Ministry of the
Solicitor General

OCC Inquest Chapman 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: CHAPMAN, Bradley John
Held at: 25 Morton Shulman Ave., Toronto
From: Nov. 26, 2018
To: Dec. 20, 2018
By: Dr. David Eden, Coroner for Ontario
having been duly sworn/affiremed, have inquired into and determined the following:

Surname: Chapman
Given name(s): Bradley John
Age: 43
Date and time of death: August 26, 2015 at 9:10 p.m.
Place of death:  Toronto General Hospital, Toronto, Ontario
Cause of death: Acute opiate toxicity
By what means: Accident

(original signed by Foreman and Jurors)


This verdict was received on December 20, 2018
Coroner’s Name: Dr. David Eden
(original signed by Coroner)


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


Inquest into the death of:

Bradley John Chapman


Jury Recommendations

  1. All recipients of these recommendations should recognize the urgent nature of the opioid overdose crisis and should consider and implement recommendations with the utmost urgency.

1. Provincial Strategy

The Government of Ontario (“Ontario”) should:

  1. Assign a provincial coordinator within the Ministry of Health and Long-Term Care for the provincial response to the opioid overdose crisis.
  2. Develop a comprehensive provincial strategy to address the opioid overdose crisis, based on a public health approach that addresses the social determinants of health that takes a non-discriminatory approach to drug overdose prevention and harm reduction.
  3. The provincial strategy should:
    1. evaluate and implement harm reduction approaches using current scientific and practice-based knowledge, particularly with respect to effectiveness in prevention of opiate-related deaths
    2. research and implement programs from other jurisdictions that have been effective in reducing opiate deaths
    3. take into account the unique experience of persons who are experiencing homelessness and use drugs
    4. consider the unique challenges posed by the criminal justice setting, inherent vulnerabilities and increased risk of overdose following release from incarceration
    5. comprehensively coordinate overdose response with other levels of government
    6. identify systemic social factors that can lead to overdose and other health harms related to substance uses, such as the lack of supportive housing and services for people who are experiencing homelessness
    7. devise anti-stigma/anti-discrimination training for all professional organizations (e.g. the Ontario Medical Association, the Registered Nurses’ Association of Ontario, the Toronto Police Service etc.) that connect with people who use drugs and people who are experiencing homelessness

2. Opioid Emergency Task Force

Ontario should:

  1. Resume regular meetings of the Opioid Emergency Task Force (“Task Force”), within 60 days of these recommendations being issued, maintaining current membership and adding the new provincial coordinator. In addition to its existing duties, the Task Force should be asked to:
    1. Assist in the implementation of the recommendations from this inquest.
    2. Conduct an evidence-based assessment and re-evaluation of the Consumption and Treatment Services Model that assesses potential barriers to access. In particular, the review should re-evaluate the proximity requirements; the public consultation requirement; the decision to limit the number of sites at 21 for the province; as well as the requirements regarding pathways to services. This evaluation should include consultation with people with lived experience of using drugs.
    3. Provide input on developing a provincial opioid overdose crisis strategy.
    4. Make recommendations for specific additional funding and resources where there is an identified shortfall, particularly in relation to: evidence-based treatment programs, withdrawal management services (e.g. detox beds), safe beds, supportive housing, harm reduction services (including number and hours of operation of Overdose Prevention Services (which includes Supervised Consumption Sites, Overdose Prevention Sites, and Consumption and Treatment Services); trauma support for harm reduction workers, people who use drugs and family members impacted by the opioid overdose crisis; and data collection and analysis.
    5. Provide advice on the expansion of naloxone availability, training and distribution.
    6. Provide standardized education to any organization, group or pharmacy that receives naloxone for distribution about the opioid overdose crisis, discrimination, and responding to overdoses.
    7. Research and make recommendations on responses to the opioid overdose crisis shown to be effective in other jurisdictions.
  2. Suspend the transition to the Consumption and Treatment Services model pending consultation with appropriate stakeholders on this model, including front line workers and people with lived experience who have used drugs. Existing Supervised Consumption Sites and Overdose Prevention Sites should continue to receive funding until consultation is completed and a new model (if any) is fully implemented. Existing Supervised Consumption Sites and Overdose Prevention Sites should be ‘grandfathered’ into the new model (if any).  
  3. Consider and address the risks posed by stigma, discrimination, and NIMBYism (“Not in my Backyard”) in assessing the extent to which community support plays a role in any decisions regarding an application to establish a Consumption and Treatment Service or other harm reduction services.

