An Alberta provincial court judge commended Edmonton Institution for doing a decent job trying to prevent fatal drug overdoses.
But in a fatality inquiry report published Friday, Judge Terry Matchett recommended the maximum security federal penitentiary make more frequent and effective cell searches and security patrols.
A three-day inquiry was held last September in Edmonton into the May 2016 death of Jason Clarke Croft.
The 38-year-old with a lengthy criminal record was serving more than 11 years for drug and weapons-related offences. It was his third prison sentence and he had already racked up a long list of institutional charges for possession of contraband drugs.
Even so, Croft was not regarded by staff as a problem inmate.
"He represented a threat only to his own well being because of his drug addiction and abuse," the report states.
An autopsy showed Croft died of methadone toxicity with pneumonia as a significant contributing factor.
The day before he died, Croft was taken to the emergency room at the Fort Saskatchewan Community Hospital because he hadn't been feeling well for a few days.
Doctors discovered a small shadow on his right lung that could have been a possible infection. He was given a prescription for an antibiotic and sent back to prison.
After taking a nap and eating dinner, Croft got high.
"He then ingested methadone and snorted Wellbutrin, both of which he had purchased or bartered from another inmate or inmates," the report states. Wellbutrin is used to treat depression.
The last time anyone knew for sure that Croft was alive was around 3:30 a.m. when his loud snoring woke up his cell-mate.
Correctional officers were supposed to conduct hourly security patrols to make sure all inmates were "living and breathing," the report says.
Matchett concluded there were several instances of correctional officers not complying with that requirement.
Croft was discovered not breathing was at 9:34 a.m. At that point, two shots of Narcan, or naloxone, were administered and CPR was performed. Croft was rushed to hospital where he was pronounced deceased.
"While it's impossible to know with any certainty whether discovering that Mr. Croft was in distress earlier may have resulted in a different outcome, that possibility certainly exists," Matchett wrote.
Recommendations to prevent similar deaths
Officers searching Croft's cell after his death found a partially-dissolved Wellbutrin tablet and three blister packs of another antidepressant.
A subsequent search of Croft's unit turned up five prison cells that contained contraband.
The deputy warden testified at the inquiry that hoarding of contraband medication is still an ongoing problem at Edmonton Institution and he agreed with the judge that it would be beneficial to conduct regular cell searches more than the currently-required once per month.
Matchett also recommended that Correctional Service Canada (CSC) use ion scanners and detector dogs for more frequent and more effective cell searches, along with added audits on security round videos.
He gave "high marks" to CSC for the changes they've made since Croft's death regarding methadone and opiate abuse inside the prison.
The fatality inquiry report notes that Suboxone, a form of opioid replacement therapy, is now the first choice for treating addiction, rather than methadone. Six times as many inmates are now taking part in the revised therapy program.
The institution has also improved access to Narcan. When Croft died it was only available through injection by healthcare professionals. Now it's on all units along with the gym and library in inhalant form and can be administered by any trained CSC staff member.
Fatality inquiries are not conducted to find blame, but rather to make recommendations to prevent future similar deaths.