Jury makes 22 recommendations in coroner's inquest into death of Windsor man at local jail

CBC

19 hours ago

The jury in a coroner's inquest tasked with examining the fatal overdose of a Windsor father of two at a troubled local jail delivered its verdict Thursday, issuing nearly two-dozen recommendations aimed at preventing similar deaths.
Joseph Gratton, 31 at the time, died of fentanyl toxicity after overdosing at the South West Detention Centre nearly six years ago, the five-person jury confirmed.
Gratton, who was in custody awaiting court proceedings, was confirmed dead at a local hospital just after midnight on Oct. 30, 2019.
The five-person jury deliberated behind closed doors for nearly six hours before delivering a verdict and 22 non-binding recommendations to the Ontario government. The first two were related to improving staffing at the provincial facility, which has for years been plagued by overcrowding and understaffing concerns.
Five inmates, including Gratton, overdosed over a roughly two-week period at the time, which the union representing jail staff attributed to a lack of resources.
The inquest jury said the Ministry of the Solicitor General, which oversees corrections in Ontario, should "identify and address the number of unfilled staffing positions in healthcare" within the entire system, and "take additional measures to attract and maintain staff."
The Windsor facility, specifically, should review staffing levels to make sure that a medical professional is always available to assess inmates "in a timely manner," the jury said.
The inquest heard earlier in the week that Gratton's cell mate had been sick and vomited three hours before both men were found unconscious on the floor. But the cell mate, Blake Carter, told a nurse and correctional officer doing a standard medication round that he had just eaten something bad.
The nurse and officer accepted Carter's reasoning, gave him Gravol, and continued on with their round. The nurse, who no longer works at the jail, testified earlier in the inquest that she remembers "being very short-staffed" on night shifts and having a "very heavy client load."
If she'd had more time, she probably would have dug deeper into Carter's symptoms, she said. Carter, who survived that night but has since died, later told a correctional officer that he and Gratton had been doing fentanyl throughout the day.
Other recommendations included making sure that medical staff handle inmate requests promptly, and that those who say they are experiencing opioid withdrawal symptoms are quickly assessed for potential treatment.
On day two of the inquest, which began Monday, the jury learned that Gratton had made multiple requests for a drug that treats opioid addiction in the weeks before his death. A nurse practitioner denied Gratton's request for suboxone eight days before he overdosed on fentanyl.
That nurse practitioner, who saw 20 to 30 patients per day as the jail's only person in that role at the time, said she was worried Gratton might misuse suboxone because he had a history of hoarding his prescription medication. She also testified that she lacked enough evidence to prescribe him the drug, which can be harmful to those who abuse or don't need it.
The jury's recommendations addressed issues that likely slowed the jail staff's response to Gratton and Carter's overdose as well.
Video and testimony from the inquest revealed that the officer who first discovered Gratton and Carter unresponsive at around 11 p.m. did not have the keys to open the cell when a supervisor arrived to assist. The officer who did have the keys had been doing earlier rounds, but had just gone on break.
The province needs to make sure that all officers supervising a unit have keys and radios on them at all times, the jury said.
The inquest also heard that the officer who first saw Gratton and Carter on the ground of their cell had previously alleged that Gratton had threatened her, leading to a police investigation. That correctional officer was working an overtime shift, and wasn't usually assigned to the behavioural unit where Gratton was housed at the time.
It's unclear what came of the police probe, but the jury said the province should "ensure that correctional staff who are complainants in criminal investigations in relation to a particular inmate not be deployed to supervise" their unit.
Other recommendations included "continuously upgrading equipment" to help jail staff stop illicit drugs from getting into the building.
The provincial government has said it will publicly share the jury's full findings and recommendations. The inquest heard that the correctional service and South West Detention Centre have already made several changes in response to Gratton's death.