3. Public Awareness

Ontario should:

  1. Conduct a public awareness campaign across multiple media platforms, which should involve consultation of people with lived experience who have used drugs and experienced homelessness, with respect to:
    1. the opioid overdose crisis and steps being taken to address it
    2. the stigma and discrimination against people who use drugs and/or are experiencing homelessness
    3. encouraging First Aid training and assistive behaviours in possible overdose situations, including broader availability and use of naloxone
    4. using 911 to request ambulance rather than police in cases of clear overdose situations
    5. good Samaritan legislation to encourage people to respond appropriately to overdose without fear of being charged with drug possession
    6. use Coroner’s data in the public awareness campaign to highlight the number of Ontarians lost to the opioid overdose crisis
    7. declare a public health emergency in relation to the opioid overdose crisis

4. Drug Overdose Prevention, Harm Reduction and Homelessness in the Community

The Government of Canada (“Canada”) should:

  1. Consider decriminalizing the possession of all drugs for personal use and increase prevention, harm reduction, and treatment services.
  2. Consider providing a class exemption under the Controlled Drugs and Substances Act, (similar to the class exemption currently provided to the province of Ontario for Overdose Prevention Sites), to the City of Toronto. This would allow the City of Toronto to rapidly respond to the opioid crisis by providing harm reduction services when it’s needed, where it’s needed.

Canada and Ontario should:

  1. Engage in discussions to promote measures to reduce the unnecessary interaction of persons who use drugs with the criminal justice system.
  2. Engage in discussions regarding the implementation of a strategy to make available a clean, legal and non-toxic opioid drug supply at Supervised Consumption Sites, Overdose Prevention Sites and other settings as may be appropriate.

The Chief of the Toronto Police Service should:

  1. Evaluate the risk of police not attending overdose calls in consultation with Toronto Fire Services and Toronto Paramedic Services.  Where possible, implement measures to address the concern that people are not calling 911 in overdose situations because of possible police attendance. In the interim, officers should be advised to use their discretion, with preference to not lay charges against persons at, or assisting with, an overdose call.

Ontario should:

  1. Provide appropriate support, including possible increased funding and resourcing for:
    1. harm reduction programs and services in Ontario, including comprehensive services and support for people who use drugs with multi-faceted needs such as homelessness and mental health issues
    2. consider expediting the implementation of managed opioid programs (e.g. pharmaceutical heroin/diacetylmorphine and/or hydromorphone), including low barrier options, across Ontario
    3. hiring, retaining and appropriately compensating community workers, including those with lived experience, to assist with overdose prevention and response, and other harm reduction initiatives
    4. overdose Prevention Services to provide appropriate coverage, including hours of operation (e.g. 24 hours a day), location (e.g. where there are concentrations of overdoses) and at peak times throughout the month (e.g. cheque week)
    5. drug checking programs to allow people to test illicit drugs for the presence of toxic contaminants, adulterants or unexpected drugs (e.g. fentanyl)
    6. trauma counselling for harm reduction workers, people who use drugs, and family members impacted by the opioid overdose crisis
    7. ensure availability of supportive housing, detox and safe beds to meet demand including ability for probation officers and those working in or with corrections to access safe beds reserved for police
  2. Ensure that a standardized supply of take-home naloxone kits is available for distribution with appropriate provision of training at:
    1. community service providers
    2. appropriate provincial offices, such as probation and parole offices
    3. court Houses
  1. Provide Corrections, Probation and Parole staff with regular, in-person training on overdose identification, prevention and response, including administering naloxone and other harm reduction supports and services.
  2. Continue the funding to equip police officers with naloxone and ensure adequate funding to expand naloxone distribution to all frontline police officers (including training), for any jurisdiction that identifies that need.

