SUDBURY -- During the first day of the coroner's inquest into the 2018 death of an inmate at the Algoma Treatment and Remand Centre (ATRC), witnesses discussed drug use inside the facility.

Joshua Daniel Dumanski died in custody July 16, 2018, due to fatal concentrations of cocaine and fentanyl in his body, after being in the ATRC for almost five months.

The hearing began Monday morning at the Water Tower Inn in Sault Ste. Marie. It is taking place under the direction of inquest coroner Dr. David Eden, with his counsel David Kirk.

Over three days, the inquest will hear from 10 witnesses about the circumstances surrounding Dumanski's death. It is closed to visitors, but is available to view via video conference on the OCC Inquests YouTube channel.

The jury is expected to make recommendations aimed at preventing similar deaths in the future.


The first two witnesses were Dr. Michael D'Agostino, a forensic pathologist at Sault Area Hospital, and forensic scientist Kirk Unger, who graduated from Sudbury's Laurentian University.

They said Dumanski had high qualities of cocaine and the opioid fentanyl in his system when he died and said that cocaine breaks down in the body within hours.

Dumanski had 15 nanograms of fentanyl per millilitre of blood and 0.20 milligrams of cocaine per litre of blood, amounts that individually could have caused death.

D'Agostino said there was no evidence of recent injury at the time of the autopsy.

Fellow inmate's perspective

A former inmate and recovering addict that was also in the ATRC at the time of Dumanski's death testified Monday.

William Sinclair said he met Dumanski at the remand centre in July 2015 when they were in custody together the first time. Sinclair said he became close with the deceased when they attended Bible study together.

Sinclair said Dumanski was struggling with drug addiction and was trying to stay clean. He testified Dumanski was addicted to crack cocaine and had been avoiding it for several months.

Dumanski was upset with himself, Sinclair said, because his father, who had recently died, had worked hard trying to get him off drugs.

"Josh felt he let him down and was sad because he couldn't be there when he died," said Sinclair.

The weekend before the overdose happened, two new inmates came into the facility and one of them, Cody Cuthbertson, was assigned to share a cell with Dumanski.

"There was a lot of chaos and running around when the two new guys came in," said Sinclair.

He said the inmates were all on lockdown and that correctional officers were only letting three cells out at a time to use the showers.

Joe Lepore, the centre's deputy superintendent of operations, later confirmed the centre was on lockdown after an inmate-on-inmate assault.

Drugs showed up that weekend

That weekend is also when drugs showed up inside the facility, said Sinclair. His cellmate returned to their unit with what was believed to be carfentanil and shared it with him. Despite being on the methadone program, Sinclair took some of the opiates.

"It was pretty strong, so it cut through my methadone pretty quickly," said Sinclair.

The former inmate said he had seen Dumanski snorting something Saturday, presumed to be cocaine, and that he got "pretty loud that night."

"Josh wanted to stay off it, but unfortunately as soon as a little was available, his willpower wasn't strong enough to stay off it," said Sinclair.

On Monday morning, Cuthbertson called Sinclair over and asked him to get a guard.

"Drugs are always a problem inside, as long as they come in, someone will always die," said Sinclair. "Especially with the carfentanil and the fentanyl … Before people were dying of heroin and they don't realize the strength of it. It is way stronger than heroin."

Sinclair said accessing treatment in the centre is simple, but it's up to the individual to want to stop using drugs for it to be successful.

He also said despite the various new ways to screen inmates, people always find a way to circumvent the system and drugs end up inside.

"As good as the system gets, the criminals come up with other ways to beat it," said Sinclair.

Inmates searched, while others in the facility are not

Lepore oversees the sergeants and staff that report to them.

Inmates at the ATRC are divided between inmates serving sentences and those who are awaiting trial or sentencing, so the average length of stay varies.

"Drugs are always a problem," said Lepore. "It goes in spurts."

He said he believes the most common way for drugs to get into the prison is internally by an inmate coming in from outside, despite an admission process that involves a frisk, strip search and body scan.

If an officer is suspicious the inmate is bringing in drugs, they are put in a cell by themselves, water is turned off and they have to go to the bathroom in front of a staff member and they are frequently searched afterwards.

Lepore testified that inmates are re-searched if they have to leave for any reason, for instance, a court appearance or hospital visit.

The superintendent said professionals, staff, visitors or volunteers are not searched when they come into the prison, nor are any non-inmate areas.

Lepore said several types of checks and patrols go on throughout the day and night. From 9 p.m. to 8 a.m., inmates are locked in their cells and a correctional officer does a security patrol at least twice an hour and that a "clock punch" indicates when they are in each area. They look for anything unusual and record any incident of note in a logbook.

Night patrol

Derek Morgan was a second-level correction officer with four years experience who was on night shift the weekend Dumanski died.

Morgan said he knew Dumanski because he had come in and out of the centre a couple of times. He and two other officers, one with 15-18 years experience and the other with about two years, were on shift the night before Dumanski was found dead.

Morgan recalled an interaction with Dumanski on Sunday morning during one of his patrols where the inmate passed him a note asking him to procure him a contraband lighter in exchange for a $200 e-transfer.

"He always followed the rules, never was out of line, always kept to himself," said Morgan of Dumanski, who said he believed it was a request for someone else.

"I didn't take it lightly. I finished my tour of the areas then went to the sergeant's office, I believe at the time it was Ms. Kain. Didn't have a great feeling about Josh's cellmate due to previous encounters. Asked to have the cell search the next morning. I believe the next morning the cell was searched."

The correctional officer did rounds Monday morning at 4:30, 5, and 5:30 a.m. and Morgan noticed Dumanski was sleeping in the bottom bunk in the same position he usually sleeps in with no evidence of trauma.

Dumanski was later found unresponsive in his cell and was administered CPR and an automated external defibrillator before he was taken to hospital and pronounced dead.