The ministry should explore safer alternatives to wooden pencils being provided to Inmates. The ministry should take steps to actively promote awareness of information, services and programs available to persons in custody regarding opioid/other substance use. 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. However, the Coroner may decide to hold an inquest to establish the facts. 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. The Toronto Police Service should improve delivery of relevant information to the inner perimeter where crisis negotiations are taking place without unduly disrupting the negotiation process. Coroners are independent judicial officers who investigate deaths reported to them. Police services and police services boards shall consult with third-parties, including individuals from the Black community, Black advocacy community organizations, persons with lived experiences from peer-run organizations, and appropriate content experts, and: develop an objective methodology to measure and evaluate police service performance on use of force, take corrective action to address systemic discrimination, provide clear and transparent information to the public on biased and discriminatory use of force. Regular meetings between mine emergency response team and. That the sobering center meet the criteria for the designation of an alternate level of care by the Ministry of Health to permit paramedics to transport patients to the sobering center rather than an emergency room. It is most commonly used when none of the other verdicts are appropriate. Explore digitized records of over a century of coroner's records from Stark County, Ohio, available online . The ministry should conduct regular reviews to ensure its complement of nurses is sufficient to allow thorough assessments of each Inmate. The ministry should retrofit all units within. Encourage review and participation in all best practices regarding cyanide safety put forth in the international Cyanide Management Code. That the services collaborate to discuss the practice of wave offs, and develop policies and training for first responders, on how a wave off should not occur. This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities. The ministry shall consult with the federal government and other provinces and territories to determine if there is bedding that is less susceptible to tearing for use by persons in custody not on suicide watch. Coroner's Officer. 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. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. The ministry shall ensure that wherever a serious mental illness is suspected or identified through mental health screening, that the person in custody will not be placed in conditions of segregation. Coroners will look to establish the medical cause of death. Continue to train staff to identify and address suicidal ideations and risk factors (acute and chronic) associated with suicide. Institute a policy to mandate regular debriefs with officers involved with incidents that engage the Special Investigations Unit to ensure that supports are in place and the incident to be used as a learning tool so that future incidents can be prevented. The provision of therapeutic care. Presiding Coroner: Witness List: Livestream Instructions: Note or copy the passcode BEFORE clicking on the Livestream Link Click on the link above When prompted, enter passcode, your name and email address You will automatically be connected when the Inquest is in session 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. Reconvene one year following the verdict to discuss the progress in implementing these recommendations. Develop and implement a new approach to public education campaigns to promote awareness about, Complete a yearly annual review of public attitudes through public opinion research, and revise and strengthen public education material based on these reviews, feedback from communities and experts, international best practices, and recommendations from the Domestic Violence Death Review Committee (, Use and build on existing age-appropriate education programs for primary and secondary schools, and universities and colleges. A list of the inquests scheduled for hearing in the Oxford Coroner's Court. That the Thunder Bay Police Service Board retain an expert consultant for the purposes of providing an independent assessment of the level of staffing required of the Thunder Bay Police Service. This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools. 42. Measures to improve public awareness should be developed in consultation with content experts and community organizations that represent persons with lived experience. 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. 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. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. And people detained in hospital under the Mental Health Act. We recommend that locates in the vicinity of power lines should include underground, on grade, and above grade utilities or hazards, as well as current, voltage and distance from grade to the high-power line. That the use of paper green sheets be discontinued, that the booking process and prisoner management systems be digitized, and that documentation used for charges in court be separated from the documentation used to manage and care for individuals in custody. That sufficient staff be hired and maintained to allow for constant visual monitoring of the living units and to adequately and immediately intervene in any circumstances of drugs or other contraband being found. risk assessment training with the most up-to-date research on tools and risk factors. The ministry should develop training for correctional officers on strategies to work constructively with Indigenous men in custody, similar to the Biidaaban Kwewok and Biidaaban Niniwok Beginnings for Indigenous Women and Men training. It is essential that services provided by all institutions listed below be reflective of Indigenous cultural needs. provide mandatory standardized training bi-annually on de-escalation strategies and empathy for community mental health-related situations. 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. The Toronto Police Service should review research and studies in regard to use of non-lethal tools to incapacitate a subject in possession of a firearm. Research and, if appropriate, develop and integrate additional flags into the records management systems that accurately identify an active, serious threat to officers and the public, including behavioural and mental health flags, and a numerical measurement of risk. Provide training to workers on the signs and symptoms of heat stress and heat stroke, how to prevent heat-related illness and first aid steps to be taken should a worker believe they or their co-worker are showing signs of such illness. Inquest to conclude. 