OCC Inquest - Thompson-Hardy 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Thompson-Hardy
Given name(s): Cody Allistair
Age: 18

Held at: Thunder Bay
From: Oct. 16
To: Oct. 20, 2017
By: Dr. David Cameron, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Cody Allistair Thompson-Hardy
Date and time of death: Aug. 19, 2011 at 6:55 p.m.
Place of death: Thunder Bay Regional Health Sciences Centre
Cause of death: Anoxic brain injury resulting from methadone toxicity
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 20 of Oct., 2017
Coroner's name: Dr. David Cameron
(Original signed by coroner)


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


Inquest into the death of:

Cody Allister Thompson-Hardy


Jury Recommendations

To the Ministry of Community Safety and Correctional Services:

  1. Where clinically indicated, inmates be initiated on opioid substitution therapy, e.g. methadone and/or suboxone following a clinical assessment. The ministry shall enhance its current policy to reflect this medical practice.
  2. Given the potential for diversion of methadone at Ontario correctional facilities, the ministry shall consult with the College of Physicians and Surgeons of Ontario regarding the adequacy of methadone administration guidelines, considering factors such as pre-administration and post-administration supervision time, fasting prior to administration of medication, administration in the morning and prior to breakfast.
  3. The ministry shall revise its policy to consider extension of post-administration supervision beyond minimum requirements where there are suspicions of OST diversion.
  4. The ministry shall revise its policy to specifically recognize cultural and spiritual support as a fundamental healthcare right to all.
  5. The ministry shall ensure the following training, including re-certification, occurs:
    Health Care Managers and staff
    1. Recognition and appropriate responses to suspicion of methadone diversion, including information from inmates
    2. Naloxone training including recognition of signs and symptoms of drug use, intoxication and overdose
    3. In accordance with the Truth and Reconciliation Commission’s Calls to Action, 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
    4. Recognition and response to the particular issues faced by young adults housed in adult institutions
    5. Documentation standards relating to patient intake, assessment, interactions, and consultations to ensure timely and accurate records
    Operational Managers, Deputy Superintendents and Superintendents
    1. Recognition and appropriate responses to suspicion of methadone diversion, including information from inmates
    2. Naloxone training including recognition of signs and symptoms of drug use, intoxication and overdose
    3. In accordance with the Truth and Reconciliation Commission’s Calls to Action, 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
    4. Recognition and response to the particular issues faced by young adults housed in adult institutions
    Correctional Officers
    1. Recognition and appropriate responses to suspicion of methadone diversion, including information from inmates
    2. Naloxone training including recognition of signs and symptoms of drug use, intoxication and overdose
    3. In accordance with the Truth and Reconciliation Commission’s Calls to Action, 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 and
    4. Recognition and response to the particular issues faced by young adults housed in adult institutions.
  6. The ministry shall ensure that new or acting health care managers receive the information and training necessary to fulfill their responsibilities.
  7. In accordance with the Truth and Reconciliation Commission’s Calls to Action, the Ministry shall require its contracted and/or fee for service staff, including physicians and psychiatrists, 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.
  8. 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 and
    6. Develop an alert and notification system to ensure compliance with provincial standards of care.
  9. In accordance with the Truth and Reconciliation Commission’s Calls to Action, the Ministry shall work with Indigenous communities to develop and deliver "culturally relevant services to inmates on issues such as substance abuse, family and domestic violence, and overcoming the experience of having been sexually abused".
  10. As part of the ministry modernization of correctional services, the following shall be considered:
    1. The benefits of case management of inmates
    2. Alternative or specialized care units
    3. Parent-child programs
    4. The individual needs of access to family support (e.g. visits)
    5. Additional nurses including addictions-trained nurses and Indigenous nurses
    6. Options for appropriate governance of health care services (e.g. transfer to Ministry of Health and Long-Term Care)
    7. Whether health care services should be accredited
    8. Establishment of Indigenous program support units within each correctional institution and
    9. Ensuring inmates are aware of and have access to Indigenous healing practices, including access to Indigenous healers and Elders.
  11. The ministry shall conduct a webinar for health care staff regarding the issues identified in this inquest within one year.
  12. The ministry shall establish a policy that ensures that a cell or other area is treated as a crime scene in appropriate circumstances.
  13. The ministry shall explore options and adopt short- and long-term governance strategies to ensure that all institutional personnel have appropriate professional oversight and the decision-making capacity to ensure safe, appropriate, and timely care.
  14. The ministry shall ensure that the Superintendent or designate of a correctional facility informs the appropriate regional supervising coroner if an inmate is taken to the hospital where death is possible.

