SUDBURY -- Following three days of witness testimony last week in Sault Ste. Marie, a jury has ruled Joshua Dumanski's drug overdose death in 2018 at the Algoma Treatment and Remand Centre was accidental.

Dumanski, 31, died after ingesting cocaine and fentanyl July 16 while incarcerated at the Sault jail. A coroner's inquest heard from several witnesses from both sides of the bars. Inmates and staff at the jail testified the drug crisis plaguing the north is also rampant in the prison system.

Despite the searches and body scans, illicit substances are still being brought into the facility.

As a result, a jury has delivered a list of recommendations to the facility and the Ministry of Community Safety and Correction Services in hopes of preventing similar deaths in the future.

Preventing more overdose deaths

Recommendations include new staff training and procedures, including the creation of a standardized checklist specific to the Sault jail for all cell checks, mandatory annual training for signs of intoxication and suspected overdoses, continuous training on interpreting body scans, implementing scenario-based cell check training and formalized training development structure.

Because Dumanski was found unresponsive in his cell in the morning, the jury recommended night rounds performed by correctional officers include changing some of the intervals from 30 minutes to an hour-long "proof of life" check, where officers could use flashlights to check for inmate's breathing and possibly entering a cell to verify.

An issue identified during the witness testimony is the lighting inside the cell at night, so the jury has recommended exploring different options to give better visibility of the inmates inside their cells at night.


Joe Lepore, the deputy superintendent of operations at ATRC, testified that canine units from both Sault Ste. Marie Police Service and Ontario Provincial Police are used infrequently to search areas inmates have access to, and that most of the staff is aware ahead of time.

However, the jury recommended the facility implement more searches using drug-sniffing dogs with minimal staff being told in advance, and that the whole facility, including staff areas, would be searched.

Every inmate that enters the jail is subject to a mandatory body scan, which is analyzed by two correctional officers. If drug smuggling is suspected, the inmate is placed in dry cell protocol, which involves being in a cell by themselves, searched frequently by staff and made to go to the bathroom in front of a correctional officer.

The jury has recommended mandatory and periodic training in the interpretation of body scans and that the Ministry of Community Safety and Correction Services stay on top of new trends in ways drugs are smuggled in, look for opportunities to buy updated scanning equipment and establish a central review hub to review all uncertainties in scans.

The jury has recommended cell searches should require a mandatory follow-up with police after drugs are confiscated, with knowledge of laced drugs, as well, and consideration for technology that can detect small concentrations of substances.

Inmate education and programs

The jury also recommended training about safe drug use be offered to inmates and include buddy systems, alerting staff to signs of overdose, drug interactions and using naloxone.

It is also recommended health care case managers be assigned to inmates to provide continuity of care, as well as increased access to social workers on the remand side of the ATRC and removing barriers so that social workers both inside and out of the facility can collaborate.

The jury also called for developing an acute intervention program and have it be readily available on the remand side of the facility.

Finally, the jury said all staff who interact directly with inmates should be equipped with naloxone spray while on duty, including correctional officers conducting rounds.

Dumanski's mother, Susan, followed the inquest proceedings and said through an emailed statement she hopes it can be an opportunity for change.

She shed some light on her son, saying before his incarceration he was clean and sober while caring for her and her husband, but relapsed when his father passed away.

William Sinclair, a former inmate, told the jury Dumanski had worked hard on his sobriety during his incarceration.

The only question the inquest didn't answer was where the drugs that killed Dumanski came from.