WARNING: This story contains graphic content and may affect those who have experienced drug poisoning or know someone affected by it.
The coroner’s inquest into the deaths of five Niagara Detention Centre inmates between 2018 and 2022 opened with a lawyer reading heart-wrenching stories from some of the families and the medical officer of health testifying on the high opioid death rate in the region.
Timothy Anderson, Murray Balogh, David Cowe, Michael Croft and Jahrell Lungs all died of drug toxicity within 10 days of being transferred to the Thorold, Ont., detention centre, inquest jurors were told Monday, when the agreed statements of facts were also presented.
People in jail “have little to no control over what happens to them,” so when they die, it’s our societal responsibility to ask why and examine those circumstances, said inquest counsel Phillip Tsui.
Inquests for people who died in custody are mandatory under Ontario’s Coroner’s Act.
The task of coroner’s juries is to determine, on a balance of probabilities, who died, when, where, how and by what means. They may also make recommendations to prevent other deaths.
This inquest, which is expected to last nine days, is being held virtually and can be viewed online. Dr. Richard McLean, the presiding officer, said he is in Burlington and most jurors are in Niagara.
Tsui said the inquest will look at topics including preventing access to drugs at the Niagara Detention Centre, identifying people in custody at risk of overdoses, and the impact of understaffing and overcrowding.
The other inquest counsel, Peter Napier, read statements from some of the men’s family members.
Son ‘not another name or statistic,’ mom writes
Lungs’ mother wrote that her son won academic awards growing up. As an adult, he was a “loving” father to an eight-year-old and a six-year-old, and had plans to get married.
“He was not just another name or statistic. He was my child,” she wrote. “He had his struggles, as many young people do, but he was trying and he deserved a chance to live and grow.”
She said that since police informed her of Jahrell’s death, she’s been “living a nightmare” and left with questions, including how her son could enter the detention centre and never return home, she wrote. She hopes the inquest can prevent similar pain being inflicted on other families.
Anderson’s brother, Mathew, wrote a statement with his cousins, saying Timothy loved art, skateboarding and philosophy, and “his time in jail rarely offered him time to heal.”
Balogh’s adoptive parents, Frank and Christine, said the last few years of their son’s life were “filled by many struggles, but he should have been safe in the custody and control of the system.”
Timeline of what led up to each death
Napier read the statement of facts agreed to by parties with standing at the inquest, including representatives for the men’s families, a Niagara harm reduction coalition and the Ministry of the Solicitor General, which oversees correctional institutions.
The document included a timeline of events leading up to each man’s death, and described their contact with medical professionals, corrections staff and other inmates.
According to the agreed statement of facts:
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Cowe, 32, died on Jan. 11, 2018, less than 48 hours after arriving at the jail. He had been living in Welland and had a history of substance abuse that included hospitalizations for overdoses in 2010 and 2017. Cowe was arrested for alleged drug trafficking and admitted to the Niagara Detention Centre, where he had previously been incarcerated, on Jan. 9. He was placed on “withdrawal protocol,” meaning he could access treatment for withdrawal symptoms as needed. Cowe was housed alone and records show he did not take his medications on Jan. 10 or Jan. 11. On Jan 11, inmates told staff he was going through withdrawal. A corrections officer checked on him at 5 p.m., but when an officer checked Cowe again an hour later, he was not responsive. Corrections officers and nurses tried to resuscitate Cowe. EMS arrived and took him to hospital, where he was pronounced dead. Later, some inmates told investigators they could tell Cowe was unwell and had told staff.
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Croft, 38, died on July 25, 2020, three days after entering the jail. The Niagara Falls resident had a history of criminal convictions, including for theft as well as drug and weapons offences. He was known to smuggle drugs into the Niagara Detention Centre, where he was remanded on July 22 following his arrest on drug and weapons charges. Staff scanned Croft and determined he had no contraband. Croft told a registered nurse who assessed him that he had taken fentanyl and meth prior to his arrest. Staff placed him on withdrawal protocol. On July 24, Croft refused medication and medical assessment. Later that day, staff checked his cell and found fentanyl, as well as notes indicating he had been involved in drug trafficking. They moved him into segregation and put him in a cell where he was observed every 20 minutes. In the evening, a guard was present while Croft and another inmate cleaned and removed garbage through a slot in their cells. Croft disposed of an item in an envelope that another inmate appeared to take from a garbage bin. At about 7:50 p.m., security cameras recorded Croft having spasms and bleeding from the mouth. Officers and nurses responded and began treating him for a seizure. They called 911 after about 10 minutes, and administered naloxone, which can temporarily restore breathing in someone who has overdosed on opioids. EMS declared Croft dead within 40 minutes of arriving. A post-mortem found substances including fentanyl, cocaine and meth in his blood. A pathologist said he may have ingested a baggie of drugs that leaked.
