Deaths in correctional facilities demand systemic response, former investigator says

CBC

13-06-2025

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Former federal correctional investigator Howard Sapers says more needs to be done to address the systemic problems that lead to deaths in Canadian correctional facilities.
Sapers says coroner's inquests investigating those deaths often repeat the same themes over and over, including issues with staffing and training; questions about the adequacy of policy; and matters related to the infrastructure at individual facilities.
"It's like Groundhog Day," he said.
"I've read so many of these and participated in so many that … your mind wanders. 'Like, OK, am I still looking at the right inquest? Is this the outcome from that process? Because so often, you see the same things."
Sapers made the comments on Windsor Morning Friday after a coroner's jury released 22 recommendations in an inquest into the death of Joseph Gratton.
Gratton died of fentanyl toxicity at the age of 31 after overdosing at the South West Detention Centre in 2019.
The inquest heard that a cellmate had been sick earlier in the day, but had blamed the illness on something he ate.
A nurse on staff had failed to further investigate his symptoms and told the inquest she had a heavy client load and likely would've looked into the situation more thoroughly if she had more time.
Jurors also heard that a nurse practitioner at the jail had denied Gratton's requests for Suboxone, a drug used to treat opioid addiction, because he had a history of hoarding medication, and she was concerned he might abuse it.
But Sapers said correctional facilities are doomed to repeat the same circumstances if inquests only look at the details of individual cases, instead of addressing systemic problems such as chronic understaffing and overcrowding.
"There's these spasms of reform, and then there's backsliding," he said.
"And so what we really need is sustained political commitment to getting things as right as we can."
Recently, Sapers said, there have been moves to conduct joint inquests into multiple deaths that share common circumstances.
Experts already know how to address many of the problems facing the corrections system, he added.