Coroner's inquest jury hears about health-care challenges at the Thunder Bay Jail (original) (raw)

Thunder Bay

The former health manager at the Thunder Bay Jail said about 40 per cent of inmates were receiving opioid agonist therapy in 2020, and “it's much higher now.” Melissa Boban provided testimony during the fifth day of a coroner’s inquest into the death of Kevin Mamakwa, who died at the jail June 2, 2020 at 27 years old. Here's what the jury heard on Friday about health care at the jail.

Inquest into Kevin Mamakwa's death in 2020 continues in Thunder Bay

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A close-up of a sign outside of a jail.

Kevin Mamakwa died at the Thunder Bay Jail June 2, 2020. The 27-year-old was a member of Kingfisher Lake First Nation, a remote Oji-Cree community in Treaty 9 territory about 350 kilometres north of Sioux Lookout. (Sarah Law/CBC)

The former health manager at the Thunder Bay Jail said about 40 per cent of inmates were receiving opioid agonist therapy in 2020, and “it's much higher now.”

Melissa Boban provided testimony during the fifth day of a coroner’s inquest into the death of Kevin Mamakwa, who died at the jail June 2, 2020 at 27 years old. He was a member of Kingfisher Lake First Nation as well as the nephew of Kiiwetinoong NDP MPP Sol Mamakwa.

On Friday, Boban told the jury about the health-care services at the jail at the time of Mamakwa’s death, as well as the challenges of accessing opioid agonist therapy — which includes methadone and suboxone for the treatment of opioid use disorder — in correctional settings in 2020.

Earlier, the jury heard Mamakwa received his four doses of suboxone at a pharmacy May 14, 2020, which would have run out four days later. He was remanded into custody May 28, 2020 and died five days later.

Boban explained that in 2020, if a person missed six consecutive doses of suboxone, they had to be re-assessed by a doctor in person before they could receive additional doses.However, the jury heard Mamakwa had no chance to see a doctor during his time at the jail.

A person is seen playing hockey in an area.

Kevin Mamakwa is seen playing on Kingfisher Lake First Nation's men's hockey team. (Submitted by Sol Mamakwa)

Boban also said it seemed it was unclear to jail staff whether Mamakwa had an active prescription, and they didn't know he was given a 21-day prescription May 14 which would have lasted until June 3, the day after he died.

There have been several policy changes made related to opioid agonist therapy since Mamakwa’s death, said Boban.

For example, suboxone patients can now be re-assessed by doctors over the phone, she said.

“At that time, there [were] multiple policies to navigate — so there was a policy on methadone, there was a policy on suboxone, there was a policy on admissions, there was a policy on withdrawal,” Boban said.

“They've combined several policies into one now, so it's easier to follow.”

As well, “treatment practices also changed since then and how we manage withdrawal and how we manage methadone and suboxone.”

Looking forward, Boban said she wants to see more doctors and psychiatrists at the jail and extended service hours, but acknowledged there are recruitment challenges with bringing health-care staff to correctional settings.

Space, staffing constraints at the jail

The inquest jury also heard from Zarah Neubauer on Friday, a registered nurse who works at the Thunder Bay Jail and was there at the time of Mamakwa’s death.

Neubauer described the jail as a loud, cramped space, making it challenging to provide health-care services. However, she also told the jury there’s a sense of community there.

“It feels like a submarine,” she told the jury. “I'd love to just blow a hole in the wall and build another section.”

A wide shot of an old gothic-looking building.

The Thunder Bay Jail, located at 285 MacDougall St., shown on June 5, 2026. The facility was built 100 years ago in 1926. (Sarah Law/CBC)

That said, while more space would help, Neubauer said that must come with enough correctional staff to escort inmates to their check-ups and manage security issues, which is an ongoing challenge.

“It's all like a web and they're all connected. Everything is connected. It has to work like poetry,” she said.

She also spoke about the poorer health outcomes among those in correctional settings, noting that as the opioid crisis has worsened over the years, “our patient population is sicker.”

Neubauer said she wants to see nurses on site 24-7 at all correctional settings across Ontario, as well as a province-wide electronic medical record system that can be accessed by all care providers.

“I wish that [in] Ontario, across the board, physicians, GPs [general practitioners], the jail, hospitals, that we were all under one program,” she told the jury.

“That no matter where you are caring for an individual in Ontario, that you've access to see what has happened with your patient.”

Mamakwa’s inquest continues in Thunder Bay and is being streamed in English online with Oji-Cree translation.

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ABOUT THE AUTHOR

Sarah Law is a CBC News reporter based in Thunder Bay, Ont., and has also worked for newspapers and online publications elsewhere in the province. Have a story tip? You can reach her at sarah.law@cbc.ca.