Inquest Jury Rules Jail Death was Accidental

TORONTO - May 14, 2008 - After hearing six days of evidence and a full day of submissions, a five-member coroners jury has released its verdict into the death of Keigo White. 

Suffering from an opiate addiction, White entered Toronto's Don Jail on October 5, 2006 while awaiting trial in respect of driving and drug charges.  He informed the jail authorities of his methadone use and was placed on the medical unit of the jail.  Methadone was withheld, however, and White underwent severe withdrawal symptoms.  As his distress level rose over the next three days, White was reported to have said that he would kill himself without the medication.  On October 9, 2006, guards found him unconscious in his cell, having hung himself using torn hospital bed sheets.

Paramedics were able to revive White and he was transported to St. Michael's Hospital.  He died in hospital on January 6, 2007, never having regained consciousness.  The Chief Coroner's office initially refused to hold an inquest, asserting that the death had occurred in hospital, rather than at the jail.  Under the Coroners Act, inquests into custodial deaths are mandatory.  The family retained Swadron Associates to reverse the ruling and the matter was pursued to the level of then Minister of Community Safety and Correctional Services, Monte Kwinter.  With the family poised to escalate the matter to judicial review, the Chief Coroner's office relented and agreed to hold an inquest.

The inquest opened on May 5, 2008 and the jury heard evidence from the jail physician, other inmates, correctional officers and medical experts.  It also heard evidence from Mr. White's brother, Michael White.  Michael White, himself a methadone recipient, provided the jury a first-hand account of methadone withdrawal.  He described the experience as feeling "like you've got worms crawling through your body and you want to punch the walls."  Michael White further doubted that his brother has intended to kill himself, noting that he too had attempted to asphyxiate himself while detained in the very same jail in an effort to take away the pain of withdrawal.

The jury ruled that the cause of death was complications of hanging but refused to rule the death a suicide, concluding instead that the death was accidental.  Its verdict included ten recommendations directed at correctional and health care authorities intended to prevent deaths in similar circumstances.  Please click here to read the jury's verdict.

"The family feels vindicated" said their lawyer Barry Swadron, noting that nearly all of the recommendations that the family had urged upon the jury made their way into the verdict.  He added that Michael is particularly grateful that the jury appreciated that Keigo's intention was to relieve the symptoms of withdrawal rather than end his life. 

Mercedes Perez, who also represented the family at the inquest, pointed to the jury's recommendation that the Ministry of Community Safety and Correctional Services commission a study directed toward establishing the delivery of seamless methadone maintenance programs between correctional facilities and the community.  "This recommendation could end the significant divide between provincial institutions and Corrections Canada, which has had a policy requiring initiation of all opiate dependent inmates on methadone since 2001." 

Statistics maintained by the Office of the Chief Coroner indicate that a large proportion of inquest jury recommendations are implemented in some form.  The family's hopes for prompt action are particularly high in this case given that the recommendations are directed to the same Ministry as oversees the Chief Coroner's Office - the Ministry of Community Safety and Correctional Services.

Please click here or here for media coverage of the case.