Joel Dick of Howie Sacks & Henry on the human and systemic cost of losing mandatory inquests
Ten years ago, an incarcerated person in an Ontario jail suffering an opioid overdose was at the mercy of the nursing station’s hours. Naloxone was available, but it wasn’t accessible: it sat on nursing carts, too far away from the correctional officers (COs) who were first on scene to reach in time.
Coroner’s inquests changed that. Through a series of verdicts examining in-custody overdose deaths from the mid-2010s onward, juries flagged the disconnect in hearing after hearing. Their recommendations drove policy change: today, naloxone is available at the bubble, the CO station at the centre of every Ontario jail.
“At a more systemic level, coroner’s inquests are really the only tool in our system designed to be both backward and forward looking,” says Joel Dick, a partner at Howie Sacks & Henry LLP. The civil actions he brings are completely backward-looking, asking what damages are affixed to this specific instance of negligence. Coroner’s inquests ask much broader questions. How do staffing levels, for example — a perennial concern — relate to an inmate’s death within the prison walls?
“The inquests allow for conversation about the way policy impacts the reality on the ground, how things interact, and how they might be prevented in the future.”
A move away from accountability
Dick’s practice centres on personal injury but he has carved out a distinctive niche in correctional misconduct, negligence, and custodial injury where he represents incarcerated people and their families against government defendants.
In that role, he’s accompanied families at numerous inquests. It’s given him insight into how the process is healing for them, but also how outcomes can drive change, at a higher level, for the better: lives are saved because of them. In Dick’s eyes, these inquests are worth protecting. But they’re currently under threat.
In December 2025, Ontario’s Ministry of the Solicitor General launched stakeholder engagement on a proposed legislative change to end mandatory inquests for non-natural in-custody deaths and replace the process with annual reviews for deaths in correctional institutions.
Dick takes issue with the proposal, as do the Canadian Prison Law Association, the John Howard Society, and the Canadian Civil Liberties Association, all of which submitted formal feedback opposing the change. He calls it “a move away from direct accountability, and certainly a move away from transparency.”
“I’m concerned that when we take away the inquest, we take away the ability to really look at a particular death — or the deaths that a coroner groups together — in the context of systemic issues,” he says. “The public won’t know exactly what happened and it’s not as good for the families, as there’s not going to be closure.”
A pattern of pulling back
The government also recently changed the province’s building code, removing any minimums for personal space for inmates. No official, from the Solicitor General to the housing minister, has addressed why the standard was removed. However, the prison system is at 123% capacity on any given day.
“It’s not a stretch to think the change was made with a view to making what has been a temporary solution to overcapacity permanent,” Dick says.
Reinforcing that assumption are reports of plans already in motion at the Quinte Detention Centre to officially add third bunks in existing cells. This comes despite research confirming that overcrowding in small cells is linked to all kinds of mental health issues including more fights and disruptions, as well as worse health outcomes. Maplehurst had two people die from invasive group A streptococcal disease, which swept through the building. It’s well-established that close quarters allow infectious disease to spread more quickly.
“When you combine getting rid of the building code standards, which will allow for more triple bunking with the removal of coroner’s inquests as an automatic inquest in cases of deaths in correctional facilities, you have a real move away from transparency and governmental accountability,” Dick says. “And that troubles me.”
A precursor to something worse
When someone is in jail, their entire lives are controlled by the state. When they eat, when they see a doctor, when they shower, when they sleep. Though not a politically popular cohort to defend, it’s indisputable that they’re vulnerable. That means these institutions should be places where we demand maximum transparency around how the government is treating them.
For those who have lost someone inside those walls, that transparency is not an abstraction. Dick has seen that firsthand in the coroner’s inquests he’s been involved in: how important it was for family members to display a photo of their family member as an official exhibit for the jury and how meaningful an opportunity it was for them to share an opening statement.
Many deaths won’t result in a civil action, but the bereaved are able to learn about their loved one’s last hours beyond a fragmented incident report. As hard as it may be, there’s often CCTV footage for them to review. The inquest is really the first time, and maybe the best and only time, where that information is gathered, Dick says, and his clients, uniformly, report a sense of closure.
“Everybody in an Ontario jail has an Otis number for the inmate tracking system, and it’s very easy to feel like your loved one has become that number. Coroner’s inquests are a chance to reassert the humanity of what’s been lost.”
Maybe that’s not the most important reason to have inquests — the accountability and the transparency of the government rank at the top — but it’s an important byproduct. Is losing that mechanism really where we want to go as a society? Dick asks, adding that we mustn’t become indifferent to inhumane treatment. He warns that the prison population is also, in many ways, the canary in the coal mine.
“When governments start to move away from accountability in jails and prisons, inevitably they pull back from accountability across the board,” Dick says. “We haven’t seen that yet in Ontario, but I do worry that this could be a precursor to the provincial government moving away from transparency in all sorts of areas.”
This article was produced in partnership with Howie Sacks & Henry LLP
