On Prisoners’ Justice Day, we must acknowledge that Canada’s prison system does not keep people safe from drug-related deaths. We have known what changes are needed for years, but governments have yet to listen to their own coroner’s juries.
Despite decades of efforts to keep drugs out of Canada’s prisons, drug use remains a reality behind bars. More than half of people in custody are estimated to have a “substance use disorder” and recent surveys found that as many as one in three people in federal prisons reported using drugs while incarcerated. In Ontario, people who have been imprisoned are 45 times more likely to die from opioid toxicity than those who have not, with Black communities bearing a disproportionate burden of these preventable deaths during and after incarceration.
While the risks of overdose do not begin or end in prison, correctional institutions have a critical role to play in preventing deaths. Ensuring that people in custody have access to evidence-based treatment, harm reduction services, and healthcare equivalent to what is available in the community is essential to saving lives. Time and again, coroners’ juries in Ontario have recommended these reforms, yet governments have largely failed to implement them.
Recent drug-related deaths at Collins Bay Institution in Kingston, Ontario are telling. Between 2018 and 2022, five people in custody at Collins Bay died of complications directly related to opioid toxicity: Shane Gammie, Christopher Sipes, Qinlong Xue, Quinn Borde, and Shimon Abrahams. These men ranged from 26 to 51 years old at their time of death and were ultimately ruled to have died by accidental means.
An Ontario coroner’s inquest followed in January and February of this year, with the goal of preventing similar deaths in the future. As part of our standing in the inquest, the HIV Legal Network raised questions about and advanced recommendations focusing on harm reduction. And the importance of harm reduction was evident in the jury’s final recommendations: to increase access to evidence-based drug treatment consistent with options available in the community; improve naloxone access for both correctional officers and people in custody; and ensure that people in custody are aware of their rights under the Good Samaritan Drug Overdose Act.
These recommendations, alongside calls to move away from punitive responses toward holistic health-focused interventions, have been repeatedly advanced year after year. In other words, they are not new; they simply remain unactualized. Coroner’s inquest recommendations are not binding — despite their importance in affirming the need for harm reduction to save lives — so such reforms will not be fully realized until governments get on board.
What happened at Collins Bay is a key example of the Canadian prison system’s failure to keep those in custody safe, especially with respect to the toxic drug supply. Comprehensive harm reduction policies that focus on preventative, rather than punitive, measures are deeply needed at a time where toxic drug deaths in prison are on the rise. The lives of people in Canadian prisons are being neglected — not for a lack of knowledge of what works, but because of governmental inaction.
Coroners’ inquests remain one of the few public processes capable of exposing systemic failures in prisons, identifying ways to prevent future deaths, and holding correctional systems accountable. The Ontario government’s recent proposal to amend the Coroners Act would significantly weaken this critical process and add fuel to the fire. By replacing mandatory inquests for non-natural deaths in provincial and federal correctional institutions with coroner-led annual reviews, the government risks weakening one of the only mechanisms that brings these preventable deaths — and the reforms needed to stop them — into public view.
Ontario has rationalized these changes as efficiency. But if the goal is to reduce unnecessary investigations, the answer is not fewer inquests: it is fewer preventable deaths. Implementing the Collins Bay inquest recommendations, and the many others that have preceded it, would save lives while reducing the need for future inquests. Real efficiency means preventing deaths, not simply changing how we review them after the fact.
Canada maintains its war on drugs in which punitive policies prevail over lifesaving interventions in prisons. Thanks to the recommendations from coroner’s inquest juries, governments know what they need to do to prioritize the latter. Without meaningful change, prison terms will continue to turn into death sentences.
Anne-Rachelle Boulanger & Holly Kohler – HIV Legal Network