SUDBURY—When correctional officers found 44-year-old Justin Alexander Trudeau in his Sudbury Jail cell on February 13, 2021, he was already gone—his body cold, blue and locked in rigor mortis. He had been dead for hours.
A father of five and a member of Wiikwemkoong Unceded Territory, Mr. Trudeau had entered the Sudbury District Jail just five days earlier to serve a 30-day sentence. By the time he was found, a severe and drug-resistant bacterial infection had filled his lungs with pus and fluid, cutting off oxygen and overwhelming his organs. He died of acute methicillin-resistant Staphylococcus aureus (MRSA) pneumonia and septicemia—a catastrophic blood infection.
The ongoing coroner’s inquest, which concluded its testimony October 23, is not about blame, but about prevention. Over five days of evidence, jurors heard from nurses, doctors, correctional staff and experts in infectious disease. What emerged was a portrait of a system strained to breaking—short-staffed, digitally outdated and medically unprepared for the complexities of illness in custody.
Dr. Martin Queen, the Sudbury-based forensic pathologist who performed the autopsy, told the jury that Mr. Trudeau’s lungs were “three to four times the normal weight,” heavy with infection. “Normally lungs are light and airy,” he said. “These were dense and firm, filled with pus and fluid.” He found no evidence of trauma or rib injuries, despite Mr. Trudeau’s earlier complaint of rib pain—pain Dr. Queen now suspects came from the pneumonia already “brewing” when he entered the jail.
Dr. Queen described MRSA as a “smart bacteria,” one that has evolved to resist common antibiotics. “It’s found on the skin or in the nose of about one in three people,” he said. “Most never know it’s there. But in crowded, unhygienic conditions like jails, it can turn deadly.”
According to Dr. Queen, Mr. Trudeau’s infection likely developed over five to seven days before his death—meaning he was already ill when he was admitted on February 8, 2021. Because of pandemic restrictions, new inmates were placed in 14-day isolation. No nurse was available for intake that day, so Mr. Trudeau was examined the next morning. He reported rib pain and methadone use for opioid addiction, and had a mild fever.
A nurse later noted a wound on his hand and swabbed it for bacteria. Test results returned positive for Group A streptococcus, and an on-call physician—working virtually—prescribed an antibiotic known to treat drug-resistant strains. But the infection spreading through Mr. Trudeau’s body was far worse.
By February 12, his temperature had dropped into hypothermic range—a red flag for sepsis. Dr. Dominik Mertz, an infectious disease specialist from Hamilton, told the jury that this reading should have triggered immediate reassessment. “A low temperature can be a sign of severe sepsis,” he said. “If repeated and confirmed, it’s a medical emergency.” Instead, there was no follow-up.
When asked how Mr. Trudeau’s pneumonia could have been detected, Dr. Queen said simply, “A stethoscope.” Listening to the chest, or a routine blood test, might have revealed the infection early enough to intervene.
Every medical witness who testified—including nurses Meaghan Kallio, Chantal Shambrook and Tammy French—called for the same reforms: 24-hour on-site nursing care and digital medical records that follow inmates between institutions. Ms. Shambrook described pandemic restrictions as “crippling,” limiting nurses’ ability to move between units and assess patients.
Ms. French, now the jail’s health care manager, told jurors that the complexity of inmates’ medical needs has risen sharply in recent years. “Patient acuity is about 200 times greater than when I started,” she said. “We have far more anxiety, depression, concurrent disorders, addictions, mental health.”
For Indigenous peoples, those realities are magnified. Despite making up roughly five percent of Canada’s population, Indigenous people account for over 30 per cent of those incarcerated in provincial and federal institutions. The proportion is even higher for Indigenous women. Centuries of displacement, residential schools, and state-sanctioned child removal have left deep intergenerational trauma—trauma now often criminalized instead of cared for.
Many of those who enter jail, like Mr. Trudeau, carry untreated mental health conditions, addictions and histories of violence or poverty—symptoms of systemic neglect that the justice system is ill-equipped to heal. In Northern jails especially, where staffing shortages are chronic and health care is patchwork, the line between illness and punishment blurs into something that can be seen as more cruel.
Mr. Trudeau’s death, therefore, could be not just the failure of antibiotics, but of infrastructure—an echo of policies that continue to fail Indigenous people both inside and outside the walls.
The inquest closed with ceremony. Elder Dorothy Fox of Wiikwemkoong Unceded Territory opened and closed the proceedings with Anishinaabe prayer, grounding the process in respect and accountability—a reminder that justice, too, can be ceremony when institutions have forgotten their humanity.
The jury will reconvene next week to deliberate its recommendations—recommendations that, for Trudeau’s family and community, may be the only justice left to find.
The inquest continues until October 29.
