Coroner’s inquest into death of inmate at Sudbury jail makes 13 recommendations

Coroner’s inquest into the 2021 death of a Sudbury Jail inmate has ended. The jury issued recommendations including staff training & Indigenous protocols.

A coroner’s inquest examining the 2021 death of inmate Justin Alexander Trudeau at the Sudbury Jail has ended with several recommendations aimed at preventing a similar tragedy.

Trudeau, a 44-year-old from Wiikwemkoong Unceded Territory, was found unresponsive in his cell on the morning of Feb. 13, 2021, just four days into his 30-day sentence.

The cause of death was determined to be acute staphylococcus aureus pneumonia and septicemia.

The eight-day inquest focused on whether the jail’s care protocols and systemic issues, including those related to Trudeau’s Indigenous background, played a role in his death.

On Monday, the jury heard from coroner co-counsel Robert Kozak, who thanked Trudeau’s family for participating in the process and said the purpose of the inquest is to prevent future deaths.

Kozak said Trudeau was brought to jail Feb. 8 and was serving a 30-day sentence. The night before he died, he told his mother, Brenda Trudeau, that he was extremely short of breath.

His recommendations included improved staffing levels at the jail for overnight shifts and renovating segregation cells with windows to improve the ability of staff to monitor prisoners.

Kozak also said there should be better communication between correctional officers about the status of prisoners and training improvements, especially observation reports and handwritten documentation.

The jury delivered its recommendations Tuesday. Read by presiding officer Dr. Ronald Goldstein, the jury delivered a total of 13 recommendations for the Sudbury Jail and the Ministry of the Solicitor General.

Improved staffing

The recommendations include improving staffing at the jail during overnight shifts, retrofitting segregation cells with windows so staff can better monitor inmates, defining standards for how often prisoners are monitored, “specifically requiring officers to seek visible signs of life, movement and distress.”

“The Sudbury Jail must review and expand methods to improve communications regarding the status of persons in custody, particularly during shift changes and between security patrols,” another recommendation said.

“The jail will provide ongoing training to correctional officers on documentation standards. This training will emphasize the handwritten documentation … being legible and detailed.”

The ministry also agreed to try and have one staff person responsible for organizing and dispensing medication, “thereby allowing existing nursing staff more time for in-person client services.”

An assessment of new arrivals will be a priority, and a review will aim to increase physician and “nurse practitioner coverage and implement a 24-hour nursing schedule.”

Other recommendations

Enhanced Monitoring for Infections: If a person in custody presents with symptoms of a viral or bacterial infection, the Jail must ensure they undergo enhanced frequency of monitoring, including health observations in addition to vital signs (temperature, blood pressure, pulse, breathing rate, and blood oxygen concentration).

EMR Implementation: The Ministry must continue the planned, phased implementation of the Electronic Medical Record (EMR) for the Sudbury Jail.

Septic Shock Training: The Ministry will provide broader education and learning opportunities to nursing staff on assessing signs and symptoms of septic shock and the necessary escalation measures.

Vulnerable Populations Training: Broader education efforts will be provided 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.

Indigenous Cultural Safety: The Ministry will provide broader, reconciliation-focused education efforts and learning opportunities. This training will cover historic perspectives, cultural awareness and safety, and will embed Indigenous knowledge in staff orientation and practice.

The inquest concluded with Goldstein acknowledging the difficulty of the inquest for Trudeau’s family and thanking them for their involvement.

He said the process had uncovered ways to ensure a death like this never happens again.