Ontario’s Office of the Chief Coroner has scheduled a December inquest into the death of David Johnson, nearly a decade after he died following injuries sustained while in custody at the Maplehurst Correctional Complex in Milton. The proceeding, announced Wednesday by the Ministry of the Solicitor General, will examine the circumstances surrounding the 67-year-old’s death and consider potential systemic recommendations aimed at preventing similar incidents.
Dr. Kenneth Peckham, Regional Supervising Coroner for Central Region, Central West Office, said the inquest will begin at 9:30 a.m. on Tuesday, December 16, 2025. It will be presided over by Dr. David Eden, with Roger Shallow serving as inquest counsel.
“Dr. Kenneth Peckham, Regional Supervising Coroner, Central Region, Central West Office, announced today that a date has been scheduled for the inquest into the death of David Johnson,” the announcement stated. “The inquest will begin at 9:30 a.m. on Tuesday, December 16, 2025. Dr. David Eden will be the presiding officer and Roger Shallow will be the inquest counsel.”
Johnson died on May 14, 2016 at Joseph Brant Memorial Hospital in Burlington. According to the release, his death resulted from injuries he sustained while incarcerated at Maplehurst, a provincial correctional facility often scrutinized for crowding, staffing pressures and operational challenges. Under Ontario’s Coroners Act, an inquest is mandatory when a person dies while in custody.
The purpose of a coroner’s inquest is not to assign blame but to establish the facts surrounding a death and allow a jury to issue recommendations intended to strengthen public safety. Inquests typically hear sworn testimony from witnesses, review evidence and assess whether existing practices or policies contributed to the circumstances.
“The inquest will examine the circumstances surrounding Mr. Johnson’s death. The jury may make recommendations aimed at preventing further deaths,” the news release said.
The hearing is expected to run four days and include testimony from approximately three witnesses. While the list of witnesses has not yet been publicly released, inquests into deaths in custody generally call on medical staff, correctional officers, investigative personnel, or subject-matter experts to outline timelines, treatment decisions and institutional procedures.
Ontario’s correctional system, including Maplehurst, has faced longstanding criticism over issues such as overcrowding, inmate mental-health management and the availability of timely medical care. Advocates have repeatedly called for increased oversight of conditions at provincial jails, particularly when deaths occur in custody. Inquests serve as one mechanism through which conditions and policies in correctional facilities can be examined in a public forum.
The proceeding will be held by video conference, continuing a format that has become common across the province following the shift to virtual hearings during the COVID-19 pandemic. The Ministry said members of the public will be able to watch the inquest live through the following link:
https://firstclassfacilitation.ca/office-of-the-chief-coroner/inquest-into-the-death-of-david-johnson/
“The inquest is expected to last four days and hear from approximately three witnesses,” the statement noted. “The inquest will be conducted by video conference. Members of the public who wish to view the proceedings can do so live at the link provided below.”
Virtual access has broadened public participation in coroners’ inquests, allowing families, media, advocates and researchers to observe proceedings without attending in person. For high-profile or systemic cases—particularly those involving correctional institutions—virtual hearings have increased transparency around the mechanisms used to review deaths and evaluate institutional practices.
Johnson’s death predates several recent reform efforts within Ontario’s correctional system, including investments in mental-health supports, infrastructure upgrades and initiatives intended to modernize inmate care. Depending on the evidence and jury recommendations, the inquest may influence ongoing policy development around inmate health, supervision and risk management.
Coroner’s inquests are a long-standing component of Ontario’s public-safety framework, aimed at examining preventable harm and guiding policy improvements. More information about the inquest process is available at:
https://www.ontario.ca/page/coroners-inquests.
The December hearing represents the latest step in establishing a complete public record of the events leading to Johnson’s death and determining whether further safeguards are needed within the provincial correctional system.
