Ministry of the
Solicitor General

OCC Inquest - England 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: England
Given name(s): Aaron
Age: 38

Held at: Welland Courthouse
From: Sept. 10, 2018
To: Sept. 13, 2018
By: Dr. J. Tang
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Aaron England
Date and time of death: November 16, 2016, 6:21 a.m.
Place of death: 1355 Upper’s Lane, Thorold, Ontario
Cause of death: Acute carfentanil poisoning
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on Sept. 13, 2018
Coroner's name: Dr. J. Tang
(Original signed by coroner)


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


Inquest into the death of:

Aaron England


Jury Recommendations

To: The Ministry of Community Safety and Correctional Services

  1. In order to ensure that screening for contraband is optimized through use of the Whole Body X­ Ray Security Scanning System, within six months of this verdict, conduct a survey of correctional staff currently trained in the use of the device to determine if valid concerns exist regarding its operation and/or if additional training is required. The Ministry should develop a strategy to address any concerns identified.
  2. To enhance screening capabilities of the whole body x-ray security scanning system, consider opportunities to implement standardized testing and ongoing training of correctional officers operating the devices including identifying and sharing of best practices across institutions.
  3. In order to detect trends and to better inform search and security practices, establish a basic statistical tracking system to record monthly records of detected contraband including total inmate population numbers, number of detected contraband incidents, how the contraband was detected, when it was detected and the type of suspected contraband.
  4. To enhance screening capabilities for the detection of contraband drugs entering the inmate population, consider and evaluate the availability and efficacy of other technology for drug contraband detection including but not limited to most current parcel x-ray technologies.
  5. In order to ensure that all relevant information relating to risk of possession of contraband drugs is readily apparent to admissions officers upon inmate admissions and readmissions by reviewing Offender Tracking Information System (OTIS) to ensure previous contraband incidents are readily apparent to officers prior to strip searches or whole body scans being conducted. This review should ensure that the process to add new alert entries is straightforward and consistent.
  6. In order to improve the ability of correctional staff to check upon the inmates during the night security rounds, the use of novel technologies should be considered and evaluated.
  7. Ensure the presence of naloxone kits in every guard station, admitting and discharge area, and medical station, within six month of this verdict, including every location where the Automated External Defibrillator equipment is currently located in order to ensure that the naloxone kits are in locations immediately accessible for use by correctional staff near inmate living units.
  8. To enhance screening capabilities for the detection of contraband, implement the use of more frequent canine searches which may include canines trained and permitted to search humans.
  9. To enhance screening capabilities for the detection of contraband, evaluate the process for inmate cell assignment including but not limited to inmate requests and intermittent inmate placement.
  10. To investigate the implementation of minimum staffing levels and develop a process to ensure staffing levels are met.
  11. Review opportunities to improve the efficiency and effectiveness of the call-in process.
  12. To ensure a consistent record of completed staff training and renewal dates is maintained and readily available to correctional staff.
  13. Investigate the opportunity to enhance Admissions/Discharge and Night Security Rounds processes using electronic records.
  14. To consider cell design in future renovations or builds to improve sight lines to facilitate compliance with Night Security Rounds and Standing Order requirements.
  15. To investigate whether any additional search steps on admission or readmission should be undertaken in relation to inmates who serve intermittent sentences, inmates who have surrendered themselves to be re-incarcerated, and inmates who have OTIS alerts related to contraband.
  16. Explore opportunities to create a compliance audit program for review of documentation and record samples for accuracy and completeness on an ongoing basis by an independent auditor.

To: The Niagara Detention Centre

  1. In order to enhance searches of the institution and to develop expertise in the area of searches, within six months of this verdict, develop terms of reference for a dedicated Institutional Security Team and make a request to the Ministry to have the resources and staff in place to fully implement this search strategy.
  2. In order to ensure consistency in night security rounds, an evaluation should be conducted to ensure correctional officers are adequately staffed, trained and equipped to check on inmates in and recognize those who may be at risk of overdose or in medical distress.