Michelle Dorey Forestell
Local Journalism Initiative Reporter
Kingstonist.com
After nearly two weeks of testimony, the jury at a coroner’s inquest into the deaths of five men at Collins Bay Institution in Kingston, Ont. has concluded that all five deaths were accidental, each involving fentanyl toxicity.
Beginning on Monday, Jan. 26, 2026, the inquest examined the deaths of Shimon Abrahams, Quinn Borde, Shane Gammie, Christopher Sipes, and Qin Long (Qinlong) Xue — all of whom died while in custody at the federal penitentiary in Kingston or after being transferred to hospital.
The proceedings were overseen by Bonnie Goldberg, a lawyer and presiding inquest officer with the Office of the Chief Coroner, who guided the jury through nearly two weeks of evidence. Kristin Smith and Erin Winocur served as inquest counsel. The jury returned its verdict on Friday, Feb. 6, 2026, along with 19 recommendations aimed at preventing further deaths in federal custody.
Abrahams, 41, died on June 13, 2022; Borde, 39, died on April 2, 2022; Gammie, 35, died on Nov. 24, 2018; Sipes, 51, died on Nov. 21, 2019; and Xue, 26, died on Nov. 13, 2020. Because all five deaths occurred while the men were in custody, inquests were mandatory under Ontario’s Coroners Act.
Throughout the proceedings, the jury heard evidence about substance use in federal institutions, access to health care, overdose prevention measures, and the availability of harm reduction services at Collins Bay Institution.
What an inquest does — and does not do
A coroner’s inquest is a public hearing held to examine the circumstances surrounding a death and to inform the public about what happened. Presided over by a coroner, lawyer, or retired judge, an inquest is heard by a jury of five community members. No one is on trial, and the jury is prohibited from assigning blame or making findings of legal responsibility.
At the conclusion of an inquest, the jury must answer five questions: who the deceased was, when the death occurred, where the death occurred, how the person died in medical terms, and by what means the death occurred — such as accident, natural causes, homicide, suicide, or undetermined. Juries may also issue non-binding recommendations intended to help prevent similar deaths in the future.
Focus on health care and mental health supports
A significant share of the jury’s recommendations were directed at the Correctional Service of Canada (CSC) and focused on improving access to health care at Collins Bay Institution.
The jury called on CSC to develop and implement a plan to increase on-site nursing and health care services. This included assessing the feasibility of providing 24-hour, seven-day-a-week care and increasing the number of registered nurses, nurse practitioners, and mental health nurses at the penitentiary.
The recommendations also emphasized the need to expand evidence-based psychosocial and counselling supports for people in custody seeking treatment for mental illness, addiction, or substance use. This includes eliminating wait lists for programs such as SMART Inside Out, a specialized, evidence-based cognitive behavioural therapy (CBT) program designed for addiction recovery within correctional facilities. It helps inmates build skills to manage emotions and behaviours, aiming to reduce recidivism by fostering self-empowerment for rehabilitation.
Surveying inmates about whether their counselling needs are better met through group programming or one-to-one support, and removing barriers to accessing those services, were also recommended.
The jury further urged CSC to reduce response times for medical requests, particularly for pain relief, mental health support, and sleep aids, noting the heightened risks faced by individuals with a known history of substance use.
Harm reduction and overdose prevention
Several recommendations focused on harm reduction and the institution’s Overdose Prevention Service (OPS).
The jury called for an analysis of whether the OPS is meeting CSC’s goals, including consideration of expanded hours — potentially operating daily from 7 a.m. to 11 p.m. — and improved confidentiality for those using the service. The jury also recommended exploring point-of-care drug checking and permitting safer methods of substance use within the OPS, such as supervised smoking and snorting, in line with community harm reduction standards.
Access to naloxone was a key recommendation. The jury urged CSC to equip all correctional officers with naloxone kits and require that nasal spray naloxone be carried while on duty. It also recommended making naloxone kits directly available to people in custody in cells and common areas and providing education on recognizing overdoses and safely administering the medication.
Additional recommendations called for better identification and safeguarding of individuals at increased risk of overdose, including people navigating transitions within the institution, those with mental health challenges or chronic pain, individuals who have experienced non-fatal overdoses, and those with previous suicide attempts.
Policy, enforcement, and contraband concerns
The jury also addressed broader policy and enforcement issues related to substance use in federal institutions.
Among the recommendations was a call to maintain the priority status of updates to Commissioner’s Directive 585, the National Drug Strategy, to ensure clearer guidance for staff on addressing contraband while supporting harm reduction approaches aligned with the Canadian Drugs and Substances Strategy.
The jury recommended creating a working group at Collins Bay Institution that includes correctional staff, health care staff, and people in custody with lived experience of substance use. That group would help update the institution’s drug strategy and develop education programs for staff and inmates on overdose risks, harm reduction services, and staff responsibilities.
On the enforcement side, the jury urged CSC to prioritize efforts to prevent trafficking, intimidation, and financial exploitation related to contraband, modernize drone detection technology to address ongoing “drone drop” threats, and review the effectiveness of body scanners currently in use at the institution.
The jury also recommended reviewing administrative and punitive consequences for people found in possession of or using tobacco.
Next steps
While the jury’s recommendations are not legally binding, the Office of the Chief Coroner will forward them to the named organizations, including CSC. Those organizations are asked to respond, outlining how they have considered the recommendations and what steps, if any, they plan to take.
The Office of the Chief Coroner publicly posts inquest verdicts and recommendations, and recipient organizations’ responses are tracked but not enforced.
For the families of the five men, the verdict and recommendations mark the formal conclusion of a process intended to shed light on what happened — and to identify systemic changes that could help prevent similar deaths in the future.
