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. Consult with the Ontario Anti-Racism Directorate to analyze race-based data collected by police services to measure and evaluate police service performance on use of force, take corrective action to address systemic discrimination and provide clear and transparent information to the public on bias and discriminatory use of force. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Safety by Design refers to the concept of incorporating worker safety into the design and planning of large construction projects. The coroner has a degree of discretion to call a jury in any case that is in the public interest, but a jury must be called if the death occurred in prison; in police custody; by accident, poisoning or any disease that requires other government departments to be notified; or when circumstances exist that might affect the health and safety of the That the use of medically fragile flags be considered for the. We recommend that where a construction project involves work in proximity to overhead power lines and equipment that has the potential to contact overhead power lines such as a boom or a crane is being operated, the. Include in those best practices training requirements or other criteria for achieving competency regarding the assessment of ice on excavation walls as a hazard. Review the mandate of Probation Services to prioritize: Require that probation officers, in a timely manner, ensure: There is an up-to-date risk assessment in the file. Employers shall ensure that workers are trained on the cell phone policy. 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. In partnership and in consultation with First Nations, provide direct, sustainable, equitable, and adequate funding to First Nations for prevention services, cultural services, and Band Representative Services to service and support both on- and off-reserve First Nations children, youth and families involved in child welfare and in support of children and youth in need of mental health supports pursuant to a needs-based approach that meets substantive equality. 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. mechanical devices, such as a pin, that can be inserted into a boom or crane to prevent movement into the prohibited zone. The coroner Sir John Goldring said he would accept a. 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). The ministry should explore safer alternatives to wooden pencils being provided to Inmates. This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities. Health and safety representatives are selected in a manner that ensures independence. A coroner's inquest . 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. . That officers and jailers continue to be trained on an ongoing basis to seek out and record answers from the arrested person about their medical condition. 4:33 p.m. - April 28, 2022. Provide Indigenous-led cultural competency and cultural safety training to all officers. Continue to train staff to identify and address suicidal ideations and risk factors (acute and chronic) associated with suicide. Held at: TorontoFrom:July 25To: July 27, 2022By:Bonnie Goldberg,Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Ricardo SoaresDate and time of death: November 17, 2017 at 2:37 p.m.Place of death:Ford Drive near Kingsway Drive, OakvilleCause of death:blunt force injuries to the head, chest and abdomenBy what means:accident, The verdict was received on July 18, 2022Presiding officer's name:Bonnie Goldberg(Original signed by presiding officer), Surname: WettlauferGiven name(s): Alexander PeterAge: 21. The ministry should engage with Indigenous communities, organizations and health care providers in the development of corporate strategies, such as the Correctional Health Care Strategy and the Mental Health and Addictions Strategy for Corrections. The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody. Evidence relating to the Five Incidents . Establish the frequency of review, for currency, accuracy, and protectiveness, of cyanide-related procedures. Ensure that security patrols are completed during shift changeovers. Regular refresher training on mental health issues should be provided to all police officers who interact with the public. Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. This includes education of workers, availability and maintenance of rescue equipment (. The ministry shall update policy so that phone calls by persons in custody are not referred to as a privilege. 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. [1] The ministry should ensure and enforce through training that all correctional staff ensure that any important information, including historical information, is entered into. Date inquest concluded. An inquest is a judicial process and a Coroner's Court is a court of law. 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. Misadventure is where someone doing something lawful unintentionally kills another. Increase sustainable and equitable funding for community-based childrens mental health services, including residential placement options and family support, that are responsive to recruitment and retention needs of service providers to employ multidisciplinary staff and professionals and programs that are flexible, responsive, and facilitate the right services at the right time for children and young people with complex needs. 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. Review the current Use of Force Model (2004) and related regulations, and consider de-emphasizing use of the term "force" and employing alternative terminology. Coroner Services is an independent and publicly accountable investigation of death agency. The dangers of working in proximity to overhead powerlines, even when no work on overhead power lines is intended. Possibilities should include, but not be limited to factors such as toxic exposure through skin or inhalation. Acknowledgement of i) and ii) by the competent assistant. And people detained in hospital under the Mental Health Act. Even in countries where the jury system is strong, the coroner's jury, which originated in medieval England, is a disappearing form. 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 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. 