The Chief of the Toronto Police Service should:

  1. Equip all frontline police officers with naloxone.

The City of Toronto (“Toronto”) should:

  1.  Appoint a dedicated lead, reporting directly to the Medical Officer of Health for Toronto, with the sole mandate to deal with overdose information, overdose response, and overdose prevention efforts. We also recommend this person have standing on the Task Force.
  2. Establish, fund and coordinate an overdose response committee (“Committee”) comprised of appropriate stakeholders, including frontline workers and people with lived experience, which should:
    1. coordinate existing and future services and committees currently provided by Toronto
    2. provide expert advice to Toronto in its management of the opioid overdose  crisis
    3. receive timely and relevant drug overdose data (e.g. paramedic and emergency room admissions, overdoses in shelters, police response and coroner data); and publish publicly no later than the 26th day of every month
    4. assist in developing and promoting evidence-based public education resources about overdose prevention and response including bystander responsibilities, Good Samaritan legislation, and naloxone training and overdose response
    5. assist in implementing Toronto’s Harm Reduction Framework across shelters, social housing providers (e.g. community and supportive housing) and agencies that provide homeless services and supports, including overdose prevention and response measures
    6. review ‘bad drug’ reporting processes and lower technological barriers to allow for easier reporting
  3. Explore eviction prevention measures to assist people likely to lose their housing during a short period of incarceration.
  4. Ensure the Toronto’s Street Needs Assessment includes people who are incarcerated and who are in hospitals who may experience homelessness.
  5. Address ways, including working with community agencies, to better measure the number of people who are incarcerated and may be experiencing homelessness upon release as part of the Toronto’s Point in Time Count.
  6. Work with Toronto Public Health to avoid overdose deaths in shelters by identifying where there might be a need in the shelter system for overdose prevention sites or services, and identify appropriate partners to provide those services at or proximate to those shelters where the need is identified. Before providing any overdose prevention services on-site at a shelter, Toronto should ensure there is no net loss of any shelter beds at any such site or in the system more generally.
  7. Design, implement and distribute a sticker campaign that would allow all establishments with naloxone on-site to publicly display on an exterior window the availability of naloxone, which should be included in Toronto’s current opioid crisis public awareness campaign.

The Toronto Police Services Board, The Chief of the Toronto Police Service and Toronto Public Health should:

  1. Improve information sharing between Toronto Police Service and Toronto Public Health by, among other things:
    1. instituting quarterly reports by the Medical Officer of Health for Toronto on relevant public health issues, including the opioid overdose crisis
    2. having a Toronto Public Health delegate sit on relevant Toronto Police Services Board advisory panels
    3. having a Toronto Police Services representative sit on relevant Toronto Public Health committees
    4. having the Toronto Police Service share information relevant to the opioid overdose crisis, subject to operational constraints

5. Identification and Management of Individuals with Drug-Related and/or Homelessness Issues While Incarcerated and Transitioning Out Into the Community

Ontario should:

