Nurses welcome jury’s recommendations in Brad Chapman coroner’s inquest

Dec. 21, 2018

Governments in Ontario and Toronto should do more to help those experiencing homelessness and struggling with addiction if others are to avoid the tragic circumstances that led to the death of Brad Chapman, a coroner's jury recommended Thursday.

In the final months of his life, Mr. Chapman, a 43 year-old father of three, sought help but did not find it on a path that took him from jail to being homeless in downtown Toronto, a journey that ended in August 2015 in an alley where he accidentally overdosed on opioids.
The jury that considered his demise issued 55 recommendations, most directed at Ontario and Toronto to better safeguard vulnerable people suffering from addictions. Those recommendations include:

  • Transfer responsibility for health in correctional facilities to the Ministry of Health;
  • Develop a province-wide electronic health record for all individuals in custody;
  • Improve delivery of health care for people who are incarcerated;
  • Ensure better planning for discharge from correctional facilities.
  • Increase availability of supervised consumption services and consider expediting the implementation of managed opioid programs;
  • Equip all frontline police officers with naloxone and first aid training for opioid overdoses;
  • The government of Canada should consider decriminalizing drug possession for personal use and focus on preventing use, reducing
    harm and treating those who use drugs.
  • Develop a comprehensive provincial strategy to address the opioid crisis;

The jury also recognized RNAO's expertise and recommended that it play a greater role protecting those experiencing homelessness, including those who struggle with mental illness and addiction, by developing and issuing a best practice guideline to serve as a model to improve their care and support.

Listening to the testimony that led to the jury's recommendations, RNAO CEO Doris Grinspun says it was evident that the system failed Mr. Chapman. "He made repeated requests for help to find housing and support to help treat his addiction but the help he needed was not available. His care within the correctional system lacked continuity. His untimely death underscores the need for readily available supervised injection services and a comprehensive approach to helping people struggling with addiction. It's a critical service to tackle this growing and unrelenting opioid crisis, which claimed the lives of 867 people in 2016, and 1,265 people in 2017."

Grinspun welcomes the jury for emphasizing the need to address the opioid crisis with a public health approach that emphasizes the social determinants of health and takes a non-discriminatory approach to drug overdose prevention and harm reduction. If governments follow these detailed recommendations, it will do more to prevent addiction and homelessness and reduce the stigma and harm it inflicts on those in its grip.

The jury's recommendations should be followed so others avoid Mr. Chapman's tragic end, RNAO president Angela Cooper Brathwaite says. "We join the family in their grief and applaud them for their courage to provide difficult testimonies. Their advocacy can create a legacy for Mr. Chapman: a more compassionate and effective system. The jury's recommendations must be enacted in full to change the way we treat people who are addicted to drugs. If Mr. Chapman were alive today, he would have had access to supervised injection services, now called supervised consumption services, and his death might have been prevented. That's why these services are vital in Toronto and in all communities in need across this province," says Brathwaite.

The coroner's office granted status for the inquest to RNAO, which enabled the association to question witnesses and make submissions. RNAO was represented by Tiffany O'Hearn Davies of Stockwoods Barristers.

RNAO is the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. Since 1925, RNAO has advocated for healthy public policy, promoted excellence in nursing practice, increased nurses' contribution to shaping the health- care system, and influenced decisions that affect nurses and the public they serve. For more information about RNAO, visit or follow us on Facebook and Twitter.