The inquest for Zakery Rogers is over, and while his sister is relieved their family has answers to many questions after his death five years ago in a Hamilton jail cell, she says they still want accountability for the “domino effect” of failures he faced.
In a recent interview with CBC Hamilton, Kylee Rogers said she told the inquest she didn’t hear “an ounce of accountability from anyone.” She also said it remains to be seen if the jury’s many recommendations to prevent similar deaths will be implemented.
“I feel like we won the battle but the war rages on,” Kylee said, noting poor mental health and addiction continue to be “huge problems” in the community.
An agreed statement of facts for the inquest, which was conducted by video conference and wrapped up Friday after several days, said Zakery died while incarcerated at the Hamilton-Wentworth Detention Centre on Jan. 31, 2021. The 26-year-old had three children and was a brother and uncle.
Zakery, who was in and out of jail, had mental health conditions and was dependent on opiates. He also experienced homelessness and suicidal thoughts.
On Christmas Eve 2020, Kylee bailed Zakery out of the Maplehurst Correctional Complex in Milton, Ont., where he had been in custody while awaiting trial for charges of robbery, theft and weapons-related offences since March that year.
Doctors and psychiatrists had prescribed him anxiety and anti-depressant medications, medicine to help him sleep and methadone. However, Kylee told the inquest, when she picked him up, he did not have a prescription to get his medications or a supply to hold him over until he could get one.
Zakery’s condition worsened, said Kylee, and he became erratic. She felt she could no longer safely be his surety, and he ran away before police could take him back into custody.
On Jan. 27, 2021, police arrested him and took him to a hospital, where he complained of a cough, abdominal pain and chills. The inquest’s agreed statement of fact noted the hospital determined a lobe in his lung had collapsed but he was otherwise OK. Zakery was admitted to the Hamilton-Wentworth Detention Centre, where he told a nurse he had chest pain.
Two days later, paramedics and jail staff responded to resuscitate Zakery after guards found him in his cell without vital signs. He was checked for drugs and none were found on him or in his cell, although a urine test indicated he had some drugs in his system.
On Jan. 31, Zakery was returned to jail, where guards were set to check on him every 20 minutes. Although a guard logged that he had interacted with Zakery at 5:15 p.m. that day, video surveillance shows nobody looked in his cell or attempted to interact with him between 4:53 p.m. and 5:40 p.m., when a guard found him unresponsive again.
About an hour later, Zakery was pronounced dead in hospital.
‘I was so relieved,’ sister says of cause of death finding
The inquest jury determined Zakery died of myocarditis, an inflammation of the heart that can lead to complications and possibly death.
Originally, a post-mortem report ruled the cause “unascertained.” But a July 2025 review by Dr. Michael Pollanen, chief forensic pathologist for the Ontario Forensic Pathology Service, found the inflammatory disease was the cause and said methamphetamines could have contributed to Zakery’s condition.
“I was so relieved,” Kylee said. She also noted that during the inquest, some expert witnesses testified against Pollanen’s findings, arguing her brother died of an overdose.
Since Zakery was incarcerated, an inquest was mandatory under Ontario’s Coroners Act. During such procedures, lawyers for the parties — including the jail, hospitals, coroners and family members of the deceased — ask questions of witnesses, who can include eyewitnesses, experts, and institutional workers and officials.
Often, families of inquest subjects are represented by lawyers. In this case, Kylee represented her family and asked questions to witnesses directly.
She said it was “discouraging” to hear witnesses and lawyers avoid taking accountability for the chain of events that led to Zakery’s death, but she worked hard and drew on her experience working as a nurse to calmly ask tough questions.
“I wanted to be taken seriously. I didn’t want to seem like a hysterical family member who’s just so angry that I’m just saying things,” Kylee said in the interview. “The questions that I have are meaningful and they are coming from somewhere important.”
At one point, Kylee said, she questioned the guard who wrote that he checked on her brother the evening he died, even though video evidence showed he didn’t. Learning that was “really upsetting,” she said.
She added she felt the guard “seemed to shrug it off” when she asked him why he wasn’t doing his checks correctly and whether he thought doing so might have meant her brother would have survived.
There have been inquests into multiple deaths at the Hamilton jail in the last two years alone, including for Ryan McKechnie, Igor Petrovic, Christopher Sharp, Robert Soberal, Paul Debien, Nathaniel Golden and Jason Archer.
Inquest juries do not make legal findings of guilt or responsibility, but can make recommendations.
In Zakery’s case, there were 13 recommendations, which focus on actions suggested for the Ministry of the Solicitor General, which oversees corrections, and the Hamilton Health Sciences (HHS) hospital network. They include:
- Within six months, create a standing committee of HHS and jail workers to review communications when someone is discharged from hospital into the jail.
- Explore updating surveillance cameras in the jail and a policy of preserving audio recordings in the event of a death.
- Audit observation logs each month by comparing them to surveillance footage to ensure rounds are being completed as logged.
- Prepare a package to give people when they’re released from jail with information on who to contact to get prescription medication and resolve health-care problems.
- Explore having a person or team that would provide information about supports to people who are released from jail and ensure they have a short-term supply of necessary medications.
Kylee said she’s pleased with the recommendations. Had they been implemented sooner, she added, they “would have made a world of difference for Zak.”
Inquest recommendations are non-binding, but she hopes the simplicity of this set will make it easier to hold the government accountable.
The “domino effect” of failures that Zakery was subjected to started with him not being able to get the medicine he needed that Christmas, Kylee said. Instead of reintegrating, she added, her brother ended up back on the street and getting into trouble again.
“These are failures to the community too.”
‘Jail is not the answer’
Kylee has watched other inquests and become involved with a community of people aimed at prison reform and preventing deaths in jail, leading her to believe “jail is not the answer at all.”
She added she was “naive” because she used to think serving jail time helped make people better. Now, she finds, “the whole system sets you up to fail” and creates new problems.
In jail, she said, people like her brother don’t just lose their freedom; they also place their lives in the hands of others, becoming unable to even call for help when they need it.
While some politicians are advocating for a more restrictive bail process that would keep more individuals behind bars, Kylee wants people advocating for different solutions that address issues like homelessness and addictions.
“It’s really frustrating to watch these inquests and see the outcomes be the same over, and over and over again. … I think that there’s more hope in speaking out and spreading the word, getting more people to see and understand what’s really going on.”