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. 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. Programs and other initiatives to address drug addiction and abuse should be encouraged, prioritized and promoted in prominent places throughout the facility where they are likely to come to the attention of persons in custody. Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. Be publicized to enhance public awareness, and become better known among policing partners possibly through All Chiefs bulletins. 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. As you say modern Coroners' inquests records can be found amongst departmental files at The National Archives including most investigations into air accidents which are open after 30 or so years, however some like the inquest into the 1974 bombing at the Tower of London (MEPO 26/252, which include a transcript of coroner's inquest and statements) is closed for 84 years and others like the . Please note inquests can be changed at the last minute, please check before attending. Coroners' appointments . whether the missing person is an Indigenous youth. Identify all ongoing construction projects involving Claridge Homes group of companies in Ontario and conduct proactive inspections of those sites. A coroner's inquest . Set up satellite offices for police officers to work safely and comfortably to spread police resources more evenly over wide rural areas (, Encourage Crowns to consult with the Regional Designated High-Risk Offender Crown for any case of. Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. Implement recommendation #20 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Work in consultation with residential homes and child and youth mental health facilities like Lynwood to develop a living document for each youth in its care that can be readily shared with police if necessary, in the event that the youth is absent from the residence without permission and a missing persons report is being filed, and in accordance with the requirements under Part X of the. . The ministry should explore the benefits and detriments of periodic re-screening for suicidal risk or mental health concerns akin to the admissions screenings to see if an inmates status has changed while in custody. The ministry should develop guidance to determine criteria by which. Held at:virtual inquestFrom: September 26To: October 7, 2022By: Murray Segal, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Victor OgundipeDate and time of death: January 26, 2017,10:14 p.m.Place of death:36 Queen Street East, TorontoCause of death:a) Hemoperitoneum, due to b) rupture of liver, due to c) blunt force injury to abdomen.By what means:accident, The verdict was received on October 7, 2022Presiding officer's name:Murray Segal(Original signed by presiding officer), Surname:FreemanGiven name(s):Devon Russell James (Muskaabo)Age:16. It should have no impact on Ontario Works or Ontario Disability Support Plan payments. 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. The ministry should explore the use of a scoring metric to determine risk in areas such as mental health and violence, assessed first at Intake and re-evaluated on a continuous basis. 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. The coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . The ministry should conduct an Indigenous led study that consults with Indigenous community organizations and Indigenous healthcare providers to obtain information regarding Indigenous cultural and spiritual healing practices and use of Indigenous traditions known to assist in prevention of substance use, wellness and a means to address addictions in a culturally sound way. The Coroners' Courts Support Service (CCVS) is an independent voluntary organisation whose trained volunteers offer emotional support and practical help to bereaved families, witnesses and others. What verdicts can a coroner give? The inquest jury consists of five people selected by the coroner's constable from a list of jurors from the community. Contact Kent and Medway Coroner. 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. Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission. 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 review the suicide awareness training to ensure that it includes a robust individual evaluation component for comprehension of the course materials. The difference can be explained as accident reflecting death following an event over which there is no human control where as misadventure is an intended act but with unintended consequence. The ministry shall update policy so that phone calls by persons in custody are not referred to as a privilege. 08:52, 2 MAR 2023. Formally declare intimate partner violence as an epidemic. In determining whether an, any history of suicidal behaviours (ideations or attempts), whether the person is in an out-of-home placement at a mental health facility for children and youth. 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. Conclusions (verdicts) At the end of the Inquest, the Coroner can give the following Conclusions about the death: Natural causes Accident or misadventure Suicide The dangers of working in proximity to overhead powerlines, even when no work on overhead power lines is intended. Ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the. Just before 4.30pm on the 94th day of the inquest, the jury forewoman told the coroner Lord. Legal Framework . Mandatory use of a signaller when operating a skid steer. 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. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services. 2.30pm Andrew Phillips, aged 56, from Altrincham, died 31/05/22 in JRH. The hazard alert should identify cyanide, in all of its forms, as a potential workplace hazards. 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. Fund for safe rooms to be installed in survivors homes in high-risk cases. 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. 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. An inquest is not a trial and does not assign blame or liability. Being accessible by clients voluntarily and via referral,and not just through the criminal justice system. The inquest will then be adjourned to be resumed at a later date. A British coroner will hear about the final hours of Amy Winehouse's life at the inquest into the soul diva's death. Expedite the processing, and provision of support (if warranted), to front-life provincial corrections staff claims when they are involved in inmate suicides. 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. The ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive awareness training regarding the causes and nature of substance use disorder to address stigma surrounding addiction. 