Latest news with #JosephGratton
CBC
13-06-2025
- Health
- CBC
Deaths in correctional facilities demand systemic response, former investigator says
Social Sharing Former federal correctional investigator Howard Sapers says more needs to be done to address the systemic problems that lead to deaths in Canadian correctional facilities. Sapers says coroner's inquests investigating those deaths often repeat the same themes over and over, including issues with staffing and training; questions about the adequacy of policy; and matters related to the infrastructure at individual facilities. "It's like Groundhog Day," he said. "I've read so many of these and participated in so many that … your mind wanders. 'Like, OK, am I still looking at the right inquest? Is this the outcome from that process? Because so often, you see the same things." Sapers made the comments on Windsor Morning Friday after a coroner's jury released 22 recommendations in an inquest into the death of Joseph Gratton. Gratton died of fentanyl toxicity at the age of 31 after overdosing at the South West Detention Centre in 2019. The inquest heard that a cellmate had been sick earlier in the day, but had blamed the illness on something he ate. A nurse on staff had failed to further investigate his symptoms and told the inquest she had a heavy client load and likely would've looked into the situation more thoroughly if she had more time. Jurors also heard that a nurse practitioner at the jail had denied Gratton's requests for Suboxone, a drug used to treat opioid addiction, because he had a history of hoarding medication, and she was concerned he might abuse it. But Sapers said correctional facilities are doomed to repeat the same circumstances if inquests only look at the details of individual cases, instead of addressing systemic problems such as chronic understaffing and overcrowding. "There's these spasms of reform, and then there's backsliding," he said. "And so what we really need is sustained political commitment to getting things as right as we can." Recently, Sapers said, there have been moves to conduct joint inquests into multiple deaths that share common circumstances. Experts already know how to address many of the problems facing the corrections system, he added.
CBC
13-06-2025
- Health
- CBC
Jury makes 22 recommendations in coroner's inquest into death of Windsor man at local jail
The jury in a coroner's inquest tasked with examining the fatal overdose of a Windsor father of two at a troubled local jail delivered its verdict Thursday, issuing nearly two-dozen recommendations aimed at preventing similar deaths. Joseph Gratton, 31 at the time, died of fentanyl toxicity after overdosing at the South West Detention Centre nearly six years ago, the five-person jury confirmed. Gratton, who was in custody awaiting court proceedings, was confirmed dead at a local hospital just after midnight on Oct. 30, 2019. The five-person jury deliberated behind closed doors for nearly six hours before delivering a verdict and 22 non-binding recommendations to the Ontario government. The first two were related to improving staffing at the provincial facility, which has for years been plagued by overcrowding and understaffing concerns. Five inmates, including Gratton, overdosed over a roughly two-week period at the time, which the union representing jail staff attributed to a lack of resources. The inquest jury said the Ministry of the Solicitor General, which oversees corrections in Ontario, should "identify and address the number of unfilled staffing positions in healthcare" within the entire system, and "take additional measures to attract and maintain staff." The Windsor facility, specifically, should review staffing levels to make sure that a medical professional is always available to assess inmates "in a timely manner," the jury said. The inquest heard earlier in the week that Gratton's cell mate had been sick and vomited three hours before both men were found unconscious on the floor. But the cell mate, Blake Carter, told a nurse and correctional officer doing a standard medication round that he had just eaten something bad. The nurse and officer accepted Carter's reasoning, gave him Gravol, and continued on with their round. The nurse, who no longer works at the jail, testified earlier in the inquest that she remembers "being very short-staffed" on night shifts and having a "very heavy client load." If she'd had more time, she probably would have dug deeper into Carter's symptoms, she said. Carter, who survived that night but has since died, later told a correctional officer that he and Gratton had been doing fentanyl throughout the day. Other recommendations included making sure that medical staff handle inmate requests promptly, and that those who say they are experiencing opioid withdrawal symptoms are quickly assessed for potential treatment. On day two of the inquest, which began Monday, the jury learned that Gratton had made multiple requests for a drug that treats