  1. Transfer responsibility for health care in correctional facilities from the Ministry of Community Safety and Correctional Services to the Ministry of Health and Long-Term Care.
  2. Improve service continuity, shared accountability, and communication across systems between correctional institutions, correctional staff and health care providers, community service providers and probation and parole offices, while respecting limitations imposed by law.
  3. Develop and implement a province-wide electronic health record for the purpose of information sharing between any provincial correctional health care professionals and any community health care system. Consent of individuals who are incarcerated should be required.
  4. Implement the use of an electronic system to enhance communication within and between facilities, and with probation and parole officers, which should include electronic health records system, electronic forms and electronic communications platforms, such as Offender Tracking Information System.
  5. Obtain relevant information regarding the opioid overdose crisis, including from correctional facilities and public health offices, to assist in the handling of overdose related issues at its correctional facilities, and such information should be shared with the Task Force.
  6. Establish a case-management approach to the care of individuals who are incarcerated and have multi-faceted health needs, such as using drugs and experiencing homelessness, at all its correctional facilities from the point of intake to discharge and probation.  The individual’s needs in the correctional facility should be managed by an Ontario employee who should:
    1. compile relevant information from appropriate individuals (e.g. health care, operations and social work)
    2. coordinate seamless transition back into the community by liaising with appropriate individuals and services (e.g. probation officers, community agencies, shelters, etc.) to establish a discharge plan, which addresses factors such as access to safe housing; income and food security; continuity of health care, mental health and addiction services; harm reduction services; and links with community services and supports
    3. engage with individuals as an advocate for their needs where appropriate
  7. Improve health care for people who are incarcerated, including those who use drugs, by providing:
    1. better access to mental health and addiction services, including upon admission
    2. increased privacy for inmates during the initial health care interview and during provision of health care
    3. comprehensive and timely assessment by a primary care provider
    4. access to harm reduction services, withdrawal management, opioid substitution, addiction treatment services and overdose prevention (e.g. naloxone) on admission into custody and throughout the course of an individual’s incarceration
    5. ensure naloxone availability throughout the entire correctional facility to maximize overdose prevention efforts
    6. coordinate access to similar services when the individual is transitioning back into the community
    7. corrections-specific training for health care staff noting the uniqueness of providing health care in a corrections environment
  1. Ensure planning for discharge from a correctional facility, including:
    1. conducting a comprehensive and timely assessment of each individual’s needs upon admission and making this assessment accessible for use in discharge planning. The assessment should be conducted in a manner that respects the privacy of the individual while maintaining the safety and security of the healthcare staff
    2. allowing community organizations to use technology (e.g. Skype and video conferencing), to connect and establish relationships with persons who are incarcerated before they are released
    3. commencing application procedures for programs and services in the community
    4. seeking access to housing
    5. continuity of health care, including primary care and addiction services
    6. offering harm reduction supplies, such as take-home naloxone kits, to everyone discharged from incarceration whether from court or a correctional facility, and providing those supplies to anyone who wants them
    7. providing links to community services and supports
    8. completion of an electronic discharge check list
    9. coordinating with appropriate agencies, such as the John Howard Society of Toronto, regarding an individual’s expected release date and time, when possible
    10. providing information, upon release, about harm reduction services, including the increased risk of overdose post-incarceration, bad drugs, local overdose prevention services and the local opioid overdose crisis
  1. Conduct regular meetings between the Toronto South Detention Centre and community agencies to improve communication.
  2. Provide ongoing and sustainable funding to the John Howard Society of Toronto Reintegration Centre (or other organizations that provide similar services), to support its work connecting people leaving custody with information and services to meet their needs.
  3. Provide appropriate, affordable and sufficient space for the John Howard Society of Toronto Reintegration Centre within very close proximity to the Toronto South Detention Centre.
  4. Provide community service agencies, such as the John Howard Society of Toronto, with space in courthouses to assist persons released directly from court.
  5. Develop transitional housing spaces with intensive case management specifically for people leaving custody with no fixed address.
  6. Track information on the number of individuals released from incarceration who are experiencing homelessness and share this information with appropriate ministries and municipalities, relevant community partners and the Task Force.

  1. Provide education and programs to raise awareness among persons who are incarcerated regarding:
    1. the risk of opioid overdoses following release from incarceration, strategies to prevent overdose, recognizing the signs of overdose, and responding to suspected opioid overdoses
    2. the use and availability of naloxone kits in correctional facilities and upon discharge
    3. the availability of programming available in custody, including the ability to initiate opioid substitution treatment
  1. Ensure that Probation and Parole services:
    1. provide sufficient flexibility to individuals to be able to choose the office they must attend
    2. provide support and assistance to individuals in seeking and maintaining housing, including advocating for them where appropriate
    3. have access to relevant information about available substance use supports, harm reduction services, including the location and hours of overdose prevention services, and communicate these to individuals as appropriate

The Registered Nurses’ Association of Ontario should:

  1. Develop evidence-based Best Practice Guidelines to advance person-centered care for people who are experiencing homelessness, including those with mental health and addiction challenges, and guidance on implementation of a harm reduction approach to addressing drug and substance use issues within correctional facilities.  These guidelines should include qualitative and quantitative evidence, as well as evidence provided by persons with lived experience.

