The Office of the Chief Coroner (OCC) for Ontario provides death investigations and inquests, when necessary, to ensure that no death is overlooked, concealed or ignored. The OCC use the findings to generate recommendations to help improve public safety and prevent future deaths in similar circumstances. The OCC distributes all verdicts and recommendations to organizations for them to implement, including:

  • agencies
  • associations
  • government ministries
  • other identified organizations may be identified in the recommendations

The OCC asks recipients to respond within six months to indicate if the recommendation(s) was implemented, and if not, the rationale for their position.

The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Older verdicts and recommendations, and responses to recommendations are available by request by:

You can also access verdicts and recommendations using Westlaw Canada.

January

Gammie, Shane
Sipes, Christopher
Xue, Qinlong
Borde, Quinn
Abrahams, Shimon

Held at: Toronto (virtual) 
From: January 26 
To: February 6, 2026 
By: Bonnie Goldberg, presiding officer for Ontario 
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Shane Gammie 
Age: 35 
Date and time of death: November 24, 2018 
Place of death: Collins Bay Institution, 1455 Bath Road, Kingston 
Cause of death: fentanyl toxicity 
By what means: accident

Name of deceased: Sipes, Christopher 
Age: 51 
Date and time of death: November 21, 2019 
Place of death: Kingston General Hospital, 76 Stuart Street, Kingston 
Cause of death: combined heroin and fentanyl toxicity 
By what means: accident

Name of deceased: Qinlong Xue 
Age: 26 
Date and time of death: November 12, 2020 
Place of death: Kingston General Hospital, 76 Stuart Street, Kingston 
Cause of death: complications of acute fentanyl toxicity 
By what means: accident

Name of deceased: Quinn Borde 
Age: 39 
Date and time of death: March 31, 2022 
Place of death: Kingston General Hospital, 76 Stuart Street, Kingston 
Cause of death: complications of fentanyl and etizolam toxicity 
By what means: accident

Name of deceased: Shimon Abrahams 
Age: 41 
Date and time of death: June 13, 2022 
Place of death: Kingston General Hospital, 76 Stuart Street, Kingston 
Cause of death: complications of fentanyl toxicity 
By what means: accident

(Original signed by: Foreperson)

The verdict was received on February 6, 2026
Coroner's name: Bonnie Goldberg 
(Original signed by presiding officer for Ontario)

We, the jury, wish to make the following recommendations:

Inquest into the deaths of: Sane Gammie, Christopher Sipes, Qinlong Xue, Quinn Borde, Shimon Abrahams

Jury recommendations
To the Correctional Service of Canada (CSC):

Health care

  1. Develop and implement a plan to increase the availability of on-site nursing and health care services for persons in custody at Collins Bay Institution (CBI). Examine the feasibility of expanding the hours of service to be 24 hours a day, 7 days a week, and increasing the number of Registered Nurses, Nurse Practitioners and Mental Health Nurses.
  2. Develop and implement a plan to increase evidence-based psychosocial and counselling supports for persons in custody who are enrolled in, referred to or request mental health, addiction or substance use counselling or support.
    1. Take steps to reduce, and within six months eliminate, the waiting lists for the SMART Inside Out and peer-led programs at CBI.
    2. Survey persons in custody at CBI to determine if the psychosocial and counselling needs of inmates are better met in their opinion through group programs and / or one-to-one counselling.
    3. Take steps to improve access to these supports and remove barriers to access.
  3. Take steps to reduce response times for medical requests for pain relief, mental health support, and/or sleeps aids, with particular attention to patients who have a known history of substance use.
  4. Expand the physical capacity of Health Services at CBI to create additional clinic rooms to provide all harm reduction and substance use health services and supports within Health Services and to ensure greater confidentiality during the provision of such services and supports.
  5. Consider making nicotine replacement therapy available through health services.

Policy

  1. Maintain the current priority status assigned to the revision of the Commissioner’s Directive 585: National Drug Strategy to facilitate a timely release.
  2. The update to Commissioner’s Directive 585 should provide clarity to all CSC staff about ways to address the introduction of contraband and provide and support harm reduction approaches to substance use in CSC institutions, to align with the Canadian Drugs and Substance Strategy.
  3. Create a working group of correctional staff, health care staff and people in custody with lived experience of using substances at CBI in preparation for updating CBI’s Institutional Drug Strategy to align with the update to Commissioner’s Directive 585.
  4. The working group will, among other things, develop and implement a new education program for staff and people in custody to accompany the update to Commissioner’s Directive 585 and the update to CBI’s Institutional Drug Strategy. Suggested topics should include but not be limited to:
    1. documented reasons why people use substances, and warning signs that someone may be at risk for an overdose
    2. the roles and responsibilities of all staff as described in the updated policy
    3. the harm reduction programs and services available to persons in custody at CBI and how to access them.
  5. Continue to promote, as a guiding policy principle, the provision of health care services in accordance with professionally accepted guidelines and standards.