opioid addiction in the weeks before his death. A nurse practitioner denied Gratton's request for suboxone eight days before he overdosed on fentanyl. That nurse practitioner, who saw 20 to 30 patients per day as the jail's only person in that role at the time, said she was worried Gratton might misuse suboxone because he had a history of hoarding his prescription medication. She also testified that she lacked enough evidence to prescribe him the drug, which can be harmful to those who abuse or don't need it. The jury's recommendations addressed issues that likely slowed the jail staff's response to Gratton and Carter's overdose as well. Video and testimony from the inquest revealed that the officer who first discovered Gratton and Carter unresponsive at around 11 p.m. did not have the keys to open the cell when a supervisor arrived to assist. The officer who did have the keys had been doing earlier rounds, but had just gone on break. The province needs to make sure that all officers supervising a unit have keys and radios on them at all times, the jury said. The inquest also heard that the officer who first saw Gratton and Carter on the ground of their cell had previously alleged that Gratton had threatened her, leading to a police investigation. That correctional officer was working an overtime shift, and wasn't usually assigned to the behavioural unit where Gratton was housed at the time. It's unclear what came of the police probe, but the jury said the province should "ensure that correctional staff who are complainants in criminal investigations in relation to a particular inmate not be deployed to supervise" their unit. Other recommendations included "continuously upgrading equipment" to help jail staff stop illicit drugs from getting into the building. The provincial government has said it will publicly share the jury's full findings and recommendations. The inquest heard that the correctional service and South West Detention Centre have already made several changes in response to Gratton's death.
CTV News
12-06-2025
- CTV News
Windsor inquest jury sequestered to consider recommendations in jail overdose death
Joseph Gratton, 31, died on October 30, 2019 from a fentanyl overdose while incarcerated at the South West Detention Centre. (Courtesy: Lori Clifford)
CTV News
11-06-2025
- CTV News
‘Not uncommon': Inmate slides unknown item under cell door hours before overdose at South West Detention Centre
A Windsor jury is watching surveillance video from inside the South West Detention Centre from October 2019 in the ongoing inquest into the death of Joseph Gratton. (Courtesy: Coroners Office) An inquest continues into the death of Joseph Gratton, 31, an inmate who consumed a fatal quantity of fentanyl at South West Detention Centre on Oct. 29, 2019. Warning: contains graphic content. The jury has seen surveillance video from inside SWDC from that evening. Around 7:17 p.m., two corrections officers enter a cell and ask an unidentified inmate to step out into the common area so they can speak with his cellmate. The inmate walks directly to cell #4 – Gratton's cell – and appears to speak to him and his cellmate, Blake Carter. They slide something out of their cell to the common area. After a brief conversation, the unidentified inmate takes that item and walks back towards his cell. He picks up what appears to be cleaning solution left on the table, appears to speak to a jail officer and goes back to Gratton's cell. He places something on the ground, talks to Gratton and Carter, and walks away. You can see in the video; the item being pulled into Gratton's cell. The jury has no evidence about what the item was. 'It's not uncommon,' Staff Sgt Randy Mascarin testified Tuesday. He told the jury inmates trade things like peanut butter packets or salt and pepper under their cell doors on a 'quite frequent basis.' Mascarin said the inmate – who he was directed to not identify – had been out of his cell for most the day and would have had plenty of other opportunities to smuggle contraband to Gratton or Carter during the day. 'I wouldn't have had an issue with this,' Mascarin said while telling the jury he did not go and inspect what the items were. In 2019, Mascarin said the unidentified inmate did not have a history of smuggling illegal drugs into the jail but that has since changed. Mascarin agreed with the lawyer for the Ministry of the Solicitor General that a 'simple thing' like peanut butter can mean a great deal to people who have so little choices in what they eat, how they live, who they talk to, when they shower or go outside. Inquest into inmate's death First day of an inquest into the death of inmate Joseph Gratton at South West Detention Centre. CTV Windsor's Chris Campbell has details. Overdose timeline The jury is starting to get a very clear timeline of the events that lead to Gratton's fatal overdose. After the 7:17 visit to his cell by an inmate, Mascarin and the other officer working with him on 'inmate adjudication' visited Gratton's cell to check on both. There is no evidence about what they discussed. The next surveillance video is from 8:15 p.m., during a 'pill pass' by the jails nurse. Jessica Chu told the jury she doesn't specifically remember her interaction with Gratton's cellmate Blake Carter. Mascarin however testified Carter complained of vomiting in his cell toilet and asking for anti-nausea medication. Carter, according to Mascarin, complained of eating bad food before throwing up again in the cell toilet. Mascarin told the jury an inmate must have 'proof' they are sick to get anti-nausea medication which Chu dispensed. 