A man’s death from a severe lung infection just days into serving a sentence at Sudbury Jail has prompted a coroner’s inquest jury to recommend sweeping changes to how the local jail operates.
The jury in the coroner’s inquest into the death of Justin Alexander Trudeau of Wiikwemkoong found he died of natural causes. But that doesn’t tell the whole story.
Trudeau died on Feb. 13, 2021, while in custody at Sudbury District Jail. A father of five, Trudeau had been incarcerated for a little more than four days when he was found in his cell. He had several infections, one resistant to antibiotics and one so severe that fluid had filled his lungs.
A pathologist who testified at the inquest said Trudeau died of acute staphylococcus aureus pneumonia and septicemia from a drug-resistant bacteria that was likely in his system when he entered the jail to begin his 30-day-sentence on Feb. 8. When he was found in his cell, he was blue and in full rigor mortis.
Though originally set to take nine days, running from Oct. 20 to Oct. 30, the inquest jury was sent to deliberation on Oct. 27 just after 11 a.m. After hearing from two registered nurses and two health care managers, who at one time worked or still work at the remand facility, as well as three corrections officers and three doctors over the course of the inquest, the final day included suggested recommendations from each party given standing in the inquest: the solicitor general’s office, counsel for Dr. Bineet Moudgil, an on-call physician who spoke with a nurse at the jail regarding Trudeau's health, and the counsel representing the public interest, known as inquest counsel.
At the closing of the evidence at the inquest, Inquest counsel Robert Kozak read from the recommendations suggested by those given standing. You can find those details here.
Now, the jury has released their own recommendations with an aim to ensure a death like this is not repeated.
To the Ministry of the Solicitor General (the ministry):
- The ministry will explore how to optimize Correctional Officer staffing levels during overnight shifts at the Sudbury Jail with the goal of having enough Correctional Officers available to provide escorting services in case of an emergency.
- The ministry will work with any other relevant provincial ministries, bodies, and/or agencies to explore retrofitting segregation cell doors at the Sudbury Jail with windows suitable to improve the ability of corrections staff to make accurate observations of persons in custody housed in these cells.
- The ministry will further define standards for observation of persons in custody in all medical and segregation units on night shift security patrols to seek visible signs of life, movement, and distress.
To the Sudbury Jail:
- The Sudbury Jail will review and expand methods to improve communications between the correctional officers concerning status of persons in custody during shift changes, and between security patrols.
- The Sudbury Jail will provide correctional officers ongoing training regarding documentation standards pertaining to their role. Said training and reviews will continue to emphasize the importance of any handwritten documentation, including observation reports and institutional logbooks, being legible, comprehensible, and appropriately detailed. Sudbury Jail should also continue to conduct routine audits of staff compliance with expectations with respect to observation reports and institutional logbooks.
- The Sudbury Jail will consider, when operationally feasible, reducing the number of different correctional officers that check on persons in custody held in segregation cells during night shift security patrols.
Health care:
The Sudbury Jail and the ministry will explore the optimization of healthcare staffing levels at the Sudbury Jail with the goals of:
- Staffing a specific position (e.g., a pharmacist or pharmacist technician) that would focus on the role of organizing and dispensing of medication, to allow existing nursing staff more time to provide in-person client services.
- Reviewing clinical service needs, including physician, nurse practitioner, and nursing hours, to increase physician and/or nurse practitioner coverage and implement a 24-hour nursing schedule.
- For persons in custody requiring medical assessment at the Sudbury Jail, priority should be given for new arrivals.
- The Sudbury Jail will ensure, when a person in custody presents with one or more symptoms of viral or bacterial infection, they shall undergo enhanced frequency of monitoring, which would include health observations in addition to body temperature, blood pressure, pulse, breathing rate, and blood oxygen concentration.
To the ministry:
- The ministry will continue the planned, phased implementation of the electronic medical records for the Sudbury Jail.
- The ministry will continue to provide broader education efforts and learning opportunities to nursing staff on assessing for signs and symptoms of septic shock and further escalation measures that should be taken when a person in custody presents with concerning symptoms.
- The ministry will provide broader education efforts and learning opportunities to staff on the specific medical and social needs of vulnerable populations including those experiencing substance use disorder, and persons who are unhoused or underhoused.
- The ministry will provide broader, reconciliation-focused education efforts and learning opportunities to staff on the specific medical and social needs of Indigenous persons, including historic perspectives, cultural awareness and safety, and shall embed Indigenous knowledge in staff orientation and practice.
Jenny Lamothe is a reporter at Sudbury.com.