As Ontario considers changing its Coroners Act to end mandatory inquests into jail deaths, the family member of a woman who collapsed in a holding cell and later died in hospital says it would cause more harm than good.
Amanda Bolt, 28, was being held in custody at London Police Headquarters after being arrested twice on Nov. 2, 2019. She went into medical distress while still incarcerated the following morning and was taken to Victoria Hospital, where she was put on life support until her death 10 days later.
During a week-long coroner’s inquest that ended on Dec. 5, 2025, a jury determined that she died of a brain injury following a heart attack she experienced in her holding cell. Jury members put forward 10 recommendations to London police aimed at preventing future deaths.
Amanda’s brother, Chris Bolt, was watching the inquest closely and said that while it wasn’t perfect, it was an important step in closing this chapter of his sister’s story.
“It helped. Personally, it gives me closure. But as a whole, it still makes me concerned for these accidents continuing to happen in the future,” Bolt said.
However, it’s uncertain whether other families will experience that element of closure in the future.
On Monday, Ontario’s Ministry of the Solicitor General finished gathering feedback on a possible amendment to its Coroners Act that may replace mandatory inquests with coroner-led annual reviews.
“This approach would support a system-wide review of in-custody deaths and help ensure recommendations are delivered faster and more efficiently to prevent any further deaths,” said Solicitor General spokesperson Saddam Khussain.
The government is still reviewing feedback and consulting with stakeholders before making a decision, Khussain said.
Currently, the Coroners Act requires an investigation into deaths of people in custody at an Ontario correctional facility, if the coroner suspects they were the result of non-natural causes. A jury is tasked with answering who, when, where, how and by what means a person died.
Their most important task is to come up with a list of recommendations to prevent future deaths in similar circumstances.
Anita Szigeti, a Toronto-based lawyer and president of the Law and Mental Disorder Association, said it can take a long time for an inquest to begin.
“Delays and backlogs in the system and overwhelm of the system have meant that it’s five to seven years from the date of the death,” she told CBC’s London Morning, adding that the inquest itself can take anywhere from a week to several years before the jury comes to a conclusion.
Bolt said the five years it took before his sister’s inquest started was stressful.
“It is very much picking at old wounds … Just having to rehash all the information every time you get asked questions about it or anytime there’s a new court date just makes it hard to move past it,” he said.
The ministry’s proposal suggests that rather than using a jury, an advisory committee of experts, including family members, legal representatives or advocacy organizations, would determine the outcomes of all cases from the previous year, along with a list of recommendations based on the findings.
“You’re turning a person into a number,” Bolt said. “You get rid of the personal aspect of it when you’re like, ‘Well, Joey, Bobby and Sue all died within the last seven months’ … It makes it so there is no sympathy towards the people. All the inquest staff will be seeing are numbers.”
Szigeti said she is not in favour of replacing mandatory inquests with an annual review, but would support adding the coroner-led review to current procedures.
“There would be additional value in these systemic reviews that could very effectively support the inquest process,” she said.” I can see value in annual reviews [where participants] come up with some recommendations, then put those recommendations to witnesses at an inquest to see whether or not the government has acted on those recommendations.”
Bolt agreed that he would rather see the current inquest system improve and police take recommendations seriously, rather than change the Coroners Act overall.
“If anything, they should be working harder to do more with [inquests],” Bolt said.
“Any sort of disclosure of information that might help somebody in the future is beneficial, but it depends on who’s hearing that information and whether or not it’ll actually benefit people within the system.”
