The ministry shall treat people in custody on remand as presumed to be innocent. 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. For the purpose of assisting clinicians in directing patients to receive timely mental health services and promoting accountability of community mental health services, a direction requiring that all hospital and community-based mental health services that receive funding from the Government of Ontario: collect and publish monthly non-identifying data regarding: wait times for treatment (i.e., actual receipt of mental health services by mental health professionals as opposed to waiting times for intake) and patient volumes, days and hours of mental health services provided, provide the resources to allow hospitals and community-based mental health services to provide this data, increase mental health awareness and promotion of initiatives within communities to address the lack of familiarity of services and options available for persons and families dealing with mental health situations. Held at: OttawaFrom:April 20To: April 29, 2022By:Dr.Bob Reddochhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Babak SaidiDate and time of death: December 23, 2017 at 11:30 a.m.Place of death:Morrisburg, OntarioCause of death:gunshot wounds to the right shoulder and right side of the back.By what means:homicide, The verdict was received on April 29, 2022Coroner's name:Dr.Bob Reddoch(Original signed by coroner). Provide professional education and training for justice system personnel on. A coroner is an independent judicial office holder. 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. Improve mental health awareness of housing support personnel, and in particular, concerning the recognition of mental health crisis. 17 June 2022 . Specifically: ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the, Conduct a comprehensive post audit to determine the correctional staffing levels needed at the, Analyze the causes of correctional staff absenteeism at the, Complete an action plan based on the results of the post audit and staff absenteeism analysis. The ministry should implement dedicated and centralized real time monitoring of cameras at. To ensure that First Nations children benefit from their legal entitlements under, In the spirit of recommendations made in the past in other settings, including those in the, residential treatment resources for Indigenous communities, service coordination for children with complex trauma and complex needs to ensure safety, continuity of care, and the avoidance of long wait lists. 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. The Ontario Use of Force model should be renamed to accurately capture the intent and purpose of the model, which is a guide to police engagement with the public rather than to suggest that force is inherent in police interactions. This would include training, equipment or work processes and the continued availability of safety data sheets. Provide Indigenous-led cultural competency and cultural safety training to all officers. 4.1 It is recommended that employers, constructors, supervisors ensure that any hazard identified in risk assessments be relayed to workers together with the associated level of risk. These solutions should be communicated to relevant staff and stakeholders in a timely manner. Regular refresher training on mental health issues should be provided to all police officers who interact with the public. The audit should be independent and should result in an action plan that must be submitted to the. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current andprevious year. . We recommend that the frequency of required refresher courses/training for Constructors, Employers, Supervisors, and Workers, who work in proximity to overhead power lines. Consideration for the needs of rural and geographically remote survivors of. Start grassroots Safe Spaces program that businesses can participate in where survivors can feel safe and ask for information (. These solutions should be communicated to relevant staff and stakeholders in a timely manner. Related Information. Make adjustments to program curriculum and delivery methods according to gaps and opportunities identified. When a community prescription for an opioid medication is discontinued or amended by a. Utilize the resources generated by the Ministry of Labour, Immigration, Training and Skills Development and Infrastructure Health & Safety Association to develop a comprehensive safety plan for when a skid steer (owned or operated by Green Star or one of its employees) is in use at a construction site. This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities. Assess the feasibility and impact of establishing a mental health advocate role (or enhancing the abilities of social workers) to be the point person helping patients and families coordinate mental health services: this advocate assists with scheduling follow-up sessions after appointments; check-ins, and visits; support after medication changes; recommends community services; collecting collateral information from relevant parties, based on demand and proper funding, this advocate will be required to manage multiple concurrent cases effectively within a framework of flagging and following up with the highest-risk outpatients, consistently offer a family meeting within 48-72 hours of hospital admission, regardless of the patients status in hospital, to collect collateral information, documented offer of a meeting with family members or support team occurs prior to discharge from hospital to ensure a patient with mental health issues has support, provide mental health services 24 hours a day to better assist communities by expanding self-help services to those in need through online, hybrid, or in-person supports, The Ministry of the Solicitor General (ministry) should review the Offender Tracking Information System. The foundation of training should include, but not be limited to, the history of colonization and the impact on Indigenous peoples; residential schools; trauma informed approaches; anti-Indigenous racism; unconscious bias; and Indigenous cultural safety training. Held at:SudburyFrom: August 29To: September 2, 2022By: Dr. David Cameron, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Richard Raymond PigeauDate and time of death: October 20, 2015 at 12:06 p.m.Place of death:3259 Skead Road, Skead, ON, P0M 2Y0 1660 Level, 1660-021 RampCause of death:crush-type blunt force injuries to torsoBy what means:accident, The verdict was received on September 2, 2022Presiding officer's name: Dr. David Cameron(Original signed by presiding officer), Surname: GordonGiven name(s): JacobAge:24. The ministry should review the suicide awareness training to ensure that it includes a robust individual evaluation component for comprehension of the course materials. Prohibiting the use of skid steers in reverse unless it is operationally necessary. Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a pilot project. 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). At every employer site at least two physician assistants / medical professionals should be available to perform medical assistance. The following are few of the most commonly used inquest verdicts: Natural cause (this includes cases of fatal medical issues) Misadventure and/or accidents Industrial disease (you can get this as coroner's inquest for asbestosis that causes death) Unlawful killing Lawful killing (this includes cases of death by acts of war or self-defense) 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. Explore and research the availability and efficacy of additional less-lethal use of force options for officers. The pilot whose plane crashed at the Shoreham Airshow in 2015, killing 11 men, has asked for permission to judicially review the inquest into their deaths. 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 task force would involve representatives from, and meaningful input from: Members of the Thunder Bay community including individuals with lived/living experience, members of the Thunder Bay District Mental Health & Addictions Network, Superior North Emergency Medical Services, Nishnawbe Aski Nation and Anishinabek Nation, other Indigenous and community partners who wish to participate. In partnership with childrens mental health residential service providers, develop and effectively fund programs that are responsive to the needs of hard-to-serve young people presenting with high-risk behaviors such as aggression or suicidal ideation and other complex needs. If a police service has a joint mental health-police team, give studied consideration to implementing a police policy that provides, once police officers attending a call identify a potential mental health concern and provided it is safe to do so, that the joint mental health-police team should be engaged. Fund for safe rooms to be installed in survivors homes in high-risk cases. The ministry should deliver alerts to persons in custody on an urgent basis regarding new and emerging threats from novel street drugs. arrives at St. Pancras Coroner's Court for a hearing into the singer's . Ensure that persons with lived experience from peer-run organizations are directly involved in the development and delivery of both mental health crisis and de-escalation training. Signaller be equipped with a remote e-stop. The Boards Governance Committee will consider creating an implementation plan that includes but is not limited to: a timeline for implementation of all recommendations received through various reports, inquests and inquiries; a plan for how the recommendation will be implemented; and how consultation and follow-up with Indigenous community will take place. Compensation should include: cost of medicines or supplies required to facilitate service. The ministry should abandon its zero-tolerance policy with respect to both the use of street drugs and the diversion of prescribed drugs, recognizing that this policy stigmatizes and punishes people for behaviours that stem from underlying medical issues. Consider using specialized care units for inmates who have been removed from suicide watch. Prior to commencing work, survey worksites where high temperatures are a concern and ensure that every reasonable precaution is taken to protect workers from heat stress and heat related illnesses. Training should be given to establish who should lead the call when dealing with a potentially violent incident or crisis. 05/09/2022. Workplace incidents are properly investigated and addressed, and the results of those investigations are communicated to the relevant workplace parties. Consider providing cognitive behavioural therapy, and/or other evidence-informed clinical interventions, for inmates who may be at risk of suicide. The ministry should explore safer alternatives to wooden pencils being provided to Inmates. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care. The Coroner investigates deaths in order to establish who . Roger and Bradley Stockton crashed on the second lap of last year's final sidecar race. A variety of group-based interventions augmented with individual counseling and case management sessions to assess and manage risk and to supplement services, as needed, to address individual needs. In recognition of the important roles of family and Indigenous communities, offer to involve the family and the Indigenous community of a deceased Indigenous young person in the Pediatric Death Committee Review process where appropriate, having due regard to confidentiality concerns. Roger and Bradley Stockton, from Crewe, crashed on the second lap of the sidecar race on . Reinforce the policy requirement for a Part C health care summary to be completed in every patients health care record. Include coercive control, as defined in the. Names of the deceased: Rajendiran, Arun Kumar;Tavernier, Darrel; Kelly, StephenHeld at:TorontoFrom:May 30To: June 13, 2022By:Dr.Robert Reddoch, coroner for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:RajendiranGiven name(s):Arun KumarAge:25, Date and time of death: November 12, 2014 at 8:16 p.m.Place