Executive Summary: Key Legal and Evidentiary Issues

• The appropriateness of including best practices for correctional programming and staff retention/absenteeism within the scope of a Coroner’s Inquest into inmate deaths.

• The threshold for admitting issues into the scope of an inquest, specifically whether there was “enough evidence” to warrant their consideration as contributing factors.

• The preliminary admissibility of expert evidence regarding correctional programming and its relevance to the inquest.

• The principle of judicial review prematurity and whether exceptional circumstances justified early court intervention.

• The extent of a coroner’s discretion in determining the scope and evidentiary matters of an inquest.

• The court’s role in reviewing the reasonableness of administrative decisions without re-weighing the underlying evidence.

Background and facts of the case

From 2017 to 2021, seven men died while incarcerated at the Elgin-Middlesex Detention Centre (EMDC) in Ontario—five from drug overdoses and two from suicide. These deaths occurred in the context of a broader concern about fatalities in provincial custody, with 13 deaths at EMDC over 15 years and 46 in provincial custody in 2021. The Coroner’s Act mandated an inquest into these deaths, and the Chief Coroner directed that all seven cases proceed together as a single inquest.

Scope of the inquest and policy terms at issue

Dr. John Carlisle, the Presiding Coroner, drafted a statement of issues for the inquest. These included the circumstances of each death, best practices regarding correctional programming (including policies, practices, and staffing), staff retention and absenteeism as they relate to inmate safety, the availability of Indigenous-specific services, ministry progress on supporting inmates with substance use, family supports after a death, and suicide in custody. The Coroner also retained Ms. Andrea Monteiro as an expert to provide an opinion on best practices for correctional programming.

The Solicitor General (SG) challenged the inclusion of issues relating to correctional programming, staff retention, absenteeism, and family supports, as well as the admissibility of Ms. Monteiro’s expert evidence. The SG argued that there was insufficient evidence to warrant these issues being within the inquest’s scope and that Ms. Monteiro’s evidence was not directly relevant.

The coroner’s decision and rationale

The Coroner dismissed the SG’s motion, holding that programming and staffing issues were properly within the inquest’s scope. He reasoned that substance use, addiction, mental illness, and suicidality were central to the circumstances of the deaths, and that programming—including substance abuse and trauma counseling—was relevant to understanding and potentially preventing such deaths. The Coroner acknowledged that direct evidence linking lack of programming or staffing to the deaths was rare, but found it important to explore whether increased access could prevent future fatalities. He also found that staffing levels had been identified as significant in previous inquests and reports, and that there was enough evidence to warrant consideration of these issues.

Regarding Ms. Monteiro’s evidence, the Coroner applied the Supreme Court’s test for admissibility of expert opinion and found her qualified to assist the jury on best practices in correctional programming, even if she lacked specific knowledge of EMDC.

Judicial review application and preliminary issues

The SG sought judicial review of the Coroner’s decision, arguing that the inclusion of programming and staffing issues was unreasonable and that Ms. Monteiro’s evidence should not be admitted. The respondents (the Coroner and families of the deceased) argued that the application was premature, as the inquest process was ongoing and the scope and admissibility of evidence could still evolve.

The court addressed several preliminary matters, including whether the Coroner could argue the reasonableness of his own decision, the admissibility of new evidence from one family, and whether the judicial review application was premature. The court found that, while the application was generally premature, exceptional circumstances justified addressing the scope issues at this stage, but not the evidentiary issue regarding Ms. Monteiro.

Court’s analysis and outcome

The court reviewed the legal threshold for including issues within the scope of an inquest, which requires only “enough evidence” to warrant considering whether an issue could have contributed to a death—a threshold described as “by no means high.” The court found that the Coroner had some evidence before him regarding programming and staffing, including reports and inferences from the absence of programming for the deceased, and was entitled to rely on his expertise and previous reports.

The court concluded that the Coroner’s decision to include programming and staffing issues within the inquest’s scope was reasonable and satisfied the low threshold required. The court emphasized that its role was not to re-weigh the evidence but to assess the reasonableness of the administrative decision.

Final ruling and successful party

The application for judicial review was dismissed. The court found no unreasonableness in the Coroner’s decision to include the challenged issues within the scope of the inquest. By agreement, no costs were awarded. The successful parties were the Coroner and the families of the deceased. No specific monetary amount was ordered or awarded in this decision.