OCC Inquest - Seaton 2016

Office of the Chief Coroner

Verdict of Coroner’s Jury

Office of the Chief Coroner

The Coroners Act – Province of Ontario


Surname: Seaton
Given name(s): Trevor
Aged: 28


Held at: Sault Ste. Marie, ON
From: November 21
To: November 24, 2016
By: Dr. David Andrew Cameron, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Trevor Seaton
Date and time of death: 22 May 2014, 0314 hours
Place of death: Sault Area Hospital, 750 Great Northern Road, Sault Ste. Marie, Ontario
Cause of death: Combined Drug (Fentanyl, Cocaine, Oxycontin) Intoxication
By what means: Accident

(original signed by Foreman and Jurors)


This verdict was received on the 24th of November, 2016
Coroner’s name: Dr. David Andrew Cameron
(original signed by Coroner)


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


Inquest into the death of:

Trevor Seaton


Jury Recommendations

To the Ministry of Community Safety and Correctional Services:

  1. Ensure naloxone is accessible and available for use 24 hours per day in each correctional facility to administer to inmates, effective immediately.
  2. Provide training for correctional officers and operational managers to recognize drug addiction, signs and symptoms of drug use, intoxication, overdose as well as the required observation and interventions for those inmates.
  3. In order to address the present crisis and future threat of opioid overdose in Ontario correctional facilities, particularly in light of newer more potent drugs appearing in Canada, the ministry continue to work with Ministry of Health to immediately produce visual and educational materials to convey to all inmates the recognition and danger of illicit drug possession, use, intoxication and overdose, particularly within the custodial facility.  These materials should also address harm reduction strategies for inmates. This information to be also available as part of the inmate handbook.
  4. Continue to reduce the incidence of contraband (drugs) entering provincial jails through:
    1. Using modern available technology such as body scanners and drugloos. The ministry continue to move forward with installation of this technology at the ATRC as soon as possible;
    2. Pursue all legal avenues to enforce the use of body scanners and body x-rays in order to detect contraband (drugs);
    3. Provide photocopy to inmate of all incoming mail, with originals to be placed in inmate property which will be provided to them upon their release from facility.
  5. Implement an electronic health record 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. Ensure access to inmate Electronic Health Records are standardized across all correctional facilities within Ontario and if possible Canada wide.

To the Algoma Treatment and Remand Centre

  1. Upgrade video monitoring capability within the facility to reflect more modern and comprehensive coverage of the institution, including the below capabilities:
    1. Including zoom with pan and tilt where necessary;
    2. Higher resolution allowing a clearer picture of inmates identification and their activities;
    3. Monitors available to guards in areas such as the segregation area to allow a clear picture of activity within their areas.
  2. Investigate upgrades to Silver Guard system to ensure that all rounds are recorded properly, or to consider another monitoring system if such fail-safe mechanism is not possible with the Silver Guard system. Policy should also be reviewed to ensure that the responsibility is assigned for the accuracy of the collected information. If the Wand system is to be used moving forward the download of the wand data should be on a daily set schedule and logged to ensure policy is followed.
  3. Review the roles of all institutional staff to mitigate risk of opioid overdose by inmates and identify and address gaps and inefficiencies.
  4. Develop additional recreational activities and/or educational opportunities for longer-term, non-treatment inmates (both remand and sentenced):
    1. Develop access for non-treatment and/or remand inmates to use the existing recreational facilities as soon as possible.
  5.  Develop a change to the door system to prevent the use of 'fishing' to move contraband between cells, Range and segregation doors, i.e., vertical pins or special designed barrier on the bottom of the doors.
  6.  Develop a proper K9 program either internally or with 3rd party provider to allow weekly internal inspections.
  7.  Expand the use of the video remand system to minimize the travel of inmates outside of the facility to attend court.