A coroner's inquest jury has made 13 recommendations aimed at improving health care at the Sudbury Jail following the death of a Wiikwemkoong man in custody four years ago.
Justin Alexander Trudeau, 44, died on Feb. 13, 2021, five days after arriving at the jail to serve a 30-day sentence. A post-mortem found he died from a severe antibiotic-resistant infection that spread from his lungs into his bloodstream.
The five-member jury released its recommendations after a week of testimony revealed staffing shortages for medical staff and guards.
The 13 recommendations include eight proposed by lawyers for the coroner's office, as well as the jail and its doctor, plus five recommendations added by the jury.
The recommendations are not legally binding but instead are issued to encourage changes in policies and procedures.
Within six months of the inquest, the Ministry of the Solicitor General and the Sudbury jail will be asked by the Office of the Chief Coroner to respond to the recommendations, confirming their implementation or providing reasons for non-implementation.
Recommendations directed to the Ministry of the Solicitor General:
Recommendations directed to the Sudbury jail include:
Recommendations directed to both the ministry and the jail include:
Trudeau had a mild fever when he arrived at the jail, resulting in him being placed in isolation for COVID-19 observation. He was being treated for a hand wound that later tested positive for streptococcus and received antibiotics.
He also reported rib pain and requested methadone.
The night before his death, Trudeau phoned his mother, saying he was struggling to breathe and asking her to bring an inhaler.
Forensic pathologist Dr. Martin Queen testified that Trudeau's infection had spread from his lungs into his bloodstream, causing organ failure.
Dr. Dominic Mertz, an infectious disease specialist, told the jury that closer monitoring could have caught warning signs of sepsis pointing to a low temperature reading taken the day before his death.