Work with the Infrastructure Health and Safety Association to develop guidance material for employers and constructors on how to address the hazard of falling ice. Funding to be provided on an annualized basis, with adequacy assessed and considered after the first three years. The data should be standardized, disaggregated, tabulated and publicly reported. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. Consider conducting an ice management campaign for large construction projects in Eastern Ontario. Where gaps exist, the ministry should explore and research means to increase actual programing at Detention and Correctional Centres: Analysis of data collection or research of Indigenous core or other programing should include identification of gaps, steps taken to resolve gaps, improvements and best practices; This analysis and research should be reported, maintained and disseminated to Ontario`s correctional Institutions, service providers and for use with consultation with First Nation, Metis and Inuit community; The ministry should consider evaluating and modifying their policies on allowing volunteers into the facility that have a criminal record. The Office of the Chief Coroner should consider conducting inquests within a timely manner, within 24 months from the incident date with the exception of extraordinary circumstances. Said plan should include (but not be limited to): A mandatory mechanical safety review that each skid steer operator must complete each day, prior to commencing work. The provision of therapeutic care. To support the well-being of children, continue to ensure that, as part of the intake process, staff acquire and review all relevant information and documents relating to a young person, including any plans of care developed by prior residential facilities and any information relating to suicidal behaviour or ideation. Advocating for survivors and their families having regard to addressing the systemic concerns of survivors navigating the legal system. The following recommendations are made in recognition and acknowledgement of the following principles: Surname:BruneauGiven name(s):OlivierAge:24. The ministry should ensure that correctional officers investigate cell change requests immediately, and grant same immediately, where merited. To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. consider the need for Navigators, in addition to resource persons, adult ally and circle of supportive persons to assist First Nations youth, as both a prevention and protection resource and for youth both on and off reserve, in navigating various systems such as child welfare and protection, mental health and criminal justice. Held at:LondonFrom:November 21To:November 30, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Murray James DavisDate and time of death: August 17, 2017 8:00 a.m.Place of death:Elgin Middlesex Detention Centre, 711 Exeter Road, London, ONCause of death:Acute combined fentanyl and hydromorphone toxicityBy what means:accident, The verdict was received on November 30, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:AmaralGiven name(s):JoseAge:49. How employers should prepare their workers and their job sites to ensure safe working conditions during periods of high temperatures. Prohibiting the use of skid steers in reverse unless it is operationally necessary. All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. The action plan should be completed in consultation with the. The 74,160 records in this database were extracted from the Cook County Coroner's Inquest Records. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers). That the Community Inclusion Coordinator be part of the process for reviewing relevant. 08:52, 2 MAR 2023. The Toronto Police Service should provide emergency task force (. Held at:25 Morton Schulman Avenue, Toronto (virtually)From:February 28To:March 11, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Quinn EmmersonMacDougallDate and time of death: April 3, 2018 at 4:23 p.m.Place of death:Hamilton General Hospital, 237 Barton Street East, Hamilton, OntarioCause of death:gunshot wound of the torso (right chest)By what means:homicide, The verdict was received on March 11, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:SantosGiven name(s):FernandoAge:59. Ensure that all safety plans are written down and shared with Lynwood staff, the young persons guardian, and other members of a young persons circle of care where appropriate and consistent with privacy legislation and rights. This would both provide a warning and a specific ongoing reminder to any person entering such areas. Reinforce the policy requirement for a Part C health care summary to be completed in every patients health care record. Review existing training for justice system personnel who are within the purview of the provincial government or police services. Unfortunately, we cannot provide any additional information other than what is on the Court List. Improve public awareness of both policing and non-policing community-based crisis responses to mental health crisis. 