of death: Central East Correctional Centre, Lindsay, OntarioCause of death:hangingBy what means:suicide, Surname:TavernierGiven name(s):DarrelAge:42, Date and time of death: January 1, 2018 at 8:37 a.m.Place of death: Ross Memorial Hospital,Lindsay, OntarioCause of death:hangingBy what means:suicide, Surname:KellyGiven name(s):StephenAge:62, Date and time of death: May 18, 2019 at 9:10 a.m.Place of death: Ross Memorial Hospital,Lindsay, OntarioCause of death:hangingBy what means:suicide, The verdict was received on June 13, 2022Coroner's name: Dr.Robert Reddoch(Original signed by coroner), Central East Correctional Centre (CECC) Health Care Review. An inquest is not a trial and does not assign blame or liability. Advise all workers that they should report health and safety concerns to their health and safety representative, joint health and safety committee, to Fermars Health and Safety Department, or directly to the. Coverage of cellular networks, particularly in remote and rural regions. Held at:TorontoFrom: September 6To: September 9, 2022By: Dr. Mary Beth Bourne, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Jacob GordonDate and time of death: November 24th, 2015 at 10:23 a.m.Place of death:Mackenzie Richmond Hill Hospital, 10 Trench Street, Richmond HillCause of death:electrocutionBy what means:accident, The verdict was received on September 9, 2022Presiding officer's name: Dr. Mary Beth Bourne(Original signed by presiding officer), Surname: MahoneyGiven name(s): MatthewAge:33. risk assessment training with the most up-to-date research on tools and risk factors. Require employers to develop and implement cyanide awareness training that meets requirements set out in the Regulation for the content of such training and frequency of refresher training. Coroners' appointments . Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Inquest to conclude. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. The ministry should ensure that healthcare and correctional staff at correctional facilities receive additional training about building rapport and resolving challenging encounters with persons in custody. The circumstances in which judges can lead inquests and details of notable inquests overseen by a judge. In consultation with residential homes and child and youth mental health facilities like Lynwood, develop a common joint responsibility protocol governing the process, roles and responsibilities when it comes to searching for youth who have left congregate settings without permission. Coroner's Duties The office of coroner became constitutional with statehood in 1818. Why was the coroner's inquest suspended despite it was open for public and the Russian Investigative Committee was duly represented there? Clarify the definition of accident in sections 52 and 53 of the, Consider studying the effectiveness of Albertas. Ensure that health care transfer summaries are completed in compliance with provincial policies when inmates are transferred between institutions. 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 the capability of the information management systems to accurately capture the number of calls for service which are initially reported and dispatched as another type of call but are later assessed by the responding officers to be a call which has a significant person in crisis component. Prioritize developing and implementing a long-term plan to establish adequate housing for male/female inmates. 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. Coroner's inquests are held in cases of sudden, unexplained or suspicious deaths. 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. In addition, the panel will identify priorities for funding from existing resources to support Indigenous welfare programs and First Nation communities. Seek and allocate adequate funding and resources to implement the above recommendations. Strike a sub-committee of industry partners to review hazards presented by the formation of ice on excavation walls and develop best practices for eliminating or mitigating those risks. If not already provided, the ministry should explore the availability of substance abuse treatment programs for all Ontario detention centres such as Narcotics Anonymous, and if not available, explore alternatives to that. Any requests to obtain and use video or other recordings from the inquest shall be made to the Office of the Chief Coroner for their consideration. To the extent that this training is not already provided, that educational institutions such as colleges and universities provide training for first responders on the history of colonization; residential schools; trauma informed approaches; anti-Indigenous racism; cultural safety, and unconscious bias. Identify all ongoing construction projects involving Claridge Homes group of companies in Ontario and conduct proactive inspections of those sites. The Coroner may also hold an Inquest if the death was due to natural causes and is considered by the Coroner to be in the public interest. This should incorporate recognition of the historical and ongoing traumas faced by Indigenous communities and adequate cultural competency to provide care/services in a manner that recognizes these traumas. 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. In partnership and in consultation with bands and First Nation communities, and affiliated Indigenous stakeholders, provide direct, sustainable, equitable, and adequate funding accessible to childrens aid societies and residential service providers to access Indigenous-led cultural services, culturally restorative practices, cultural competency, and educational supports and other cultural supports within the child welfare system. The Ontario Provincial Police (OPP) should: The Ministry of the Solicitor General should: Surname:EkambaGiven name(s):Marc DizaAge:22. This should include the provision of adequate space within, The ministry should conduct a review of the barriers to accessing, The ministry should conduct a needs assessment to determine whether patients at. The ministry should ensure that Naloxone spray devices deployed in areas accessible to people in custody are positioned in a manner that correctional staff on security rounds may determine that a device has been used or removed. Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. And people detained in hospital under the Mental Health Act. internal audits by a health care manager or designate, external audits by the Corporate Health Care Unit, Ensure that the planned Electronic Medical Record (, be available to all health care staff at the point of care, ensure that health care professionals who provide care remotely have complete access to inmates health care files, include methods of communicating health care orders electronically, Ensure that psychiatrists who provide services at the. State detention includes people in immigration detention centres. Hazard alerts should be distributed in a timely manner after a health and safety concern is made evident. Tailboard meetings/forms must be completed. 'Short form' verdicts such as accident or misadventure; natural causes; suicide; and homicide make up the majority of all verdict conclusions. Coroner's verdict in inquest into . In order to promote, protect, and prioritize worker health and safety, road-resurfacing contracts should be reviewed with attention to how time limits on construction work and limits on allowable lane closures are established. This decision is made by the Coroner. Ensure that Probation Services reviews and, if necessary, develops standardized protocols and policies for probation officers with respect to intake of. That the Community Inclusion Coordinator be part of the process for reviewing relevant. A coroner's inquest . The OCC use the findings to generate recommendations to help improve public safety and prevent future deaths in similar circumstances. The purpose of an inquest is to establish who the deceased person was, and when, where and how they died. To support ongoing consultation, communication, and transparency between the Society and the bands and First Nations communities of the children and youth it serves, the Society shall reach out to those bands and First Nation communities and offer to develop a communication protocol and offer to initiate quarterly reviews regarding all children receiving services from the Society. Clarify and enhance the use of high-risk committees by: Strengthening provincial guidelines by identifying high-risk cases that should be referred to committee. When operationally feasible, the ministry should run the scenario-based. Review, in consultation with stakeholders, the discretionary nature of inquests into the deaths of children in care and consider advocating for legislative change requiring said deaths to be the subject of mandatory inquests. Consideration should be given to disseminating information through alternative methods where cellular service is not consistently available. Coroner Current inquests Media and other observers Inquest hearings are held in public and members of the public, including the media, are welcome to attend Court in person to observe. Verdicts into the deaths of six people and the Coroner's recommendations. In addition to posting hazard alerts on the ministrys website, develop and implement a system of communication to distribute hazard alerts so that they are sent directly to constructors and employers. Develop workable practices to improve contact and connection of individual young people with safe adults in their circle of care, to reduce circumstances where children are absent and their whereabouts are unknown. Chief Prevention Officer to track effectiveness of the Working at Heights training program through regular evaluations and public-facing reporting to demonstrate the relationship between the Working at Heights training program and falls from heights data generated through the Prevention Division. The ministry shall support the National Inquiry into Missing and Murdered Indigenous Women and Girls' Call to Justice 14.6 as it applies to provincial corrections services. Review the process for obtaining inmates medical history from their next of kin when inmates are identified as potentially suicidal or violent. Consider the viability of a requirement for dump trucks to be equipped with back-up cameras that provide 360 degree visibility. Older verdicts and recommendations, and responses to recommendations are available by request by: e-mail: occ.inquiries@ontario.ca. The ministry should ensure that people in custody receive training concerning the use of Naloxone within a custodial setting, including the need to engage an emergency medical response following its use. Recognize that the best practice is to consider Indigenous Dispute Resolution by connecting with the First Nation regarding any challenges faced by a First Nations young person and/or family. The ministry should amend its policies and practices for admissions officer/. It also ruled Don Mamakwa's death in 2014 had an . The role of the coroner is to investigate sudden deaths that have been reported to them, and to hold inquests where appropriate. mechanical devices, such as a pin, that can be inserted into a boom or crane to prevent movement into the prohibited zone. Include in those best practices training requirements or other criteria for achieving competency regarding the assessment of ice on excavation walls as a hazard. Coroners are independent judicial officers who investigate deaths reported to them. To support and promote cultural safety for First Nations children and young people, the, To address the mental health needs of children and young people, the. When designing new correctional facilities, the ministry shall: minimize the construction of indirect supervision units, consider needs-based housing for women and woman-identifying mental health clients. Prioritizing the development of cross-agency and cross-system collaborative services. The ministry should ensure that all staff be trained regarding crisis and incident response and management. 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.