OCC Inquest - Stevens and Sutton 2018

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: Stevens, Paul and Sutton, Jeffrey



Held at: 25 Morton Shulman Avenue, Toronto
From: Jan. 8
To: Jan. 17, 2017
By: Dr. Robert Boyko, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Stevens
Given name(s): Paul
Age: 51
Date and time of death: February 14, 2015 at 11:15 p.m.
Place of death: St. Joseph’s Health Centre – Intensive Care Unit, Toronto, Ontario
Cause of death: Mixed drug (fentanyl, cocaine, and buproprion) intoxication
By what means: Accident

Surname: Sutton
Given name(s): Jeffrey
Age: 36
Date and time of death: Sept. 8, 2010
Place of death: Toronto South Detention Centre, Toronto, Ontario
Cause of death: Acute cocaine toxicity
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 17 of January, 2018
Coroner's name: Dr. Robert Boyko
(Original signed by coroner)


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


Inquest into the deaths of:

Paul Stevens and Jeffrey Sutton


Jury Recommendations

To the Ministry of the Community Safety and Correctional Services (the ministry):

  1. Ensure correctional staff are trained regularly on the use of Naloxone including signs and symptoms of opioid overdose.
  2. Ensure regular training of health care staff on withdrawal and toxicity of commonly abused drugs including the use of the CIWA and COWS scales.
  3. Use the facts of Mr. Sutton’s and Mr. Stevens’ deaths to develop case studies to train health care staff. This training should be designed, developed and delivered in collaboration with front line staff.
  4. Ensure regular training of health care staff on documentation standards set by the College of Nurses and ministry expectations. This should include standards related to charting by exception.
  5. In accordance with the Truth and Reconciliation Commission’s Calls to Action, the ministry shall require all staff to receive training with respect to the history of Aboriginal peoples, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, Indigenous law and Aboriginal-Crown relations. This will require skills based training in intercultural competency, conflict resolution, human rights and anti-racism. This training should also include education on Indigenous specific services available at the particular institution.
  6. Within 12 months from the date of this verdict, establish a working group of experts and senior ministry staff to coordinate a strategic plan for reducing the risks from illicit drug use in custody, including and not limited to:
    1. identifying harm reduction strategies that will be employed
    2. tracking of fatal and non-fatal drug overdoses in custody
    3. the detection and screening methods to be employed such as x-rays and other new techniques to identify drug concealed within the person
  7. Revise the Special Observation Status Form to indicate:
    1. when operational staff has notified health care
    2. the content of communication between operational staff and health care including a plan for the health care assessment
    3. when the health care assessment has been completed
  8. Ensure correctional staff are trained on the requirement to communicate with other staff between shifts. This training should include the use of communication tools such as magnet indicators on segregation doors.
  9. Ensure ministry policy requires correctional staff to carry the one way face mask as part of their duty belt at all times. Ensure correctional staff are trained appropriately.
  10. Develop a policy that correctional staff shall pass on health related information provided by an inmate or observed by a correctional officer to health care staff in a timely manner.
  11. Corporate Health Care should develop a flowchart which represents the policy referred to in recommendation 10. The developers of the flowchart should consider including an example of when an inmate shares a health care related concern with a correctional officer. This flowchart should be distributed to all institution staff and be posted in a common work space.
  12. The ministry policy shall be updated to require health care units to receive approval from Corporate Health Care before implementing use of locally developed forms.
  13. Consider updating OTIS Alerts to make them more user friendly such as colour coding, categorization of alerts and organizing information in chronological order.
  14. Amend the Special Management Inmates Policy to ensure all health care staff document their interactions with inmates on the inmate’s Observation Record. Ensure health care staff are advised of this policy revision.
  15. Investigate the feasibility of hiring a Corporate Health Care clinical educator and regional educators to ensure standardized professional development and training is coordinated, developed and implemented province-wide for health care staff.
  16. Recognizing that unmanaged withdrawal symptoms are a risk factor for toxicity, the ministry should consider researching whether additional policies and/or training is required to ensure the health and safety of inmates beyond opioids and alcohol withdrawal management, e.g. cocaine.
  17. The ministry shall 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 care providers
  18. The ministry should consider how to improve communication with outside health care providers in order to enhance health care services for inmates. This would include:
    1. inquiries to pharmacies, physicians and other health care providers in the community about current medications
    2. providing notifications to community health care providers when a patient is in custody
    3. providing a discharge summary to an inmate’s primary care and/or methadone provider
    4. exploring privacy issues and whether correctional health care professionals can belong to the circle of care
    5. providing discharged inmates with appropriate ‘bridge scripts’, i.e. methadone.
  19. The ministry shall develop an Indigenous self-identification process for admission. The ministry shall consult with Elders’ Councils at the ministry and the Ministry of the Attorney General(MAG) and MAG’s Indigenous Justice Division.
  20. The self-identification process referred to in recommendation 19 shall:
    1. provide respectful methods at multiple points for Indigenous people to self-identify
    2. allow the inmate to provide additional information including their Nation and Community, if known
    3. ensure that self-identification is not tied to religious affiliation
    4. ensure that information that an inmate is Indigenous is provided to the Native Inmate Liaison Officer/Indigenous Client Liaison (NILO/ICL) and Indigenous program staff at the institution
  21. The ministry should develop training for admissions staff on how to conduct the self-identification process in a respectful and appropriate manner.
  22. Develop materials for inmates on the Indigenous self-identification process that would address concerns regarding stigma. These materials should be visible near the booking officer’s desk in the Admitting and Discharge area.
  23. The ministry shall work with Indigenous communities to develop and deliver culturally appropriate services in accordance with Call to Action 36 of the Truth and Reconciliation Commission’s Final Report.
  24. The inistry should ensure that each institution:
    1. develops Indigenous specific programming which reflect the local Indigenous communities and agencies surrounding the institution
    2. provides Indigenous inmates with access to Indigenous healing practices including Knowledge Keepers and Elders
    3. develop materials about Indigenous specific services available to inmates at the particular institution. These materials should include booklet style and poster based materials that should be available in the Admitting and Discharge area.
  25. The ministry shall ensure that NILO/ICL services are adequately resourced and funded to meet the needs of Indigenous inmates.
  26. The ministry should consider expanding access to NILO/ICL services beyond Monday to Friday, including inmates serving intermittent sentences.
  27. The ministry should consider developing a NILO/ICL request form for inmates.
  28. The ministry should include whether an inmate is Indigenous as part of the misconduct adjudication process in accordance with Recommendation 4.2 from Howard Sapers’ Report on Corrections Reform which directs that the “ministry broaden its response to the Truth and Reconciliation Commission’s Calls to Action by critically examining all aspects of correctional practice, recognizing the impact of systemic discrimination, and adopting measures to counteract these trends. Specific attention should be paid to the meaningful incorporation of Gladue factors into every decision impacting an Indigenous person’s liberty.”