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. Review existing training for justice system personnel who are within the purview of the provincial government or police services. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. Explore developing and providing all police recruits with additional de-escalation training. Consider renaming the Model to better reflect the range of tools and techniques available to officers. 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. 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) Reinforce the policy requirement for a Part C health care summary to be completed in every patients health care record. It simply aims to gather information in order to answer these questions. The ministry should ensure cooperation between. The availability and use of weapons prohibition orders in. Fund a full range of Indigenous-led mental health services and facilities in the Hamilton region and other regions in Ontario to meet the need for culturally safe and restorative mental health and healing services for Indigenous children, youth and families. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. Continue ongoing quality assessments to drive continuous improvement of standard operating procedures and protocols, documentation, and best practices with mental health services: to review and audit core services within Windsor Regional Hospital annually to ensure compliance to standards are met and keeping pace with community demands proactively. The revisions should require correctional institutions to ensure that: one or more staff member is designated to develop a recovery plan when an inmate is removed from suicide watch, one or more staff member is designated to oversee the plan and ensure it is implemented, placement of inmates in recovery is reviewed with health care staff and this review is documented, The recovery plan is available for health care and operational staff. Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a pilot project. Older verdicts and recommendations, and responses to recommendations are available by request by: You can also access verdicts and recommendations usingWestlaw Canada. On the second day of an inquest at Dublin District Coroner's Court today, counsel for Mr Sweeney's family, Roger Murray SC, said the net effect of the patient being discharged from the high . It is recommended that training related to the management of change process take place on a regular basis (annual as a minimum) to ensure that all employees are continually informed as to what requires the initiation of the management of change process. Risk assessments and risks of lethality are taken into account when making enforcement decisions. The ministry should consult with and receive expert advice on remedies to improve living conditions and healthcare delivery and implement any potential life saving strategies on an urgent basis. Refresher training should be delivered annually. 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 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. This would both provide a warning and a specific ongoing reminder to any person entering such areas. Ensure that police officers can accurately identify their own, Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (. The ministry should review and if necessary consider enhancing the mechanisms for ensuring that all staff receive their suicide awareness training in accordance with the timelines set out in policy. Efforts to improve public awareness of these options should be developed in consultation with content experts and community organizations that represent persons with lived experience. 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. Inclusion of and consultation with Indigenous communities/agencies is essential. TT sidecar driver had passenger's dog tag - inquest. Police services and police services boards shall establish standing or advisory committees on race and impartial policing and on mental health in order to meet with representatives of peer-run organizations and members of affected communities on an ongoing basis to discuss concerns and facilitate solutions. The ministry should explore digital form tools that would ensure all required fields are completed. SUMMARY OF CORONER'S VERDICTS AND FINDINGS (KEEGAN J) I. 12/09/2022. Try to find out: the date the. Conduct a comprehensive, third-party audit of its health and safety system. Derbyshire Police. Foster and support the co-development of life promotion programs such as Promote Life Together between Indigenous and non-Indigenous stakeholders to establish and develop meaningful programs and services, with an emphasis on the inclusion and engagement of Indigenous stakeholders from inception. This would both provide a warning and a specific ongoing reminder to any person entering such areas. Ensure that adequate staffing is provided at each institution to implement recovery plans. Require emergency response personnel in plants using cyanide to be provided with basic first aid/. The ministry should position equipment necessary for an emergency medical response close to living units. Blackburn. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards. A health care manager and/or physician should be notified when an inmate brings a suspected opioid or prescription medication into the institution or when an inmate appears to be intoxicated while in custody. Improved supervision of high-risk perpetrators released on probation, including informed decision-making when applying or seeking to modify conditions that impact the survivors needs and safety. Within 6 months of the jurys verdict, strike a task force to review, report on, and initiate changes to: funding, accountabilities, and timely access to care for all community-based mental health services that receive funding from the Government of Ontario, available resources and supports for family members and/or caregivers of patients and community services receiving mental health services, how family members and/or caregivers and community services can provide support and/or information about patients when patient consent is not provided, address what information can be shared from family members and other stakeholders, align services and community agencies to better share information about individuals with mental health concerns in the community, Establish further study and review of the criteria and training associated with the, mandatory refresher training for emergency room physicians and psychiatrists in the province of Ontario on when and how to use the Form 1 options associated with mental health, the assessment of Box A and Box B criteria for psychiatric evaluation and involuntary detention, to determine how best to ensure collateral information from family members and relevant community services information can be included as part of the process for determining appropriate treatment options.