Ministry of the
Solicitor General

OCC Inquest - Henke 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Henke
Given name(s): Ryan
Age: 29

Held at: Napanee
From: April 11, 2018
To: April 12, 2018
By: Dr. Gautam Walia
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ryan Henke
Date and time of death: February 19, 2016 at 2:30 p.m.
Place of death: Collins Bay Institution, Kingston, ON
Cause of death: Accident
By what means: Acute combined fentanyl and doxepin toxicity

(Original signed by: Foreperson)


The verdict was received on the 12 of April, 2018
Coroner's name: Dr. Gautam Walia
(Original signed by coroner)


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


Inquest into the death of:

Ryan Henke


Jury Recommendations

  1. With respect to Collin's Bay Institution, Correctional Services Canada institutes another Stand To Count in the morning hours, or changes the 3:45 p.m. Stand To  Count to a Stand To Count in the morning.  
  2. Correctional Services Canada to consider making Naloxone Kits directly available and accessible to inmates in common areas.
  3. Correctional Services Canada institute private, confidential programs focused on drug use and abuse, including addictions counselling that are accessible to all inmates.
  4. Correctional Services Canada partners with the local Health Units in inviting them to provide ongoing direct education about prevention and harm reduction for substance abuse for all willing inmates.
  5. Correctional Services Canada should communicate clearly to all staff who are directly involved with inmates what harm reduction strategies are available to inmates with respect to drug use and abuse.
  6. At Collin's Bay Medium Institution, Correctional Services Canada ensure that staff are complying with their attendance checks following daily work up.