OCC Inquest - Romero Astorga 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Romero Astorga
Given name(s): Francisco Javier
Age: 39

Held at: 161 Chisholm Dr., Milton ON
From: June 12
To: June 16, 2017
By: Dr. William Lucas, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Francisco Javier Romero Astorga
Date and time of death: March 13, 2016 at 9:04 a.m.
Place of death: Halton Healthcare Services - Milton Site
Cause of death: The combined toxicity of fentanyl and methamphetamine
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 16 of June, 2017
Coroner's name: Dr. William Lucas
(Original signed by coroner)


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


Inquest into the death of:

Francisco Javier Romero Astorga


Jury Recommendations

To the Government of Ontario and Ministry of Community Safety and Correctional Services:

  1. Establishment of  “Drug/Contraband Security Committees” at both the Maplehurst Correctional Complex and the Ministry of Community Safety and Correctional Services.  This would be for the purposes of sharing information and intelligence and to discuss and seek improvements to enhance security measures in the jail.  eg. New technologies that may assist to detect drugs in the jail.
  2. The Ministry of Community Safety and Correctional Services should improve/replace meal “hatches” in the cell doors so that the inmates are unable to open them.  Also review and address the gap under the cell doors to avoid articles such as contraband being passed through this space.
  3. The Ministry of Community Safety and Correctional Services should direct correctional officers to ensure that meal hatches are closed at appropriate times including routine checks.
  4. The Ministry of Community Safety and Correctional Services should explore ways to facilitate inmates’ abilities (whether immigration detainees or not)  to access phones and communication with family and friends outside of North America, without making a special request or requiring permission. 
  5. The Ministry of Community Safety and Correctional Services should reinforce the underlying policy rationale regarding the proper completion of all institutional forms, including the requirement for a signature, date and time.
  6. The Ministry of Community Safety and Correctional Services should make available to all inmates the most current version of the Inmate Information Guide for Adult Institutions.