OCC Inquest - Lacelle 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Lacelle
Given Name(s): Neil
Age: 28

Held at: 155 Elm St., Sudbury, ON
From: May 1
To: May 3, 2017
By: Dr. Ray Sawkiw, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Neil Lacelle
Date and time of death: June 5, 2014 at 11:30 p.m.
Place of death: Health Sciences North, Sudbury, Ontario
Cause of death: Anoxic ischemic encephalopathy due to hanging
By what means: Suicide

(Original signed by: Foreperson)


The verdict was received on the 3 of May, 2017
Coroner's name: Dr. Ray Sawkiw
(Original signed by coroner)


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


Inquest into the death of:

Neil Lacelle


Jury Recommendations

  1. Sudbury Jail shall continue to review its record keeping practices and procedures to ensure accuracy.
  2. Sudbury Jail shall review its policies and procedures to ensure that medical staff are notified of “code blue” medical emergencies in a timely manner.
  3. Ministry of Community Safety and Correctional Services shall continue to review, and if required amend, its segregation policies and procedures, including mental health practices.
  4. Ministry of Community Safety and Correctional Services shall continue to review, and if required amend, its Opioid Withdrawal policies and procedures.
  5. Ministry of Community Safety and Correctional Services shall review the frequency of nurse visits for inmates who have identified themselves as recent or regular opioid user and are likely to experience withdrawal.
  6. Sudbury Jail and Ministry of Community Safety and Correctional Services shall investigate if there are “closed blade” cutting devices available that would meet the jail’s safety and/or security requirements that could be carried by all Corrections Officers.
  7. Sudbury Jail shall review the availability of alcohol and drug treatment programs, such as Alcoholics Anonymous and Narcotics Anonymous through its health services.
  8. Sudbury Jail shall investigate if cell door hatches and flaps can be modified to prevent the ability to tie or wrap a ligature on them.
  9. Sudbury Jail shall review the protocol for relaying information between Corrections Officers and nursing staff when behaviours consistent with mental health issues are observed.