Jury makes recommendations after five Collins Bay deaths

A coroner’s jury in Kingston, Ont., ruled in February that five men who died after being held at Collins Bay Institution all died accidentally of drug toxicity, and directed a long list of recommendations at Correctional Service Canada (CSC) on health care, harm reduction and contraband.

The verdict, received on Feb. 6, 2026 and posted on the Ontario government’s page of 2026 coroners’ inquest verdicts and recommendations, listed fentanyl among the causes in each death. Coroner Bonnie Goldberg presided.

According to the official verdict, Christopher Sipes, 51, died on Nov. 21, 2019; Qinlong Xue, 26, on Nov. 12, 2020; Quinn Borde, 39, on March 31, 2022; and Shimon Abrahams, 41, on June 13, 2022. All four died at Kingston General Hospital. A fifth man, Gammie, 35, died on Nov. 24, 2018, according to the Kingstonist’s coverage of the inquest. The provincial page spells his first name “Sane”; the Kingstonist reported it as Shane.

The jury’s recommendations to CSC begin with health care. It asked the service to develop and implement a plan to increase on-site nursing and health care at Collins Bay, to examine round-the-clock service and more registered nurses, nurse practitioners and mental health nurses, and to cut response times for requests for pain relief, mental health support and sleep aids, especially for patients with a known history of substance use.

It also recommended that CSC take steps to reduce, and within six months eliminate, the waiting lists for the SMART Inside Out and peer-led programs at the institution, and expand the physical capacity of Health Services so that harm reduction and substance use care can be delivered with greater confidentiality.

On harm reduction, the jury asked CSC to analyse the institution’s Overdose Prevention Service, including point-of-care drug checking, supervised smoking rooms, operating hours of 7 a.m. to 11 p.m. every day, and wider access to prescribed medications for opioid use disorder. It recommended that all correctional officers carry nasal spray naloxone while on duty and that kits be made available directly to people in custody in their cells and common areas.

Other recommendations asked CSC to identify and safeguard people at increased risk of overdose, including those who have had non-fatal overdoses, and to keep telling people in custody about the protections of the Good Samaritan Drug Overdose Act.

On enforcement, the jury said CSC should prioritize preventing muscling, financial exploitation and intimidation over detecting illicit substances, upgrade drone detection technology to address “drone drops”, examine how well body scanners work, and review the administrative and punitive consequences for people found with tobacco.

The Kingstonist reported that the jury returned 19 recommendations in total after nearly two weeks of testimony. Coroners’ inquest recommendations are not binding on the agencies they are directed to. Canada News Media did not find a published CSC response to the Collins Bay recommendations on the provincial page.

Earlier this fall, Canada News Media reported on an inquest that opened into an Indigenous man’s death in a B.C. prison, and published a guide on where to get a free naloxone kit in each province.

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