'I had no reason to believe it was anything other than being ill,' Mascarin told the jury. Neither Mascarin nor Chu spoke with Gratton during the final medical check of the night and he appeared to be fine. Corrections officers conduct cell checks every half hour in the unit where Gratton was held. The jury has seen surveillance video of no issues on a check by Mascarin around 9:02 p.m. He told the jury his colleague Christine Rogers had previous conflicts with Gratton so he agreed to do checks until lights out, to ensure Rogers and Gratton did not have interact. The next surveillance video for the jury is 11:04 p.m., on a check by Rogers. On her first lap of the ward, she kicks on the bottom of cell door #4 before carrying on. She returns to the unit a minute later and goes directly to cell #4 and kicks the door again. The silent video then appears to show Rogers speak into her radio. Another officer attends and he too kicks the door. It appears both try to get reaction from the inmates inside and when they don't, it appears they try to open the door but the keys don't work. By 11:06 p.m. the main lights in the common area go on – and the lights in the cells go out – as two other officers, followed by Mascarin race into the unit and open cell #4. The video ends when the officers get into the cell. 'Extremely strange' sight Mascarin told the jury they found Gratton on his back laying with his feet closer to the toilet. He had vomit on his mouth, and he was unresponsive. Carter, however, Mascarin said was in an 'extremely strange' position. 'I was caught off guard,' he testified. 'It was unlike anything I've seen.' Carter, according to Mascarin, was flat on the floor with his arm 'draped' over Gratton's body and blood on his mouth. He felt it looked 'staged', not like two people who unexpectedly pass out from a drug overdose. Mascarin and two other officers tried performed CPR on Gratton while they waited for paramedics. Gratton and Carter were rushed to hospital, but Gratton was declared dead in the emergency room. Mascarin said Carter turned to him in the hospital and said 'Randy, looked how (expletive) up my face looks!' before admitting he might still have contraband hidden inside his body. Carter, the jury has learned, survived the 2019 overdose. When he returned to SWDC, Mascarin says Carter admitted he and Gratton had 'consumed drugs all day'. 'I'm getting tired of this life,' Carter allegedly said to Mascarin. The jury has learned Carter has since died.
CBC
11-06-2025
- Health
- CBC
Windsor man who overdosed in jail was denied opioid meds because he wasn't eligible: nurse
In the weeks leading up to his death, Joseph Gratton had asked medical staff at the local jail multiple times for drug tests and a medication that helps treat opioid addictions. But the Windsor father of two would never access the prescription drug, and on an October night nearly six years ago, he overdosed on fentanyl in his cell at the South West Detention Centre. A correctional officer found Gratton, 31 at the time, and his cell mate unconscious on the floor during a routine patrol. Despite several rounds of CPR and naloxone, Gratton was pronounced dead at the hospital just after midnight on Oct. 30, 2019. A legally mandated coroner's inquest into the circumstances around his death began Monday. Inquest counsel Julian Roy revealed that a nurse had denied Gratton a prescription for suboxone, which helps people with opioid addictions fight cravings and tame withdrawal symptoms, eight days before his death. On Tuesday, the jury heard directly from the nurse practitioner in question. Julie MacVoy, who no longer works at the facility, testified that she denied Gratton suboxone because he wasn't eligible for the drug, in part because he hadn't been formally diagnosed with an opioid use disorder. MacVoy said she also didn't see any clear signs of withdrawal — though she acknowledged that those symptoms might not be present if he was still using illicit drugs. She noted that he had a history of hoarding prescription medication as well, leading her to believe that he might misuse the suboxone — a drug that poses health risks if abused or prescribed to someone who doesn't need it. "He was known to do that," she said. A previous urine test had come back negative, too. Gratton, the inquest heard Tuesday, had been transferred back to Windsor from