A recently concluded coroner’s inquest into the death of a Wiikwemkoong First Nation man at the Sudbury Jail has drawn attention to what advocates and correctional officers say are long-standing, Ontario-wide failures in correctional health care.
Sara-Jane Berghammer, CEO of the John Howard Society of Sudbury, said she wasn’t surprised by nurses’ testimony about staffing shortages and lack of overnight medical coverage at the jail.
“My initial thoughts are, no, I’m not surprised. This is stuff that’s been happening for as long as I can remember,” Berghammer said. “An inmate’s health is not governed by the Ministry of Health. It’s governed by corrections, and corrections [and] their mandate is care and control. It’s not health.”
Berghammer said her organization regularly hears from inmates and families saying people aren’t receiving medication they were prescribed before entering custody.
“We sometimes get phone calls from inmates themselves or from family members saying, ‘Can you please help me? My son isn’t receiving medication that he should be inside.’”
Jury recommendations aim to better medical care
The inquest examined a 2021 case involving 44-year-old Justin Alexander Trudeau, who died five days after arriving at the Sudbury Jail to serve a 30-day sentence. A post-mortem found he died of pneumonia and blood poisoning caused by an antibiotic-resistant bacterial infection.
After hearing testimony from medical experts, correctional staff and health-care workers, the jury issued 13 recommendations aimed at preventing similar deaths.
Jurors urged the Ministry of the Solicitor General and the Sudbury Jail to improve health-care staffing, including by adding overnight nursing coverage and reviewing doctor and nurse practitioner availability.
They also called for better communication between guards and nurses during shift changes, clearer observation standards for inmates in segregation, and upgrades to cell doors and windows to allow officers to better monitor people in distress.
Other recommendations focused on improving infection control and medical monitoring.
The jury said inmates showing signs of bacterial or viral infection should be more closely observed and that staff should receive training to recognize symptoms of septic shock. Other recommendations include moving forward with electronic medical records, hiring a pharmacist or pharmacy technician to free up nurses’ time, and offering cultural awareness and trauma-informed training for staff working with Indigenous inmates and people with substance use disorders.
Berghammer said the same recommendations resurface after every inquest, yet little changes.
“For a number of years, I’ve been following inquests and it’s just incredibly heartbreaking because the recommendations from inquests are often the same,” she said. “The outcomes are the same, but there’s no pressure to actually improve the conditions for people inside or implement some of these recommendations.”
The government is not legally bound to implement inquest recommendations.
CBC News has reached out to the Ontario Ministry of the Solicitor General requesting an interview but instead received an emailed statement Friday.
It said the government has made “record investments” into the corrections system, including over $500 million to update and build new facilities and hire more staff, said Oleksandr Shvets, a spokesperson for the solicitor general.
“We have also established a new Health Services Division to ensure those in custody receive the care they need, including support with mental health and addiction issues delivered by social workers, nurse practitioners, mental health nurses and addictions counsellors.”
Chronic understaffing ‘nothing unusual’
Berghammer believes Ontario should move responsibility for inmate health to the Ministry of Health and take the coroner’s findings seriously.
“We do have an obligation to treat people and to try and prevent their sentence to be their demise.”
At the Monteith Correctional Complex, just outside the town of Iroquois Falls, correctional officer Ken Steinbrenner said the same problems outlined in the inquest persist.
“Our facility’s chronically understaffed in general — nothing unusual. It’s clear there’s various degrees of short-staffing right across the province and it’s consistent everywhere,” said Steinbrenner, who’s also president of Local 642 of the Ontario Public Service Employees Union (OPSEU) and sits on the union’s executive board.
He said Ontario’s reliance on private-agency nurses is worsening the situation.
Agency nurses “make more money, but they’re not invested in the place, they’re not part of the workplace.”
Steinbrenner said staff nurses have to constantly train agency nurses set to work in the facility. Agency nurses aren’t able to complete all expectations, such as accessing digital medical records, because they are not permanent staff members.
“The solution is not agency nurses. We really need the government to invest in recruiting and retaining everyone.”
Steinbrenner said overcrowding has also reached a breaking point.
“I’ve been doing this for almost 25 years and it’s never been this bad in the province,” he said. “You overfill the place, you’ve got people sleeping on the floor, you’ve got people sleeping near a toilet. Is that right? I don’t think so.”
He said violence has also surged.
“The offenders have never been more violent, and there’s never been more violence in my time,” Steinbrenner said.
“Somewhere in Ontario, three correctional officers are getting assaulted today. That’s the numbers we’re looking at.”
Steinbrenner said the province’s own staffing assessments often aren’t shared with unions.
“We just went through one. We participated, gave feedback, and the government won’t share the report. All I’m left to suspect is they won’t share it with us because it recommends more staff.”
Same number of nurses with 3,000 more inmates
Those problems are echoed by Adam Cygler, a social worker at the Ontario Correctional Institute in Brampton and one of the elected representatives on the ministry’s employee relations committee representing non-correctional staff across the system.
“Our inmate population has been growing … we’re housing anywhere between — I want to say — probably 3,000 more inmates than we normally did pre-COVID, and our staffing levels and health care in particular have remained relatively kind of stagnant or stable to what they were beforehand.”
He said small- and medium-sized jails like Sudbury’s don’t have pharmacists, leaving nurses to sort and dispense medication themselves.
“The medications come in in bulk, and then nurses have to pour, and dispense and sort of prepare all the medications,” Cygler said. “That’s where the room for error [appears because] you’re rushing and trying to compete with all those other duties.”
To attract more staff, Cygler believes there needs to be an increase in compensation packages.
“Our nurses show up every day in those challenging environments and do an incredible job that many people would be exposed to for a short period of time and say, ‘No thank you.’– Adam Cygler, social worker
Other health-care professionals, including social workers and psychologists, also earn less than their counterparts in the community, according to Cygler.
“Recruiting people in and then getting people to stay long term in this already challenging environment is that much harder when we’re not paying them the going rate.”
Despite that, he said, most health-care staff continue to show up out of commitment to their patients.
“Our nurses show up every day in those challenging environments and do an incredible job that many people would be exposed to for a short period of time and say, ‘No thank you.’”
‘They have rights just like we do’
Berghammer said the public often overlooks the human cost of neglecting health care behind bars.
“There’s a lot of stigma with people who commit crime, but we have to remember that just because someone’s incarcerated does not necessarily mean that they’re guilty,” she said.
“Technically, they’re innocent till proven guilty and they deserve the same rights as we are afforded on the outside.”
Berghammer attributes inaction to the significant investment required from the Ministry of the Solicitor General and the pervasive stigma associated with criminals. But, she said, providing basic health care to inmates is essential for their reintegration into society.
“They have rights just like we do. And if we want them to have a chance at getting out and becoming productive, they need to be well,” she said.
“We can’t just shut the doors and pretend like they don’t exist.”