6. First Aid Awareness and Training

Providers of First Aid Training in Ontario, including St. John Ambulance, Canadian Red Cross, and Heart and Stroke Foundation of Canada, should:

  1. Ensure their standard first aid training programs and their instructors:
    1. emphasize the primary importance of airway patency and positional safety for all ill and injured patients
    2. include a specific module on how to identify and respond to an opioid overdose, including the use of stimulation and the administration of available naloxone
    3. de-emphasize spinal immobilization and routine spinal precautions in first aid education based on current scientific data
    4. educate on the harmful effects of stigma among people who use drugs and/or experience homelessness

The Chief of the Toronto Police Service should:

  1. Ensure that first aid training for police officers:
    1. covers situations and circumstances that police officers might encounter, including opioid overdoses
    2. teaches that police officers are often the first on a scene and prepares officers for that eventuality
    3. incorporates a module on how to recognize and respond to an opioid overdose, including the administration of naloxone taught through hands on training
    4. includes hands-on scenario training based on actual circumstances confronted by police, which can include the circumstances of this case
    5. is completed prior to graduation from Police College for new officers.

  1. Consider the inclusion of an opioid overdose scenario in annual police judgment training.
  2. Research the benefits of including portable blood oxygen monitors in police officers’ first aid kits.

7. Toronto Police Response to Homelessness and Persons Using Drugs

The Chief of the Toronto Police Service should:

  1. Review the language used in the Service’s Computer Aided Dispatch system and replace any terms identified as stigmatizing, including the use of “Drunk” as an event type.  In choosing appropriate replacement language, the Chief should obtain input from subject matter experts and persons with lived experience.
  2. Work with the Service’s emergency service partners, including Toronto Paramedic Services, to develop and implement training that will optimize the information provided by police officers requesting ambulance services from a scene through dispatch.  Training should include definitions on the key symptoms (e.g. unconsciousness, alertness, breathing, etc.) that need to be communicated in order to optimally dispatch ambulance services and the language best used for communicating those key symptoms.
  3. Develop and implement training for police officers covering:
    1. The discrimination faced by persons who use drugs and experience homelessness, which should include the participation of those with lived experience.
    2. The perspectives of persons who use drugs and experience homelessness, which should include the participation of those with lived experience.
    3. The increased risk to persons using drugs as a result of the poisoned illicit drug supply.
    4. The harm reduction approach to addressing the negative consequences of drug use, including the harm reduction services available to people in Toronto and, specifically, the location and hours of Overdose Prevention Services. 
  1. Investigate a process that allows police to determine whether an officer requesting ambulance service from a scene requires additional instructions for patient care, and, if so, explore implementation of industry best practice options for providing those instructions.

8. Identification of Individuals and Family Contact

The Chief of the Toronto Police Service should:

  1. Develop and implement procedures for circumstances where police are involved in the identification of unidentified individuals admitted to hospital, which should include procedures related to contacting next of kin in a timely and sensitive manner.
  2. Review and amplify procedures to ensure there are exhaustive efforts made by police to contact next of kin and consult with the assigned detective before destroying a decedent's belongings.

9. Reporting on Opioid-related Deaths

The Office of the Chief Coroner, Ontario Forensic Pathology Service, and the Centre for Forensic Sciences should:

  1. Work together to minimize the time taken for finalizing their reports in opioid overdose-related deaths, with the goal of providing high quality information on such deaths to Public Health Ontario and other recipients as early as possible.

10. Reporting on Progress of Recommendation Implementation

The Parties towards whom these recommendations are directed should:

  1. Report to the Office of the Chief Coroner and the parties to this inquest by no later than June 1, 2019, and annually for five years, in an open letter, regarding the progress made with respect to these recommendations