk of continued presence of contraband on a living unit subsequent to a suspected overdose, the search should be conducted by the Institutional Security Team (as recommended above).  If the Institutional Security Team has not been implemented within 6 months of this verdict, all correctional staff should receive training regarding current search methods.   
  7. In order to reduce the risk associated with recent detection of drug contraband on a unit, and to improve screening procedures, detailed audits of all relevant recent admissions should be undertaken within 48 hours, including a review of Whole Body X-Ray scans performed on those suspected of bringing the contraband into the facility.
  8. In order to ensure that ministry policies relating to record keeping are followed,
    1. regular audits should be undertaken at the Hamilton-Wentworth Detention Centre to identify deficiencies in logbooks, security checks and record keeping by corrections staff and to take any appropriate corrective measures.
    2. within 6 months evaluate the feasibility of implementing electronic record keeping including log books, for entry and locking of information relating to unit activities.
  9. In order to ensure compliance with written policies regarding security checks, inmate supervision, head watches, cell searches and other security and safety requirements, regular audits, including review of video recordings, should be undertaken.
  10. In order to improve the ability to detect inmate activity that may involve contraband drugs, an evaluation of security rounds and, in particular, night security rounds, should be conducted to determine if changes should be made to ensure that correctional officers are adequately trained and equipped to recognize inmates who may be at risk of overdose.
  11. In order to increase detection of the presence of drug contraband:
    1. consideration should be given to one or more dedicated canine search teams for the Hamilton-Wentworth Detention Centre to increase frequency of canine searches and training of dogs should be expanded to include additional types of drugs
    2. other technologies designed to “sniff” out drugs should also be explored
    3. staff should be trained to recognize by sight and smell the various contraband drugs typically found at HWDC
    4. staff should be trained in proper investigative techniques to detect and respond to suspected substance abuse.]
  12. In order to ensure that inmates found in possession of contraband drugs are assessed for possible drug dependency issues, reports relating to found contraband must be provided to health care staff (i.e. nurses, physicians, social workers) for appropriate follow-up.
  13. In order to improve rapport and enhance information sharing between inmates and correctional staff, review current staffing procedures and, where feasible, offer permanent assignments to specific living units.
  14. In order to reduce the risk of contraband entering the Hamilton-Wentworth Detention Centre, consideration should be given to ways of preventing staff and other visitors from bringing in contraband.  Random searches of staff and others should also be considered.
  15. Every effort should be made to identify the specific type of all found contraband drugs.

  1. Training and Professional Development

To: The Ministry of Community Safety and Correctional Services and the Hamilton-Wentworth Detention Centre

  1.  In order to ensure the health and security of inmates, consideration should be given to the following recommendations:
    1. As part of regular community escort training, procedures specific to hospital settings should be developed
    2. Ensure all Correctional staff are aware of new and existing forms and their accurate completion with regard to inmate safety and security.
  2. Make opioid information and mental health training a part of the training for new correctional officers.
  3. Opioid, mental health, and suicide awareness training should be rolled out to all employees who have not had it within the last 6 months, and refresher training should occur every 730 days or sooner if required.
  4. Establish e-learning for policy review.
  5. In order to support correctional and healthcare staff following a critical incident (i.e., death from drug overdose) all parties involved should be convened, in a timely manner, to review all aspects of the incident (i.e., procedures, future recommendations).

Harm Reduction from a Health Care/Health Promotion Perspective

  1. Admission Procedures

To: The Hamilton-Wentworth Detention Centre

  1. In order to ensure complete and accurate health information at the time of admission for all inmates, within 6 months of this verdict, develop a strategy to introduce an internal electronic health record at the Hamilton-Wentworth Detention Centre, with a view to implementation as soon as possible.
  2. In order to respect the dignity of all inmates and promote the disclosure of personal health care information at the time of admission, including information relating to drug dependencies or substance misuse, conduct the Part A health assessment in a manner that maintains the confidentiality of that health care information.  Unless a specific request has been made by health care staff or the inmate, the health care interview at admission should be conducted in the absence of correctional staff or with correctional staff  maintaining a distance that allows for privacy.
  3. In order to assist health care staff in assessing the health care needs of inmates and develop plans of care, the health care team (i.e. nurses, physicians, social workers) should have access at the time of the Part A assessment to the medical and legal history of the inmate particularly with respect to drug abuse and other mental health issues.
  4. In order to identify needs and enhance the well-being of inmates during their period of detention, all inmates should be assessed by the Social Work department within 48 hours of admission. The Social Work department should have access to the medical and legal history of the inmate.
  5. In order to ensure continuity of care and to establish a plan of care that is compatible with health care services offered in the community, all inmates should be assessed by a physician within 24 hours of admission.