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. Continue working with the Ministry's partners to provide public awareness campaigns and educational materials relating to: Highlighting the dangers and risks associated with working in high temperatures, How workers should prepare themselves to safely work in high temperatures. Names of the deceased: Blumberg, Alexsey; Bondarevs, Aleksandrs; Fayzullo, Fazilov; Korostin, VladimirHeld at:remote inquestFrom:January 31To: February 4, 2022By:Dr.John Carlisle, coroner for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:BlumbergGiven name(s):AlexseyAge:38, Date and time of death: December 24, 2009 at 4:30 p.m.Place of death: 2757 Kipling Avenue, TorontoCause of death:multiple injuries due to a fall from a suspended work platformBy what means: accident, Surname:BondarevsGiven name(s):AlexsandrsAge:24, Surname:FazilovGiven name(s):FayzulloAge:31, Surname:KorostinGiven name(s):VladimirAge:40, The verdict was received on February 4, 2022Coroner's name: Dr. John Carlisle(Original signed by coroner). Ensure that adequate staffing is provided at each institution to implement recovery plans. There are no 'parties' and the Coroner does not make . Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. Implement more rigorous and thorough assessment of potential and current employees. In partnership with the urban Indigenous community, continue active membership on the Indigenous Child Welfare Collaboration Committee established in January 2018 to strengthen relationships, develop pathways and strategies for a coordinated approach to services and wraparound support for First Nations Inuit and Mtis children and families involved in child welfare services in Hamilton. Inform staff of the LivingWorks Start online training on suicide prevention and provide them with information to register. Probation conditions are appropriate for the level of risk of the client and written in a way they can enforce, and, if not, request a variation. In December a coroner . 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. The ministry should provide education opportunities to persons in custody on the following topics: illicit opioid/other drugs available/in circulation, mental and physical health risks of using illicit opioid/other drugs, safe drug-use practices, including never to inject, smoke or ingest drugs alone, the risks of mixing illicit opioid/other drugs with prescription drugs. Tel: 1-877-991-9959. The audit should be independent and should result in an action plan that must be submitted to the. Educate any worker who is to work for or on behalf of Green Star at a construction site where a skid steer is in use (including those who operate skid steers) regarding the risks and dangers associated with working on or near a skid steer and ensure that they are familiar with the aforementioned safety plan. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services. Inquest to conclude. 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 implementation plan should be made public in order to ensure accountability. 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. Mandatory skid steer operation certification and re-certification process. The ministry should ensure that each institution: develops Indigenous specific programming which reflect the local Indigenous communities and agencies surrounding the institution; provides Indigenous persons in custody with access to Indigenous healing practices including Knowledge Keepers and Elders. The inquest would be held in the district where the death occurred. Background: Annually, there are around 30,000 coroner's inquests held in England and Wales that conclude with a verdict. Improve mental health awareness of housing support personnel, and in particular, concerning the recognition of mental health crisis. The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. There are no fees attached to this service. how to prevent heat stress and other heat related illnesses that may arise from working in high temperature conditions, and. (Note: this is included in both mining industry and Ministry of Labour section). 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. Indigenous people must be able to access spiritual rights as well as programs with regularity and without unreasonable delay. 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 Ensure that all health care staff are trained in suicide prevention policies and documentation. Consideration for the needs of rural and geographically remote survivors of. 05/09/2022. provide mandatory standardized training bi-annually on de-escalation strategies and empathy for community mental health-related situations. The ministry should engage in community consultation on the development of Indigenous core programing with Indigenous leadership including First Nation, Metis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres. 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. These reviews should analyze relevant health care files and assess quality of care. This training should also include periodic or ongoing refresher training. If there is no individual evaluation component, the ministry should consider implementing one. A physician and/or nurse practitioner should be available to provide in-person health care services on weekends at the, Addictions counselors, discharge planners and social workers should be available to provide in-person services on weekends at the. It is recommended that the Chief Prevention Officer of the. Prepare an emergency response plan to use if a worker does come into contact with a hazard. Prohibiting the use of skid steers in reverse unless it is operationally necessary. Require cyanide distribution lines be painted purple for identification and dye be added to cyanide solutions during mixing to make it red/purple in colour. Revise the provincial Use of Force Model (2004) as soon as possible. Please note inquests can be changed at the last minute, please check before attending. The ministry should explore digital form tools that would ensure all required fields are completed. Implement the Spirit Bear Plan through collaboration with. 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. Storage rules and protocols for tracking data. responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth. How employers should prepare their workers and their job sites to ensure safe working conditions during periods of high temperatures. A coroner's inquest is a public court hearing where the coroner determines about how, when and where someone died following a post-mortem. Clarify the definition of accident in sections 52 and 53 of the, Consider studying the effectiveness of Albertas. Coverage of cellular networks, particularly in remote and rural regions. The plan should include adequate staffing and infrastructure to avoid triple bunking and to accommodate intermittent inmates and inmates in need of specialized care or stabilization. Health and safety representatives are selected in a manner that ensures independence. The death of Daniel Robert NELSON was drug related. Work with Indigenous communities to support the creation of residential treatment options that are Indigenous-run and Indigenous-informed with Indigenous-specific programming. Hearings. As inquest concludes seven years after incident, coroner says pilot should have abandoned a manoeuvre he was undertaking Caroline Davies and agency Tue 20 Dec 2022 11.47 EST Last modified on Wed . 