13 January 2022 Following a change in the law in 2013, the coroner now gives a 'determination' on the cause of death. Held at:TorontoFrom:November 21To: November 24, 2022By:Dr.Jennifer Tanghaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased: Craig BlackettDate and time of death: 17:08 - May 27, 2016Place of death: 3058 Lakeshore Blvd West, Toronto, OntarioCause of death:Multiple blunt force injuriesBy what means:accident, The verdict was received on November 24, 2022Coroner's name: Dr.Jennifer Tang(Original signed by coroner), Surname:DavisGiven name(s):Murray JamesAge:24. These supports should account for the social barriers to accessing such supports within a custodial environment. Rename crisis hotline services and create awareness campaigns to educate the public about their existence to make the public aware that these services are available before a person reaches the point of crisis. Safety by Design refers to the concept of incorporating worker safety into the design and planning of large construction projects. She said: 'I consider that based on the evidence I have heard the failure to report the smear test accurately was a gross failure and the further assessments in both August and . Consider using specialized care units for inmates who have been removed from suicide watch. The circumstances in which judges can lead inquests and details of notable inquests overseen by a judge. To Green Star Grading & Sodding Construction Ltd. (Green Star): Surname:SoaresGiven name(s):RicardoAge:32. The ministry should embrace an evidence-based approach to harm reduction in a manner that protects the mental and physical health of persons in custody. They will make whatever inquiries are necessary to find out the cause of death, this includes ordering a post-mortem examination, obtaining witness statements and medical records, or holding an inquest. Physicians should be encouraged to communicate with a patients community health care providers when discontinuing or amending a prescription for an opioid medication, when consent is provided by the patient. Continue working with their partners to provide timely alerts, reminders and warnings to the public about the dangers of working in high temperature conditions on days when the temperatures reach dangerous levels. Held at: TorontoFrom:June 29To: June 29, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Frank FerranteDate and time of death: July 28, 2015 at 8:34 p.m.Place of death:Southlake Regional Health Centre, 596 Davis Drive, NewmarketCause of death:heat strokeBy what means:accident, The verdict was received on June 29, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:YonanGiven name(s):MettiAge:66. Provide Indigenous-led cultural competency and cultural safety training to all officers. The range of verdicts that can be declared by the Coroner or jury include: Accidental death Misadventure Suicide Natural causes Unlawful killing Open verdict An 'open' verdict means that the evidence does not fully or clearly explain the cause and circumstances of death. To improve outcomes for First Nations children and youth, continue to work, through the Child Welfare Redesign Strategy, on potential further changes to the funding allocation and the child welfare service delivery model, including consideration of the following: continue monitoring the effectiveness of annualized funding announced in July 2020 as part of the Child Welfare Redesign Strategy to provide access to prevention-focused customary care for bands and First Nation communities, support the implementation of models of service to enable children and youth to have meaningful, lifelong connections to their family, community and culture; a sense of belonging; a sense of identity and well-being and physical, cultural and emotional safety; and that plans of care are reflective of the childs physical, mental, emotional, spiritual and cultural identities beginning from the time a case is opened by a society, continue to review the Ontario Eligibility Spectrum, the need for verification, and adopt a needs-based approach (instead of a caregiver deficits approach) to supporting and protecting the well-being of children and youth informed by Indigenous experts. The verdict means the jury confirms the death is suspicious, but is unable to reach any other verdicts open to them. We recommend that Occupational Health and Safety be amended to allow Health and Safety representatives and Joint Health and Safety committees authority to keep confidential the name of any workers who report unsafe conditions. Ensure all health care providers, including nurses, physicians, psychiatrists, and psychologists, are trained on the revised Recovery Plan policy. (Note: this is included in both mining industry and Ministry of Labour section). Coroner's court returns verdict of medical misadventure after inquest into death of Linda Connell (41) five days after minor surgery to remove ovarian cyst That the Thunder Bay Police Service Board consider creating a position of Deputy Chief, Indigenous Relations. Continue to ensure that all young people in care have reasonable access to cell phones or other technologies they may need to communicate with their family, their First Nation and others important to them. The Coroner's Office can be contacted by email at coroners@cambridgeshire.gov.uk