Ministry of the
Solicitor General

OCC Inquest - Kristoffersen 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Kristoffersen
Given name(s): Glen
Age: 32

Held at: 333 King St., Midland
From: June 17, 2019
To: June 27, 2019
By: Dr. M.E. Bourne
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Glen Kristoffersen
Date and time of death:  January 23, 2017 at 4:23 a.m.
Place of death: Unit 1, D Wing, Cell 12 of Central North Correctional Centre at 1501 Fuller Ave. in Penetanguishene
Cause of death: Combined toxicity of cocaine, fentanyl and heroin
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on June 27, 2019
Coroner's name: Dr. M.E. Bourne
(Original signed by coroner)


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


Inquest into the death of:

Glen Kristoffersen


Jury Recommendations

To the Ministry of the Solicitor General:

  1. Implement an electronic health 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
    7. enhance communication with community health providers.
  2. Include opioid awareness training in block training for correctional officers and supervisory staff.  The training shall include awareness of the signs and symptoms of overdose, the role of safety checks and tours in detecting overdose, and emergency responses to such events. The training must be delivered in person and completion tracked.
  3. Liaise with law enforcement and public health officials to share information regarding emerging concerns and threats related to substance use and abuse and drugs observed in the broader community.
  4. Develop a ministry policy prescribing the necessary steps in responding to a suspected overdose. This policy will include, but not be limited to, safety checks by correctional staff of all inmates who may have had access to the illicit substance, and by nursing staff where appropriate. The safety check shall include providing specific information about the presence of a potentially lethal substance in the institution to inmates. The policy shall require the safety checks be conducted as soon as practicable.
  5. Consider funding an Institutional Security Team at Central North Correctional Centre (CNCC) to include a group of correctional officers able to respond to requests for searches and emergencies day and night.
  6. Consider an outside service provider to offer assistance to operational and nursing staff who are witness to a death at a facility.
  7. Consider implementing an ion scanner at the CNCC with necessary funding.
  8. Amend policy regarding security tours to include observing for changes in appearance, behaviour and/or cognition that would indicate a need for a health assessment by health care staff.
  9. Develop and update inmate-focused posters and other media (e.g. television information segments) regarding signs and symptoms of an opioid overdose and how to respond within the institution. Ensure posters are visible for inmates from within the living units and in other key locations. Consider including this information in the inmate handbook, as well as information regarding the dangers of opioid use.
  10. Consider technological assistive devices used during periods of lockdown to detect inmate health and wellness (e.g. vital signs, body temperature).
  11. Consider harm reduction and drug addiction treatment to be offered by Addictions Counsellors for inmates with substance abuse issues identified on or after admission.

To the Central North Correctional Centre:

  1. Investigate new ways to deliver important information regarding illegal drugs to correctional officers. These new ways should include an ability to ensure that correctional officers have both received and reviewed the information.
  2. Ensure information regarding recent suspected overdoses be communicated by the sergeant or other designated person to correctional staff at muster and/or at the beginning of a shift. Such briefings shall include the Sergeant advising correctional staff of any changes that need to be made in light of these recent events.
  3. Where staffing levels do not permit a search, the correctional officer who has a reasonable suspicion of drug use or presence of contraband shall report such suspicion to his or her Sergeant in writing, with a copy to the Security Manager so follow up may occur when staff levels permit.
  4. Ensure the CNCC training unit contacts the Simcoe Muskoka District Health Unit to investigate implementing the Train the Trainer program to facilitate in-person training sessions for both staff and inmates.
  5. Continue to investigate ways to avoid staff shortages.
  6. Where a death occurs, offer a moderated debrief for all staff involved in the incident as soon as possible after the incident to review whether any lessons may be learned.  Any lessons learned shall be distributed to all operational staff.
  7. Consider increasing the number of crash carts in the institution.
  8. Consider the use of an Emergency Backpack to respond to top tier emergencies. The contents of the Emergency Backpack should be reviewed as necessary to ensure that it contains all necessary medical supplies and to ensure that medications have not expired.
  9. Develop a local policy to ensure that a social worker, counsellor or other appropriate staff member speaks to inmates who have witnessed a death at the institution as soon as practicable following the death. Such inmates shall be offered trauma-informed and culturally appropriate services, and when requested, efforts will be made to find an outside service provider.
  10. Consider review, reformation or elimination of the inmate server system to reduce the movement of drugs among the inmates.