  1. Re-admission Procedures after Hospital Transfers for Overdose Treatment

To: The Hamilton-Wentworth Detention Centre and Hamilton Health Sciences

  1. In order to identify appropriate follow-up observation and/or monitoring that may be required at the Hamilton-Wentworth Detention Centre after discharge from hospital, within 6 months of this verdict, establish a working group that will further improve the communication of discharge instructions to assist HWDC with the provision of health care services to the inmate at the detention centre. ​

To: The Hamilton-Wentworth Detention Centre

  1. In order to ensure proper monitoring of inmates returning from hospital after drug overdoses, health care staff should be immediately notified of the return of the inmate and a plan of care should be developed including frequency of checks, nature of the checks, recording of information and observations that require notification of health care staff and escalation of care.  Ideally, monitoring should be conducted by health care staff and, at a minimum, should be done every 30 minutes with assessment of the following:
    1. level of consciousness
    2. heart rate
    3. blood pressure
    4. oxygen saturation
  2. In order to prevent subsequent overdoses, inmates returning from hospital after treatment should be subject to full screening and body scanning procedures.

  1. In-Custody Health Care Services

To: The Ministry of Community Safety and Correctional Services and the Ministry of Health and Long Term Care

  1. In order to increase accountability and ensure that health care services for in-custody individuals are similar to those offered in the community, commit to the transfer of provision of health care and delivery of public health programs in correctional remand facilities from MCSCS to MOHLTC. Develop a timeline for this transfer.

To: The Hamilton-Wentworth Detention Centre, Hamilton Health Sciences and other public hospitals providing treatment and care to inmates of HWDC

  1. In order to facilitate and streamline the treatment and care of inmates, within 6 months of this verdict, establish a working group to improve communication, including the sharing of personal health information as required or permitted by law.

To: The Ministry of Community Safety and Correctional Services

  1.      In order to promote and encourage inmate use of available health care services:
    1. revise the “Inmate Information Guide for Adult Institutions” to be Hamilton-Wentworth Detention Centre specific, and to include information relating to the availability of social work services, the process for making requests to health care and social work services and information regarding the principles of the Good Samaritan Drug Overdose Act.  Provide a copy of the guide to each inmate upon admission. The information guide should be reviewed during the social work assessment
    2. advise new and returning inmates by nursing staff on admission that incarceration represents an opportunity to address drug dependencies or mental health issues, that help is available and that efforts will be made to assist them rehabilitate and reintegrate into society
    3. develop a policy that maintains confidentiality of health-related requests and ensures that health-related requests are addressed in a timely manner
    4. unless a specific request has been made by health care staff or the inmate, any health care appointments should be conducted in the absence of correctional staff or with correctional staff maintaining a distance that allows for privacy.

To: The Hamilton-Wentworth Detention Centre

  1. In order to improve communication between health care staff and correctional staff, consideration should be given to weekly case management meetings regarding needs of all inmates.
  2. In order to ensure consistency of care, briefing should occur between health care staff at shift change and report forms should be readily available to staff, in accessible locations, to document care that needs to be communicated on their shift, as well as subsequent shifts.

  1. Addressing Opioid Dependency and Response to Opioid Overdoses

To: The Ministry of Community Safety and Correctional Services and the Hamilton Wentworth Detention Centre

