In the shadow of rising public scrutiny and mounting lawsuits, the crisis of inmate deaths in North American correctional facilities has come under intense examination. Recent reports and legal actions have spotlighted the tragic consequences of alleged negligence, systemic failures, and the ongoing struggle over accountability in both Canadian and U.S. detention systems.
On September 6, 2025, Dawna La Rose filed a lawsuit in the Manitoba Court of King’s Bench, alleging that the Correctional Service of Canada and the federal attorney general were negligent in the death of her son, Ricardo Pereira. Pereira, only 23 years old, died at Stony Mountain Institution, a federal prison north of Winnipeg, after ingesting a bottle of methadone on September 5, 2023. According to CBC News, the suit claims that not only did correctional officials fail in their duty to ensure Pereira’s safety and well-being, but they also deprived him of basic necessities during a critical transfer between facilities.
Pereira had been serving an eight-year sentence for breaking and entering, aggravated assault, and other convictions when he was moved from Stony Mountain to Edmonton Institution in Alberta. This transfer, which took place in the wake of a deadly riot at Stony Mountain in July 2023, was reportedly made for his safety due to his past involvement with the Manitoba Warriors gang. However, the journey itself became a point of contention in the lawsuit. During a 14-hour drive back to Manitoba ahead of a court date, Pereira allegedly received neither food nor water—a violation, his family argues, of his Charter rights and basic human dignity.
The events leading to Pereira’s death began on September 4, 2023, when his mother arrived for a scheduled visit at Stony Mountain. She was told all visits were cancelled due to an unspecified incident in her son’s unit. Later that evening, Pereira recounted to his aunt and father on a phone call that he was being harassed by corrections officers and had been informed his mother’s visit was cancelled. Already struggling with depression and anxiety, the cancellation deeply upset him. According to the lawsuit, Pereira decided to “get high” and drank an entire bottle of methadone—something he had never tried before.
The consequences were immediate and dire. Pereira overdosed and was rushed to the emergency room in Stonewall, where he received several doses of naloxone, a medication used to reverse opioid overdoses. He was discharged that evening and returned to Stony Mountain. During a later phone call, his aunt noted that he “did not seem himself.” That night, another inmate noticed food left on the slot of Pereira’s cell and alerted guards. The next morning, Pereira’s cell was empty except for a pool of blood. Winnipeg police informed La Rose that her son had died around 2 a.m. on September 5. While the family never received a full autopsy or coroner’s report, a senior medical examiner reportedly told La Rose that methadone toxicity was the cause of death.
The lawsuit alleges a breach of duty on several fronts, including failure to obtain relevant information about Pereira’s background and failure to recognize the detrimental impact of his confinement on his mental health. It also claims a violation of his Charter rights during the transfer and seeks damages under The Fatal Accidents Act. The Correctional Service of Canada responded in a statement to CBC News, saying it “takes the death of an inmate very seriously,” but declined further comment due to the ongoing legal proceedings.
Pereira’s story is not an isolated incident. Across the border, similar tragedies have unfolded, fueling public outcry and demands for reform. In Riverside County, California, the issue of in-custody deaths has reached a critical juncture. According to a report released September 12, 2025, by Care First California, a coalition advocating for carceral reforms, 251 people died in the custody of the Riverside County Sheriff’s Department between 2012 and 2024—an average of 19 deaths per year. The report, “Riverside Lives Lost,” noted a staggering 182% increase in deaths from 2012 to 2021, with the peak occurring in 2021, when 33 deaths were recorded.
The reasons behind this surge are complex, but the report highlights several contributing factors: an 89% increase in the pretrial jail population from 2014 to 2022, persistent failures to provide adequate mental health care, and a lack of full compliance with a court-monitored decree intended to improve inmate well-being. Approximately 41% of detainees in Riverside County jails had open mental health cases, yet the Sheriff’s Department has failed to meet court-ordered standards for mental health services, according to the report.
However, there has been a notable shift in recent years. From 2021 through 2024, the number of in-custody deaths dropped nearly 58%. Luis Nolasco, a senior policy advocate with the American Civil Liberties Union of Southern California, told Southern California News Group that it’s difficult to pinpoint the exact cause of the decline. He cited factors such as a 2023 Department of Justice investigation, new laws limiting police deadly force, increased accountability, and the widespread availability of Narcan—a medication used to reverse opioid overdoses—as potential contributors. “We will need to look at the coming years’ numbers to truly determine if that drop is a meaningful one, or merely anomalies,” Nolasco said. “We hope that the growing attention to the issue has hopefully put added pressures on the department to do right by those in their custody.”
Sheriff Chad Bianco has attributed the reduction in fentanyl-related deaths to department-wide Narcan training and has defended his department’s record, calling the DOJ investigation “meritless” and dismissing the Care First report as a “completely biased, anti-law enforcement … activist hit piece.” Bianco, now a gubernatorial candidate, maintains that Riverside County’s corrections system is a model for the state.
Yet, families who have lost loved ones in custody remain unconvinced. Lisa Matus, whose 29-year-old son died of fentanyl poisoning in a Riverside jail in 2022, said, “There were just too many unanswered questions and deaths that shouldn’t have happened. The majority of deaths were preventable had they been doing their job. And no one has ever been held accountable, especially in Riverside County.”
Efforts to increase oversight have repeatedly stalled. In March 2024, the Riverside County Board of Supervisors declined to separate the coroner’s office from the sheriff’s department, instead opting for limited reforms such as outsourcing autopsies and creating a family liaison position. A July 2025 motion to establish a sheriff’s oversight committee and office of inspector general was also rejected, frustrating advocates like Supervisor Jose Medina, who vowed to keep fighting for greater transparency and accountability.
The fiscal impact of these issues is also significant. In the 2025 county budget, about $2.2 billion—or 23%—was allocated to the criminal legal system. Public safety accounted for a whopping 63% of the discretionary budget, outstripping spending on education, mental health, public health, and substance use services combined.
As lawsuits mount and reform efforts continue, the stories of Ricardo Pereira and the hundreds who have died in custody across North America serve as stark reminders of the urgent need for systemic change. Whether through legal action, policy reform, or community advocacy, the push for accountability and humane treatment in correctional facilities shows no signs of abating.