a jail in Niagara on Sept. 29. Soon after, he asked to see the nurse practitioner and for a "piss cup" — a urine drug sample. "The nurse sent my request a couple days ago," Gratton wrote on the Oct. 5 written request. "Whats the holdup." Two days later, Gratton filled out another request for a urine test, saying he had heroin in his system, was going through withdrawal, and needed suboxone. "Please and thanks. Soon as possible," he wrote. "Been asking for almost a week. Since I got shipped back." A note on the bottom of the request from an unidentified nurse indicates that the urine test was ordered on Oct. 8, more than a week after Gratton returned. MacVoy testified that urine tests typically can detect drugs in someone's system for three to five days after – and even up to seven days later in rarer cases. But by the time Gratton got tested, it had been roughly nine days. In his medical chart, MacVoy wrote that Gratton "took contraband while in Niagara" but that the urine drug test came back negative. Still, she noted that the test was "performed late." It's unclear why she didn't order another test. Even then, suboxone can still be used to curb addiction cravings in those who've been off opioids for a shorter amount of time, the inquest heard. But MacVoy also didn't know then that Gratton was referring to opioids when he said contraband, she said. She testified she didn't remember their interaction, and as the only nurse practitioner in the building at the time, saw 20 to 30 patients per day. She wouldn't have seen the written requests, either. But if he had told her what contraband he had been using, she would have marked it in his chart, she said. She said inmates can be reluctant to admit to active illicit drug use in jail because of the investigation it would automatically prompt. MacVoy said she believed "it wasn't very common for drugs to get into the jail" at the time — but that soon changed when the facility started "having some terrible outcomes." In any case, it was also rare then for an inmate to start opioid addiction medication after they'd already spent time within the jail. "It was virtually unheard of to revisit that later in custody," she said. "Generally it was frowned upon," she said, but couldn't specify why she felt that way. Those types of treatments typically started upon admission to the jail among those who had a history of drug abuse. Things, however, were starting to change during her tenure, she said, which is in part why she considered Gratton's request for suboxone in the first place. She also believes in harm reduction and working with patients to make informed decisions. Tuesday's witnesses also included a correctional officer who was assigned to Gratton's unit the night he overdosed. Randy Mascarin, now a staff sergeant, was present earlier in the night when another inmate was allowed to walk to Gratton's cell and pass something under the door — video of which was shown Tuesday. Mascarin said the man was let out of his shared cell to give privacy to the other inmate while a sergeant entered to handle a misconduct case. He said it's normal for inmates to pass each other things — a pack of unwanted peanut butter could make another inmate's day — so he didn't think anything of it at the time. He also shed light on why the key to open the cell was with him and not the officer actively patrolling the unit when Gratton was discovered at around 11 p.m. Mascarin said he had been performing the patrols before that, and that handing them over to the other officer before he went on break was simply "lost in process." He said that issue "really ate at" him "for a long time," but that he knows the facility has more safeguards in place now. On Wednesday, the inquest is expected to hear from the other correctional officer assigned to the unit that night, as well as a senior official within the provincial corrections system on the types of changes that have been implemented at the jail and other facilities in Ontario since Gratton's death. MacVoy, the jail's former nurse practioner, said they made some changes right away, though. "We didn't need an inquest," she said. "I do think inquests need to be a bit more timely," she said, noting the six year gap. Ultimately, she said she still feels her decision not to prescribe suboxone — now available in film and injection formats that are harder for inmates to divert — to Gratton was the right call at the time, because she lacked the evidence she needed. She also offered her condolences to Gratton's family. "You don't go into medicine to watch people get hurt or die," she said, her voice shaking. "We also don't have a crystal ball." Mascarin offered his condolences as well — specifically, to Gratton's mother, who is involved in the inquest. He said corrections officers might have a reputation for not caring about inmates, but that every person who responded that night wanted to save both Gratton and his cell mate's lives. "Joseph was a decent guy to me," he said.