  1. In order to assess and monitor inmates with identified drug dependencies, those inmates should be required to attend mandatory meetings with health care staff within 24 hours of admission to develop plans of care and thereafter on a weekly or bi-weekly basis to track progress and ongoing issues.  Meetings should include discussions about treatment, “triggers” and ongoing medication.
  2. Opioid Agonist Therapy (OAT) initiation should not be contingent on first identifying a community OAT prescriber.
  3. In order to manage opioid withdrawal in a consistent manner and to address the community opioid crisis, the April 17, 2018, policy in regard to the revised Methadone Maintenance Treatment and Opioid Withdrawal Management Policies should be communicated to all health care staff, correctional staff and inmates and should be immediately implemented.
  4. In order to enhance surveillance and monitoring of opioid overdoses in the correctional setting, develop a standard reporting form regarding the administration of Narcan by health care staff as well as correctional officers.
  5. In order to mitigate the risk of hoarding or diverting opiate withdrawal medication, unless contraindications exist, use current evidence-based practices, including the prescribing of Suboxone, rather than methadone, as the preferred medication for opioid use disorders.
  6. In order to provide a timely response to suspected opioid overdoses, within 6 months of this verdict, equip all correctional officers with Narcan and provide training for its use.  Ideally, training should be offered in collaboration with the local public health unit or other local community services.
  7. Place Narcan kits in every guard station, admitting and discharge area, medical stations, and in other locations where they will be immediately accessible by correctional staff.
  8. When Narcan is administered and/or an overdose occurs the inmate should be sent to hospital.
  9. In order to ensure appropriate and timely responses to opioid overdoses, within 6 months of this verdict, develop a training program for correctional staff that includes the recognition of signs and symptoms of opioid overdose, the importance of airway management and the administration of Narcan (nasal form) pending the arrival of emergency medical personnel.
  10. In order to ensure a rapid and co-ordinated response to suspected opioid overdoses:
    1. Code White Kits/Carts should be marked “CONTENTS FOR USE BY MEDICAL PERSONNEL ONLY” and equipment and contents of the Code White Kits should not be shared and/or passed on to Security Personnel
    2. Code White Kits should be available on each level of the Hamilton-Wentworth Detention Centre
    3. Regular inspection of the Code White Kits to ensure the contents are complete and in good working order
    4. Ensure medical personal are trained on all equipment in the Code White Kit.
  11. In order to reduce the risks associated with substance use while in custody and to reduce harm associated with opioid overdoses while in custody and shortly after discharge:
    1. provide inmate education and programs to raise awareness regarding the risk of opioid intoxication and overdose; preventing overdose; signs of overdose; and response to suspected opioid overdoses
    2. develop alternate responses to misconducts involving possession of contraband where suspected overdoses are reported to correctional or health care staff (refer to the Good Samaritan Drug Overdose Act)
    3. provide CPR training to interested inmates
    4. continue to educate and encourage all inmates regarding the use and availability of Naloxone Home Kits upon discharge.
  12. In order to enhance inmate education regarding drug dependency and abuse, programs and other initiatives to address drug dependency and abuse should be encouraged, prioritized and promoted by posters or other means in prominent places throughout the facility where they are likely to come to the attention of inmates.  Consideration should be given to additional poster space inside each unit and/or immediately outside the unit where it can be read by inmates.  Consideration of streaming short video clips or other helpful information via the television screens on each living unit should also be given.
  13. If, at any time, a program intended to assist inmates with substance abuse issues is cancelled for operational or other reasons, a report should be generated detailing the reason for the cancellation and corrective measures provided to ensure inmates do not miss opportunities to learn how to identify and use methods to reduce harm in the future.
  14. Require the Hamilton-Wentworth Detention Centre to record and keep track of:
    1. number of suspected overdoses, and general circumstances (date, time, unit, result);
    2. doses of Narcan administered (date, time, location, by whom, dosage)
    3. information including date, time, and location in order to help track the number of suspected overdoses, and the results of interventions in response to overdoses. 

To:  The Ministry of Community Safety and Correctional Services; Ministry of Health and Long Term Care; Hamilton-Wentworth Detention Centre and Hamilton Public Health

  1. In order to increase awareness of access to the Take Home Naloxone Program for inmates at discharge, provide the necessary resources to expand the training program delivered by Hamilton Public Health to include male inmates.

  1. Recognizing and Improving Social Determinants of Health

To: The Ministry of Community Safety and Correctional Services

  1. In order to transform the way that health care is delivered in correctional facilities and to recognize and meet the complexity of health care needs of the inmate population, continue consultation with community service providers regarding the integration of community resources pre- and post-discharge and how correctional facilities can define and measure progress in meeting the health care needs of incarcerated persons improvement of health outcomes.

To: The Ministry of Community Safety and Correctional Services and the Hamilton-Wentworth Detention Centre

  1. In order to address unhealthy living conditions associated with overcrowding, lack of fresh air and lack of recreational activities, within 6 months of this verdict, provide the necessary resources to hire four (4) recreational staff and allow access to the gymnasium for physical activities.
  2. In order to improve outcomes upon release from custody, in the weeks and months prior to release, inmates should be given information and opportunity to connect with programs, community resources, and any other agencies that can assist in reintegration in the community, including: Drug Dependency Programs, Counselling Services, Job Help/Resume writing, and Assistance in finding Living Arrangements.   

To: The Hamilton Wentworth Detention Centre

  1. Identify existing linkages for community health and social service providers and ensure all staff and inmates are made aware of them.
  2. Continue to explore additional community services to form partnerships with the Hamilton-Wentworth Detention Centre