A sweeping coroner’s inquest into a string of fatal overdoses at an Ontario detention centre concluded Friday by making more than 60 recommendations to prevent future drug deaths behind bars.

The inquest – spanning six weeks, with testimony from roughly 100 witnesses – was one of the largest in the province’s history, probing the deaths of eight inmates at the Hamilton Wentworth Detention Centre between 2012 and 2016.

One of the most critical recommendations put forward by the jury, in the midst of a national overdose crisis that continues to kill thousands of Canadians every year, is to increase correctional officers’ access to the overdose antidote naloxone, and to provide CPR training and overdose awareness education to inmates.

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April Tykoliz waited four years to learn what happened to her brother, Marty Tykoliz, who was 38 years old when he died on May, 7, 2014.

“It’s hard to listen to, what the last days of his life were like,” Ms. Tykoliz said on Friday, as the proceedings came to an end. “It’s shocking to think that all these things are going on behind those walls.”

Mr. Tykoliz had long struggled with addictions, and was in and out of jail for much of his adult life.

“He made decisions that ultimately killed him,” Kevin Egan, a lawyer who represented the Tykoliz family at the inquest, acknowledged in his closing remarks to the jury on Wednesday. “But, in our submission, the system failed him too.”

Mr. Egan described the Hamilton Wentworth Detention Centre as “an overcrowded, lawless institution where inmates are warehoused, not helped; where ranges built for 20 men to live, warehouse 72 men.”

Mr. Tykoliz, the jury heard, had asked to be put on an opioid replacement (methadone) program in the months before his death, but was denied by the jail’s medical staff.

“So what’s a man to do when he has a powerful addiction – a craving for a drug, and he can’t get treatment?” Mr. Egan asked.

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In the days before his death, Mr. Tykoliz shared a cell with an inmate whom staff were aware had smuggled “packages” of drugs into the jail. Surveillance footage – from cameras no one was watching – captured the pair moving freely around the range, openly smoking and snorting drugs off a table in the common area.

“Had there been eyes on the guys … either personal direct supervision or someone monitoring the cameras in real time, the behaviour would have been spotted, the drugs confiscated and Marty likely would have avoided death,” Mr. Egan said.

Instead, Mr. Tykoliz overdosed. He was taken to hospital and given naloxone, but returned to the jail the same night.

He was found unresponsive in his segregation cell the next morning, having overdosed a second time. Again he was sent to the hospital, but was pronounced dead that afternoon.

While Ms. Tykoliz said she is relieved to have the facts of her brother’s death on the public record, it was “hurtful” testimony to listen to. She hopes the recommendations – which are non-binding – will be implemented, so that no other family has to go through this painful process.

“It’s hurtful. How could that happen? Especially when people are reaching out for help,” she said. “There’s no such thing as corrections in correctional facilities.”

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Karen Shea, the coroner’s counsel, had presented 47 proposed recommendations to the jury on Wednesday. In the end, the jury accepted those and added another 15.

The recommendations address everything from admission and security and communication procedures to substance abuse treatment and overdose responses. They also recommend that the jail keep a record of all suspected overdoses.

Mr. Egan said the most crucial recommendations are those relating to the adequate supervision of inmates – a call that has been made repeatedly at jail inquests, he said, evidently to no avail.

“ I think the jury did an excellent job. The ball is now in the hands of government,” he said on Friday. “We must wait to see whether they pass the test in regard to the civilization of this province.”