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Anderson, 42, died on Dec. 19, 2020, 10 days after arriving at the Niagara Detention Centre, his third time there. He was admitted for breaching probation. Staff did not find Anderson to be carrying contraband or experiencing withdrawal. He reported some depression and anxiety, but a social worker did not find a need for pressing followup. Security footage from Dec. 18 showed Anderson receiving an item from another inmate. Later interviews with other inmates indicated it was an opioid. At 3:30 the next morning, a sergeant on patrol found he was not breathing. Staff attempted CPR and paramedics took over, declaring Anderson dead after 4 a.m. Police searched his cell and did not find drugs. The next day, an autopsy found a fatal amount of fentanyl in his body.
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Lungs, 26, died on Aug. 1, 2021, four days after his arrival at the facility. He has a history of drug use and previous admissions to prison. Upon admission to the detention centre, a scan found Lungs may have had contraband. On July 29, staff found Lungs smoking marijuana in his cell and placed him along in another cell. On July 31, another scan determined Lungs had contraband in his body. Staff started to check on him hourly. At about 4:10 p.m., an officer found him unresponsive and called for help. Staff were able to wake Lungs. Paramedics took him to the Greater Niagara Hospital. He refused medical treatment and asked to go back to the detention centre. Staff searched his cell and continued hourly checks. Nursing staff did not reassess him. At 2:40 a.m. on Aug. 1, an officer found Lungs unresponsive. Staff tried to resuscitate Lungs, giving him two doses of naloxone. Paramedics arrived 15 minutes later and took over. They declared Lungs dead 20 minutes later. A post-mortem investigation found tied bags containing powder and pieces of paper in his stomach. A toxicology report found a lethal amount of fentanyl in his blood.
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Balogh, 20, died on Feb. 23, 2022, nine days after entering the facility. He had been admitted to the Hamilton-Wentworth Detention Centre in December 2021 and was transferred to the Niagara facility on Feb. 15, 2022. Balogh was receiving treatment for opiate addiction that he requested to stop on Feb. 14. A doctor prescribed methadone, which he received from Feb. 17 to 22. Around 7 a.m. on Feb. 23, inmates in Balogh’s communal dorm informed a corrections officer they couldn’t wake him. Staff responded, attempted resuscitation and gave Balogh naloxone. Paramedics assumed care 15 minutes later and declared him dead at 7:40 a.m. Followup interviews with inmates indicated some thought Balogh had been high, but did not report it. A toxicology report determined methadone toxicity was the cause of death.
Niagara MOH testifies about rate of opioid deaths
Dr. Azim Kasmani, Niagara Region’s medical officer of health, was the first witness to testify on Monday.
Tsui asked Kasmani about the state of the opioid crisis in the region. Kasmani responded that in recent years, Niagara has seen a higher rate of deaths than the province at large.
He noted data from Niagara EMS shows opioid overdoses appeared to spike in 2020 and 2021.
Overdose deaths were “too high even before the pandemic,” Kasmani said, noting there were 89 in 2018, 93 in 2019, 149 in 2020, 163 in 2021, 119 in 2022 and 126 in 2023.
Lawyers for the inquest and the Prison Harm Reduction Coalition, which is a group of community organizations, asked Kasmani about public health’s approach to managing the opioid crisis, and in particular his opinion on the importance of harm reduction relative to addictions treatment and preventing drug use.
Kasmani said multiple strategies are important and that as he understands it, people need to be willing to accept addictions treatment for it to be successful.
In response to questions from lawyers representing the Ministry of the Solicitor General and the Niagara Detention Centre, Kasmani said he has no specific expertise with harm reduction in jails.
On Tuesday, the inquest was set to hear from witnesses Dr. Mikhail Epelbaum and Dr. Todd Overholt about methadone prescribing. Toxicologist Dr. Trevor Beaudoin was also scheduled to speak.
On Wednesday, Jayson Cruise, a Niagara EMS commander of operations, is scheduled to speak about paramedic responses to the Niagara Detention Centre. Nurses Melissa Valeri, Jessica Groulx and Dalene Banton are set to testify about caring for patients in custody.