or by telephone on 0345 045 1364. The inquest jury consists of five people selected by the coroner's constable from a list of jurors from the community. The verdict was received on December 1, 2021 Coroner's name: Dr. Steven Bodley (Original signed by coroner) We, the jury, wish to make the following recommendations: Inquest into the death of: Mark King Jeffrey Jury recommendations Correctional Services of Canada should: make the Anijaarniq: A Holistic Inuit Strategy publicly available Held at:HamiltonFrom: September 26To: October 21, 2022By: Jennifer Scott, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Devon Russell James Freeman (Muskaabo)Date and time of death: April 12, 2018 (October 7, 2017 April 12, 2018)Place of death:831 Collinson Rd, FlamboroughCause of death:hanging by ligtureBy what means:suicide, The verdict was received on October 21, 2022Presiding officer's name:Jennifer Scott(Original signed by presiding officer). What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. SUMMARY OF CORONER'S VERDICTS AND FINDINGS (KEEGAN J) I. The ministry should create and implement a policy that requires the use of specific language by correctional officers and healthcare workers at each correctional facility which prioritizes humanizing people in custody by addressing them as patients, persons in custody and/or persons who use drugs. The ministry shall update policy so that phone calls by persons in custody are not referred to as a privilege. Service providers provide one annual report for all funders across government to account for the funds received, articulate results and highlight key challenges, learnings, and accomplishments. To the Ministry of the Solicitor General and Windsor Police Service, Surname:OgundipeGiven name(s):VictorAge:41. Conclusions (verdicts) At the end of the Inquest, the Coroner can give the following Conclusions about the death: Natural causes Accident or misadventure Suicide Share those best practices with construction sector employers and constructors. In jury inquests, the coroner directs the jury on matters of law and the jury decides the appropriate verdict . The ministry shall actively facilitate meaningful social interaction and prioritize face-to-face and direct human contact without physical barriers, empathetic exchange, and sustained social interaction. The coroner will open the inquest in order to issue a burial order or cremation certificate (if not already issued immediately after the post-mortem examination) as well as hearing evidence confirming the identity of the deceased. Being accessible by clients voluntarily and via referral,and not just through the criminal justice system. Blackburn. That all police officers be trained that paramedics cannot medically clear any person, and that an assessment by a paramedic does not mean that a patient does not require medical treatment. The Government of Ontario should offer and arrange enhanced legal and mental health support for families of persons who die in a police encounter and ensure that those services are delivered in a timely and trauma-informed manner. Review the process for obtaining inmates medical history from their next of kin when inmates are identified as potentially suicidal or violent. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. If none already exists, explore with community mental health partners, the feasibility of establishing and adequately resourcing joint mental health-police response teams to assist with person in crisis calls for service. We recommend that tailboard documents should be standardized, regulated, and include a section that addresses possible encroachment of overhead powerlines of the minimum distance permitted under Section 188 (2) of Regulation 213/91 for Construction Projects. Held at: 25 Morton Shulman Ave Toronto (virtually)From:May 16To: May 18, 2022By:Dr.Bob Reddochhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Jean Herv VeilletteDate and time of death:January 17, 2019 at 1:21 a.m.Place of death:Ottawa Hospital General CampusCause of death:hangingBy what means:suicide, The verdict was received on May 18, 2022Coroner's name:Dr.Bob Reddoch(Original signed by coroner). An approach that is not one-size-fits-all. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. within hiring practices to ensure personality and culture fit, situational judgement, role-specific skills, incorporate in regular performance evaluations to ensure that the individuals values remain consistent with expectations. The ministry should deliver alerts to persons in custody on an urgent basis regarding new and emerging threats from novel street drugs. Continue to be accountable to the child, the childs family and the childs First Nation community to ensure First Nations children in out-of-home placements maintain connection to family, community, and culture and that plans are reflective of the childs physical, mental, emotional, and spiritual identities through the regular review of all First Nations children in care. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. All site supervisors are competent and aware of their duties and responsibilities. Ensure that adequate staffing is provided at each institution to implement recovery plans. Ensure that Probation Services reviews and, if necessary, develops standardized protocols and policies for probation officers with respect to intake of. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. This can be: accident/misadventure unlawful killing natural causes. coroner's jury, a group summoned from a district to assist a coroner in determining the cause of a person's death. Ensure that the employer continues to properly identify and review Potential Chemical Hazards of cyanide at the mine site and modify the training, procedures and medical response as required. It would also provide a primary point of communication for emergency response and medical personnel. Provide adequate and sustainable funding and resources to ensure that a range of placement options and transition services, including independent and semi-independent living arrangements, are available for children and young people receiving services from childrens aid societies and Indigenous well-being agencies. The ministry should seek funding to implement these recommendations. That training be delivered to police officers and jailers relating to medical issues that may mimic intoxication, or that may be concurrent with intoxication, and that this be provided both at the Ontario Police College and to serving officers. A jury has returned a not guilty plea in the coroner's inquest into the fatal officer-involved shooting of Johnny Lee Perry II on August 29, 2021. That the Thunder Bay Police Service review its jailer academic programming and, if not already included, incorporate an educational component on the Human Rights Code and training on cultural sensitivity. The ministry should ensure and enforce through training that all correctional staff ensure that any important information, including historical information, is entered into. To support the cultural safety and well-being of First Nations children and young people and in keeping with the Truth and Reconciliation Commissions Calls to Action (2015), continue to support a range of Indigenous programs to include Youth Life Promotion initiatives which entail both school and land-based programs, Indigenous Mental Health and Addiction Workers in the Indigenous communities across the province, Mental Wellness Teams, Indigenous Professional Development and Tele-Mental Health. The ministry should ensure that any of the Indigenous Liaison Officers and Indigenous elders are engaged in the provision of health care information and treatment when requested by patients. Inquisition and narrative verdict - Catherine Hickman; Start grassroots Safe Spaces program that businesses can participate in where survivors can feel safe and ask for information (. The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody. The ministry should engage in community consultation on the development of Indigenous core programming with Indigenous leadership including First Nation, Mtis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. We recommend that an industry wide Hazard Alert be published, alerting end-users, and manufacturers of remote-control devices for booms and cranes, to the risk of inadvertent boom or crane movement associated to the OMNEX T300 Wireless Remote Control, or any similarly designed remote control used for boom or crane operation. Enhance procedures for increasing communication and service coordination contained within the signed protocol between child welfare services and the services provided by urban Indigenous agencies, including but not limited to: De dwa da dehs nye s (Aboriginal Health Centre), Hamilton Regional Indian Center, Niwasa Kedaaswin Teg, the Native Womens Centre and the Niagara Peninsula Aboriginal Area Management Board (, Continue to prioritize the Child Welfare Sector Commitments to Reconciliation by transparently sharing data (without personal information and in accordance with Part X of the. That a Task Force be developed with a mandate to establish a sobering centre in Thunder Bay. Consider how the concept of Safety by Design has been implemented in other jurisdictions and assess whether these concepts can be incorporated into Ontarios health and safety regulations. They must make enquiries of any death that is reported to them and investigate the death if it appears that: the cause of death is unknown the. Explore options for privacy screens or barriers around toilets in cells to avoid the need for inmates to fashion their own privacy sheets. This unique intersection of Blackness and lived experience of mental health issues must be specifically addressed in any training on use of force, de-escalation, and police interaction with such persons. Recommend training programs be reviewed on an ongoing basis to maximize employees comprehension of content. Develop an expert panel including Indigenous leaders, researchers, as well as leaders from other provincial child welfare ministries, such as British Columbias Ministry of Children and Family Development who can provide expertise on best practices to revise the child welfare funding formula to address the needs of Indigenous youth. Review the current Use of Force Model (2004) and related regulations, and consider