OCC Inquest - Henke 2018
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given name(s): Ryan
Held at: Napanee
From: April 11, 2018
To: April 12, 2018
By: Dr. Gautam Walia
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Ryan Henke
Date and time of death: February 19, 2016 at 2:30 p.m.
Place of death: Collins Bay Institution, Kingston, ON
Cause of death: Accident
By what means: Acute combined fentanyl and doxepin toxicity
(Original signed by: Foreperson)
The verdict was received on the 12 of April, 2018
Coroner's name: Dr. Gautam Walia
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
- With respect to Collin's Bay Institution, Correctional Services Canada institutes another Stand To Count in the morning hours, or changes the 3:45 p.m. Stand To Count to a Stand To Count in the morning.
- Correctional Services Canada to consider making Naloxone Kits directly available and accessible to inmates in common areas.
- Correctional Services Canada institute private, confidential programs focused on drug use and abuse, including addictions counselling that are accessible to all inmates.
- Correctional Services Canada partners with the local Health Units in inviting them to provide ongoing direct education about prevention and harm reduction for substance abuse for all willing inmates.
- Correctional Services Canada should communicate clearly to all staff who are directly involved with inmates what harm reduction strategies are available to inmates with respect to drug use and abuse.
- At Collin's Bay Medium Institution, Correctional Services Canada ensure that staff are complying with their attendance checks following daily work up.