OCC Inquest - Hagen 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Hagan
Given name(s): David
Age: 36

Held at: Napanee
From: Oct. 19
To: Oct. 20, 2017
By: Dr. Gautam Walia, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: David Robert Hagen
Date and time of death: Sept. 17, 2015 at 7:12 a.m.
Place of death: Joyceville Institution, Kingston, ON
Cause of death: Heroin toxicity
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 20 of Oct., 2017
Coroner's name: Dr. Gautam Walia
(Original signed by coroner)


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


Inquest into the death of:

David Robert Hagen


Jury Recommendations

  1. Correctional Services of Canada to consider the implementation and use of full body scanners in all federal correctional institutions, with regards to all persons entering the institution.
  2. Continue to increase collaboration between Kingston Frontenac Lennox and Addington Public Health and local federal correctional institutions mandated to provide Coroner’s inquests in respect to inmate deaths, where appropriate, within a reasonable time period.