Ministry of the
Solicitor General

OCC Inquest - Piney 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Piney
Given name(s): Jesse David
Age: 34

Held at: 25 Morton Shulman Ave., Toronto 
From: Jan. 23, 2019
To: Jan. 29, 2019
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jesse David Piney
Date and time of death: August 26, 2016 at 5:03 p.m.
Place of death: St. Joseph’s Health Centre, Toronto, ON
Cause of death:  Central nervous system and respiratory depression due to heroin toxicity
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on Jan. 29, 2019
Coroner's name: Dr. Geoffrey Bond
(Original signed by coroner)


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


Inquest into the death of:

Jesse David Piney


Jury Recommendations

Directed to: the Parole Board of Canada

  1. It is recommended that in appropriate cases and circumstances and where an inmate has a history of substance abuse and relapse, consider imposing a condition that the offender enroll and actively participate in a plan of treatment for substance abuse such as a Harm Reduction program as a substitute for conditions of strict abstinence

Directed to: Correctional Service Canada (CSC)

  1. It is recommended that CSC consider making harm reduction a priority in addiction treatment programs where appropriate.
  2. It is recommended that CSC consider the use of Methadone or Suboxone treatment for harm reduction.
  3. It is recommended that Methadone or Suboxone treatment should be administered in conjunction with:
    1. mental health treatment and counseling (including where appropriate, from the perspective of previous personal trauma); and
    2. education pertaining to the risks of continued drug use.
  4. It is recommended that CSC consider imposing and enforcing policies of seamless and close integration between treatment programs while incarcerated and those within the community.
  5. It is recommended that in appropriate circumstances, and in particular where there is a history of relapse, individuals should be closely monitored to detect early relapse.
  6. It is recommended that should relapse occur while the individual is in the community, that individual should not return to their existing circumstances in the community or be introduced to a new community before the relapse is stabilized and programs are in place to address the relapse.
  7. It is recommended that given abstinence can result in loss of drug tolerance in as few as three to five days and addiction is a chronic relapsing condition and individuals frequently relapse with a lower tolerance resulting in a higher death rate, individuals with a history of substance abuse should be counseled regarding the high risk of death when leaving the setting of incarceration and returning to the use of substances in the community. Individuals should be counseled, both individually and with their families and support systems to:
    1. not inject alone; and
    2. inject only with a person supplied with and trained in the use of naloxone or in a supervised injection facility.
  8. It is recommended that early parole without evidence of successful management of an individual’s addiction should be discouraged in favour of further institutional treatment.
  9. It is recommended that statistics are gathered and analyzed on an ongoing basis to determine if the approach prioritizing Harm Reduction where appropriate and mental health treatment (especially trauma informed care) are improving the rate of successful re-integration of inmates into the community.