To the Province of Ontario:

  1. Ontario shall build a new facility to replace the Thunder Bay Jail. In planning its design and construction, consideration shall be given to:
    1. Fostering the physical, emotional and spiritual health of inmates
    2. Meeting the programming needs of inmates, including appropriate physical space and resourcing
    3. Private space for counselling
    4. An infirmary
    5. Separate housing for inmates prescribed methadone
    6. Ensuring sufficient and appropriate health care space for methadone administration, medical and psychiatric examination, assessment and medical observation
    7. Ability to better meet the needs of Indigenous inmates, including access to indoor smudging and indoor/outdoor space for ceremonies
    8. Access to appropriate technology to allow corrections staff to fulfil their responsibilities
    9. Adopting a Direct-Supervision model, as appropriate and
    10. Providing inmate visitation access through means of video teleconferencing technologies.

To the Thunder Bay Jail:

  1. Develop a standing order setting out an internal review process for critical incidents. This process shall:
    1. Be led by a senior manager (at a level above an operational manager)
    2. Include an investigation and analysis of the incident
    3. Produce a report setting out any appropriate remedial action, which shall be shared with the Superintendent and the appropriate ministry
    4. Conduct a debriefing with relevant staff and provide them with appropriate information and
    5. Not be delayed by any other ministry investigation.
  2. The Superintendent shall provide an electronic copy of this verdict and verdict explanation from this inquest to all Thunder Bay Jail staff.
  3. A copy of this verdict shall be posted in an area accessible to inmates within 30 days of receipt.
  4. The Thunder Bay Jail shall ensure that Indigenous inmates have access to both programming and private, one-on-one counselling  which may be provided by a social worker, a mental health nurse, a Native Inmate Liaison Officer, Elder or other outside service-providers.
  5. The Thunder Bay Jail shall ensure that young adult inmates have access to separate and distinct programs and services that are geared towards their cultural and developmental needs.
  6. The Thunder Bay Jail shall ensure adequate funding for at least one full-time Native Inmate Liaison Officer.
  7. The Thunder Bay Jail shall work with the Native Inmate Liaison Officer to increase his or her effectiveness in the institution including:
    1. Ongoing access to that person including a private space to speak with them
    2. Ceremonial space and activities
    3. Smudging
    4. Access to Indigenous healers and Elders
    5. Engaging in cross-training opportunities with staff and
    6. Participation in developing case management plans for inmates.
  8. The Thunder Bay Jail shall develop a standing order that sets out the expectations of health and correctional staff where methadone diversion is suspected.  This standing order shall outline potential options, including:
    1. Further investigation and assessment of the involved inmate(s)
    2. Continued observation and/or separation of inmate(s)
    3. Providing information and receiving advice from prescribing physicians
    4. Documentation and information sharing amongst staff and
    5. Development of an inter-professional plan to address the diversion including education for the inmate(s).
  9. The Thunder Bay Jail shall develop a standing order that sets out the expectations of healthcare and correctional staff when responding to a non-responsive inmate.

To the Office of the Chief Coroner:

  1. Upon becoming aware of information about a possible threat to the health of inmates, the Office of the Chief Coroner shall as soon as possible share relevant information with the appropriate superintendent.
  2. If the Office of the Chief Coroner is informed that an inmate is taken to the hospital where death is possible, the Office of the Chief Coroner in collaboration with the police service investigating the incident shall request that the appropriate hospital preserve any evidence.
  3. The Office of the Chief Coroner be mandated to provide Coroner’s inquests in respect to inmate deaths, where appropriate, within a reasonable time period.