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. Strengthen annual education for Crowns regarding applications for Dangerous and Long-term Offender designations in high-risk, Commission a comprehensive, independent, and evidence-based review of the mandatory charging framework employed in Ontario, with a view to assessing its effect on, Review and amend, where appropriate, standard language templates for bail and probation conditions in, plan for removal or surrender of firearms and the Possession and Acquisition License (, possibility of a "firearm free home" condition, past disregard for conditions as a risk factor, When evaluating the suitability of a prospective surety in. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. In the case of high risk and dangerous subjects, consider the application of Situation Mission Execution Administration Command & Communication (, Where there is an existing threat assessment on file, provide contact information so that. The ministry should ensure cooperation between. 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. Compensation should include: cost of medicines or supplies required to facilitate service. A British coroner will hear about the final hours of Amy Winehouse's life at the inquest into the soul diva's death. 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. The study would, in part, inquire into the following: The process to identify relevant findings and for sharing those findings with other justice participants. It would also provide a primary point of communication for emergency response and medical personnel. Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented. Explore and research the availability and efficacy of additional less-lethal use of force options for officers. Tailboard meetings/forms must be completed. Increasing program availability and develop flexible options for, Recognize the specialized knowledge and expertise of, Address barriers and create opportunities and pathways to services for, Improve the coordination of services addressing substance use, mental health, child protection, and, As new services are funded, include aims and outcomes associated with building an underlying network of specialized services to address, Endeavour to minimize destabilizing factors for perpetrators of, Investigate and develop a common framework for risk assessment in. Crowns should actively oppose variation requests to have firearms returned for any purpose, such as hunting. Inquests are held at HM Coroner's Court in Woking. Explore the possibility of developing and including crisis intervention training as part of the mandatory curriculum for police recruits at the Ontario Police College and the requirement that all officers re-qualify at a determined interval. The ministry should investigate how security is assessed concerning spiritual elders, knowledge keepers, and traditional teachers. Such a program should: operate only upon the consent of each individual participant, be managed in partnership between a sobering centre, managed alcohol facility and community care teams, include a system by which first responders can contact case managers/care team members to: inform them that an individual in their care has been in contact with first responders (emergency medical services (, In recognition of the seriousness of alcohol/substance use disorder (. You can also access verdicts and recommendations using Westlaw Canada. Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors. Ensure that any arrest planning course delivered by the, Develop a mandatory training course for sergeants delivered by the, Provide dedicated mandatory mental health training as part of the annual block training delivered to officers through the, Ensure, where there are no legal impediments to doing so, that debriefs are held for involved officers after every major arrest, event, or unique policing scenario to gain insight on lessons learned, and that such lessons are shared with other. In any new detention centre builds, consideration should be given in the design to allow for timely access for emergency personnel. 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. 42. The Toronto Police Service should continue to build a diverse. 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 ministry should consider changing the reporting structure for healthcare to ensure that the health care manager at the institutional level reports directly to Corporate Health Care. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current andprevious year. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. Blackburn. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards. Appropriate perpetrator programs and supports needed to accompany electronic monitoring. As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights. Held at: Toronto, virtuallyFrom: August 22To: August 26, 2022By: Dr. Bonnie Goldberg, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Alexander PeterWettlauferDate and time of death: March 14, 2016 at 1:21 a.m.Place of death:Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, TorontoCause of death:gunshot wounds to chestBy what means:undetermined, The verdict was received on August 26, 2022Presiding officer's name: Dr. Bonnie Goldberg(Original signed by presiding officer), Surname: PigeauGiven name(s): RichardAge:54. Conclusion. Programs are funded at a level that anticipates an increased stream of referrals. The following failures on behalf of the hospital charged with his mental health care contributed to his death: (1) As a result of inadequate attempts to obtain a full medical . 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. 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. Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders. 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. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. The Coroner investigates deaths in order to establish who . Understanding any impacts after an order for such technology expires. Such programs should include: violence prevention, recognizing healthy and abusive relationships, identifying subtle indicators of coercive control, understanding risk factors (such as stalking, fear caused by, Ensure teachers are trained to deliver the, Develop a roster of resources available to support classroom teachers in the delivery of primary, secondary, and post-secondary programming where local.