Harm Reduction and the Overdose Prevention Service (OPS)

  1. Develop and implement an analysis to meet CSC’s goals for the OPS. Suggested areas of focus include but are not limited to:
    1. provision of point-of-care drug checking for people who use the OPS
    2. permit safer smoking and snorting of substances in the OPS (e.g., set up supervised smoking rooms, provide specialized foil), and tell all persons in custody that this is allowed
    3. expansion of the operational hours of the OPS to between 07:00 and 23:00 every day
    4. enhance confidentiality measures for people who use the OPS
    5. increase the availability of safe prescribed medications to treat opioid use disorder consistent with options that may be available in a health care setting outside of a federal penitentiary
  2. Increase access to naloxone in CSC institutions beyond current availability, including:
    1. equip all correctional officers with naloxone kits and require that nasal spray naloxone be carried on their person while on duty
    2. in alignment with community harm reduction standards, make nasal spray naloxone kits directly available to persons in custody within their cells and common areas throughout the institution
    3. educate people in custody on recognizing the signs and symptoms of an overdose, the safe administration of naloxone and the importance of promptly alerting correctional staff to a potential overdose
  3. Develop and implement a process to identify and safeguard persons at increased risk for overdose with particular attention to:
    1. Issues identified upon admission
    2. Navigating transitions within the institution, between institutions, and to the community, including continuity of health care and wrap around services
    3. The presence of conditions which may exacerbate substance use disorder such as mental health challenges, pain, sleep challenges or interpersonal challenges
    4. Persons who have experienced non-fatal overdoses
    5. Persons who have had previous suicide attempts
  4. Continue to make people in custody aware of the protections that they are entitled to pursuant to the Good Samaritan Drug Overdose Act.
  5. Review existing policies and procedures following a non-fatal overdose and revise policies where necessary to ensure that an automatic assessment of future overdose risk is completed and documented, enhanced monitoring of the patient’s risk level is considered, and a safety and action plan is discussed with the patient.

Enforcement

  1. Develop and implement a plan to prioritize efforts to prevent muscling, financial gain from the sale of all types of contraband and acts of physical or psychological intimidation over detection of illicit substances.
  2. Modernize and upgrade drone detection technology at CBI to address the ongoing threat of “drone drops” at federal institutions.
  3. Explore the efficacy of body scanners in use at CBI to improve their utility.
  4. Review administrative and punitive consequences for people in custody who are found to be in possession of or using tobacco.

February

Hashemi, Taher

Held at: virtual, 25 Morton Shulman Avenue, Toronto     
From: February 2    
To: February 4, 2026    
By: Dr. Geoffrey Bond, presiding officer for Ontario     
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Taher Hashemi     
Age: 49    
Date and time of death: August 24, 2021    
Place of death: Ottawa-Carleton Detention Centre    
Cause of death: hanging    
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on February 4, 2026
Coroner's name: Dr. Geoffrey Bond     
(Original signed by presiding officer for Ontario)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Taher Hashemi

Jury recommendations
We, the jury, recommend to the Ottawa-Carleton Detention Centre (OCDC) and the Ministry of the Solicitor General:
  1. Court dispositions or notable proceedings, events, or results for days in court for inmates who are in the stabilization or health care units should be communicated to the OCDC health care team.
  2. Relevant minutes from health care planning for high-risk inmates should be recorded and documented and available in the health care records so that all members of the inmate's health care team have access.
  3. Recreational materials should be proactively provided to long-term inmates who are in the stabilization or health care units (such as additional reading material, crossword puzzles, sudoku, newspapers, etc.).
  4. For long-term inmates (as determined by OCDC) who are facing persistent mental health challenges, health care plan revisions should take into account an inmate's duration of stay and the period until the next court date.
  5. Room implements (i.e. light fixtures, bedding, anchor points, etc.) should be re-assessed in order to remove any means of an inmate potentially harming themselves.