London jail deaths: Government response lags to coroner’s juries’ recommendations

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In response to questions about the most recent death at London’s provincial jail, Ontario’s corrections minister, Marie-France Lalonde, noted the investigation has just begun.

In any death at a correctional facility, “if an investigation or a coroner’s inquest determines that policies were not followed, or that policies need updating, action is taken,” she said.

When, exactly, action is taken remains a question.

Eighteen months after an inquest into the 2014 death of Londoner Keith Patterson — and six months after the province expected answers — neither London’s jail nor the corrections ministry have responded to recommendations for action from a coroner’s jury.

In the meantime, several more inmates have died — at least one in a similar manner — prompting questions about the ability of Ontario’s inquest system to spur action.

“It becomes ineffective when there is this length of delay,” London lawyer and inmate advocate Kevin Egan said.

“The intent of the coroner’s inquest is to prevent similar deaths in the future. And if we’re waiting three years or longer from the time of death for some kind of reaction from the ministry, then the whole exercise is futile.”

Six inmates have died at the Elgin-Middlesex Detention Centre (EMDC) since Patterson died. At least four of those six men died after the inquest jury sent its recommendations to the province to prevent similar deaths.

“That is a frightening statistic,” Egan said.

Deaths at correctional facilities such as EMDC often lead to coroner’s inquests, where a jury of five considers the cause of death and makes recommendations to prevent further deaths.

The juries direct those recommendations to provincial ministries or agencies that can make changes.

Ontario’s chief coroner office makes it clear on its website that it expects responses to those inquest recommendations from ministries and agencies after a year.

“Those who receive recommendations are asked to provide a response to the Office of the Chief Coroner indicating their actions taken, if any, after one year of receipt,” the website states.

Patterson died Sept. 30, 2014, after hanging himself in a segregation cell at EMDC.

An inquest into his death in November 2015 made eight recommendations to the Ministry of Community Safety and Correctional Services and four to EMDC in an effort to prevent similar deaths.

The recommendations were received in January 2016, meaning the ministry and EMDC were supposed to provide responses by January 2017.

But there’s been nothing handed to the coroner’s office except one letter of acknowledgement from the ministry, according to an email received by London lawyer Kevin Egan last week, and shown to The London Free Press.

The email from the coroner’s office to Egan states: “The only response to recommendations we have received is an acknowledgment letter from MCSCS (Ministry of Community Safety and Correctional Services). So far no word from Elgin Middlesex Detention Centre.”

Four days ago, after The Free Press asked about the Patterson inquest, a ministry spokesperson said responses to the recommendations would come soon.

“When policy is being developed that addresses coroner’s recommendations, responses may be delayed to ensure that relevant information can be provided to the Coroner’s office,” Andrew Morrison said.

“The ministry is carefully considering the Patterson jury recommendations and will respond directly to the Office of the Chief Coroner this week.”

It’s impossible to know yet if the recommendations from the Patterson inquest might have helped prevent three deaths at EMDC this summer and one last fall.

But in an least one death, there are parallels.

Patterson hung himself using a strip of material from a security blanket while in a segregation cell, with a camera outside working but not being monitored.

In June, Raymond George Major, 52, apparently used a strip of material to hang himself while in a regular cell, with a camera viewing activity on the range, during what inmates have described as a lockdown with less than the usual supervision.

The inquest into Patterson’s death recommended better suicide prevention and mental health training for staff, as well as better monitoring of video cameras, and improvements to security blankets used in segregation.

The inquest also identified the stress Ontario’s jails place upon inmates, especially those with mental illness, and recommended the province study the issue.

Inmates have told The Free Press that the stress of recent lockdowns have fuelled drug use at EMDC, with the arrival of the deadly opioid fentanyl making that use riskier than ever.

The most recent death at EMDC occurred Thursday, and sources have suggested an overdose is to blame.

It’s the third death this summer, following Major’s death June 6 and the death of Mike Fall. 47, July 30.

In October 2016, Justin Thompson, 27, died of an overdose while at EMDC.

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