de-emphasizing use of the term "force" and employing alternative terminology. To ensure the safety of the children in its care, Lynwoods psychiatric nurse practitioner shall meet with staff upon admission of each new client regarding any diagnosis and/or mental health needs. Continue working with the ministrys partners to create educational materials that highlight the dangers associated with skid steer work and the risks of being struck by a skid steer. If you are thinking about challenging a coroner's decision, it is important that you seek specialist advice as soon as possible. Provide annual reports, accessible to the public, on ongoing research findings through the Chief Prevention Officer. We recommend that, absent exceptional circumstances, claims should be processed within 30 days of receipt of the documentation from the correctional facility. When operationally feasible, the ministry should run the scenario-based. All health and safety representatives are competent and aware of their duties and responsibilities. Revise the provincial Use of Force Model (2004) as soon as possible. It is recommended that the Ministry of Labour, Training and Skills Development take steps to amend the. Specifically: increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. The ability to respond immediately with risk management services in collaboration with. Re-evaluate the capacity of Community Outreach and Support and Mobile Crisis Rapid Response teams to meet the growing need for these services in the Region of Peel. The ministry should ensure mental health nurses are available on call 24 hours a day, seven days a week, to see any Inmates waiting for them as soon as possible to allow all assessments to be completed in a timely fashion regardless of whether any given Inmate has temporarily left the institution for court. Review whether one on one supervision needs to be provided to individuals in custody who pose particularly high risk, such as individuals who expressed suicidal ideation. The ministry should undertake a study to identify the effects of overcrowding, and other living conditions on inmate populations especially those with addictions and/or pre-existing mental illness and to take any appropriate corrective measures. Immediately institute a provincial implementation committee dedicated to ensuring that the recommendations from this Inquest are comprehensively considered, and any responses are fully reported and published. Held at: TorontoFrom:May 16To: June 3, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Marc Diza EkambaDate and time of death:March 20, 2015 at 10:53 p.m.Place of death:3070 Queen Frederica Drive, Mississauga, OntarioCause of death:multiple gunshot woundsBy what means:homicide, The verdict was received on June 3, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:VeilletteGiven name(s):Jean HervAge:48. Consider renaming the Model to better reflect the range of tools and techniques available to officers. These reviews should analyze relevant health care files and assess quality of care. Most medical treatment-related Inquest hearings are held in public, usually without a jury, and the Coroner decides the verdict having heard all the necessary evidence. That joint training be scheduled on an on-going basis, allowing first responders to learn more about the roles and responsibilities of other agencies. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. The ministry should require all forms related to the admissions of inmates to be completed in full, including review and signature by a sergeant (or their designate). Establish a Royal Commission to review and recommend changes to the Criminal Justice system to make it more victim-centric, more responsive to root causes of crime and more adaptable as society evolves. In recognition of the shortage of beds in detox/treatment (rehabilitation) facilities in the City of Thunder Bay, the number of beds in such programs should be increased to adequately meet the needs of the community. If the cause remains in doubt after a post mortem, an inquest will be held. Include coercive control, as defined in the. . The ministry should explore implementation of harm reduction strategies similar to those used at supervised consumption sites. Consider including conductive energy weapons training as part of the mandatory curriculum for police recruits at the Ontario Police College with a yearly re-certification. Acknowledgement of i) and ii) by the competent assistant. Develop, establish, and provide regular training to, circumstances in which the policy is applicable, including when an individual would be considered potentially dangerous, involving a supervising officer in the planning of the arrest, when possible, completing an arrest decision tool, which may include a checklist of criteria, how to identify possible factors that could complicate an arrest, such as possible mental health issues, unpredictability, past incidents with police, and violent history, In support of the planning process, develop and provide guidance and training on circumstances where it may be appropriate to contact a subject to ask them to attend a police detachment for the purpose of effecting an arrest.