Jury rules inmate’s overdose death accidental, issues recommendations for Windsor jail

Nathaniel Krug. (Source: Anderson Funeral Home and Cremation Centre)

The jury in the inquest into the overdose death of 21-year-old Nathaniel Krug has ruled his death accidental, while also issuing 23 recommendations aimed at preventing future such deaths.

Krug died on March 10, 2021, after taking fentanyl and etizolam, a sedative sometimes used for insomnia, just nine days after entering the jail.

Over the past week, jurors heard from nine witnesses — including correctional officers, medical experts, and the inmate who admitted selling drugs to Krug.

His aunt, criminologist Dr. Amy Fitzgerald, represented the family, describing him as “a sweet kid” who loved nature, travel and music and who was trying to turn his life around.

The five-person panel began deliberations late Monday morning, returning with its verdict around 5 p.m., roughly six hours later.

With the verdict official, presiding officer Dr. David Eden told the court: “Nathaniel Krug was a beloved family member or friend who died in an accidental overdose while staying in the correctional facility.”

He went on to say: “The jury, as representatives of the community have translated that evidence into findings of fact and has written, carefully considered recommendations that we all can hope will be implemented.”

Dr. Eden also thanked the Krug family.

Recommendations for South West Detention Centre

Among the 23 recommendations, six were directed specifically at Windsor’s facility:

• Developing a replacement for the Jail Screening Admission Tool (JSAT), which is copyrighted and cannot be updated to reflect Ontario’s needs.
• Daily Offender Tracking Information System (OTIS) notifications to keep frontline staff aware of potential substance use risks.
• Expanding K9 services by working with outside agencies such as CBSA, OPP, and federal corrections.
• Reducing plastic packaging inside the jail to prevent inmates from misusing it to conceal drugs.
• Creating a dedicated institutional search team to carry out random compliance checks.
• Installing naloxone in common rooms, showers and cells, paired with training for inmates on how to use it.

Copies of the jury’s verdict and recommendations will now be sent to Ontario’s Chief Coroner for distribution to relevant ministries and agencies.

Full list of all 23 recommendations:

Substance Use Alerts in OTIS

Upon receipt of information regarding an inmate’s substance use, institutional staff — including correctional officers, healthcare, and social work staff — should enter a substance use alert in OTIS.

Mandatory Review of OTIS Alerts

All healthcare, social work, and correctional staff should continue to check an inmate’s OTIS alerts as required and appropriate.

Training for Correctional Officers

All correctional officers should receive mandatory training in recognizing signs of drug use, overdose, and withdrawal, as well as appropriate response measures.

Naloxone Availability and Training

a. Naloxone should continue to be made readily available to all correctional staff, who must be trained to deploy it immediately upon suspicion of overdose.

b. Consider the feasibility of placing naloxone kits inside cells, accessible to inmates for emergency use.

Body Scanner Expertise

Correctional institutions should continue to invest in developing specialized and dedicated body scanner operators with advanced expertise in image interpretation to improve detection of contraband during admissions.

Body Scanner Gown

Have inmates wear a gown while being body scanned to prevent any obstructions on the body scan image (e.g., zippers, buttons).

Admission Search Checklist

Have a formal checklist of body areas to be searched that specifically includes foreskin, to be signed off by the searching officers.

Intake Unit Supervision

Consider appropriate enhancements to supervision of the intake unit during inmates’ out-of-cell time with a view to prevention of drug contraband trafficking.

Maintaining Adequate Staffing Levels

Ensure adequate staffing levels are maintained at SWDC to enhance the jail’s ability to intercept contraband, investigate and respond to critical incidents, provide appropriate programming to inmates as needed, and to prevent staff burnout and fatigue.

Inmate Time Out of Cells

Continue to ensure legislative requirements are met with respect to the amount of time inmates receive out of their cells.

Cell Door Improvements

Explore improved lower door sweeps on all cell doors and/or create a positive stop for the door to seal against on all four sides, to prevent contraband being passed around a closed door.

Canine Unit Enhancement

a. Expand the capacity of canine units at the institution.

b. Explore training to detect fentanyl and other opiates.

c. Explore further expansion of canine presence within provincial institutions

Drug Amnesty Program

Develop and implement a drug amnesty program at the SWDC, allowing inmates to voluntarily surrender illicit substances before, during, and after admission without punitive consequences. Inmates should be informed of this program upon arrival.a. Study and, if feasible, implement an amnesty bin system where inmates may anonymously dispose of illicit substances without penalty.

Federal-Provincial Program Adaptation

Review federal inmate rehabilitation and drug programs for potential adaptation and implementation within provincial correctional institutions.

Continuity of Care

Whether being admitted into or discharged from SWDC, ensure continuity of care for inmates with substance use disorder or who are at risk of relapse or overdose, through coordination between jail and community care providers (including but not limited to healthcare, mental health, and social work).

‘Obligation to Prevent’ Follow-up

Conduct a follow-up analysis to An Obligation to Prevent: Report from the Ontario Chief Coroner’s Expert Panel on Deaths in Custody (2023) to see if/how recommendations 16, 17, and 18 have been acted upon, complete with documented, transparent, comprehensive data.

Timely Inquests

In order to preserve evidence, ensure that inquests are conducted as soon as reasonably possible after an inmate’s death.

Replacement for JSAT

Due to the Jail Screening Admission Tool (JSAT) being copyrighted, a replacement should be developed to reflect the needs of the Ontario Provincial Correctional System that can be updated at any time.

Daily OTIS Updates

Consider daily meetings or notifications to frontline correctional staff of known OTIS alerts to highlight potential issues.

Expanded K9 Services

Explore utilizing resources of outside agencies in regard to K9 services in the regions (e.g., CBSA, OPP, federal correctional facilities).

Plastic Packaging Reduction

Eliminate the amount of plastic packaging used at the SWDC to deter unintended uses of plastic bags/packaging and/or account for plastic bags/packaging distributed being returned. Consider switching to the use of Tetra Pak-type containers where possible.

Dedicated Institutional Search Team

Develop a dedicated institutional search team to work in conjunction with correctional officers to facilitate unannounced random checks performed to assist in compliance.

Additional Naloxone Storage

Install/store naloxone in appropriate areas such as common rooms, showers, and cells to allow for emergency deployment and reduce response time. Provide training to inmates on the proper and safe use of naloxone.