To the Toronto South Detention Centre (TSDC) / Toronto Intermittent Centre:

  1. In order to address the use of contraband, improve monitoring of the intermittent dorms by considering options including but not limited to different lighting, increased surveillance cameras, additional monitoring of cameras, etc.
  2. Ensure correctional officers carry flashlights during night security patrols.
  3. Ensure the use of body scanners at the Toronto Intermittent Centre.
  4. Ensure that health care staff are advised when an inmate’s unit placement differs from that recommended by health care.
  5. Investigate ways to make programs and services available for inmates serving intermittent sentences.
  6. Ensure TSDC immediately implements use of the ministry developed Health Care Record – Part E – Readmission Assessment Form.
  7. In order to ensure that health care professionals have adequate time to deliver services for each inmate according to policy, the health care manager shall conduct regular workload analyses across units and shifts. Workload measurement should include but not be limited to health care assessments and charting processes.
  8. Prior to the implementation of the ministry wide electronic medical record system, the health care manager will investigate ways of providing administrative support, i.e. medical clerks, to health care professionals for record management.
  9. The health care manager shall conduct spot audits on a regular basis and across all shifts to ensure compliance with all applicable policies and nursing standards. An audit should review issues including, but not limited to: charting, health care assessment upon admission and readmission, and file transfer request. Audits should also be initiated by events such as staffing fluctuations, trends in inmate health needs, and health and safety risks/occurrences.
  10. The superintendant shall conduct spot audits of correctional staff on a regular basis and across all shifts to ensure compliance with all applicable policies and operational standards. An audit should review issues including, but not limited to: fulsome documentation and interdepartmental communication.
  11. TSDC shall meet with Methadone Works / Methadone Treatment Clinics / Toronto Public Health to discuss ways to improve health care information sharing.

To the Ministry and the Ministry of Health and Long-Term Care (MOHLTC):

  1. In order to address the present crisis and future threat of opioid overdose in Ontario correctional facilities, the ministry continue to work with the MOHLTC 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 should also be made available as part of the inmate handbook.