Held at: WindsorFrom:June 20To: June 30, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Delilah SophiaBlairDate and time of death: May 21, 2017 at 8:58 p.m.Place of death:Windsor Regional Hospital Ouellette CampusCause of death:hangingBy what means:suicide, The verdict was received on June 30, 2022Coroner's name:Dr.David Eden(Original signed by coroner), The term SWDC/ministry means SWDC and the ministry, Surname:FerranteGiven name(s):FrankAge:44. Held at:North BayFrom: November 21To: November 24, 2022By:Dr.S.C. Bodleyhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Gordon Dale CouvretteDate and time of death: February 22nd 2018 06:21Place of death:North Bay Regional Health Centre, 50 College Dr, North Bay, Ontario, P1B54ACause of death:Sudden death with no anatomical cause associated with acute-on-chronic cocaine and amphetamine abuse/intoxication, forcible struggle and possible Autonomic Hyperactivity SyndromeBy what means:accident, The verdict was received on November 24, 2022Presiding officer's name:Dr.S.C. Bodley(Original signed by presiding officer), Surname: Blackett,Given name(s):CraigAge:41. 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. Include in those best practices training requirements or other criteria for achieving competency regarding the assessment of ice on excavation walls as a hazard. The data should include age, gender, perceived race, and officer perception of whether the individual has any mental health issues; The results of the data collected on use of force incidents must be taught to all frontline police officers. The action plan should be completed in consultation with the. The ministry should also consider what, if any, supports or agencies that are local to the bereaved can be referred, or assist the family, in receiving the news. 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. Inject a significant one-time investment into, Realign the approach to public funding provided to. Crowns should also consider a history of, Study the best approach for permitting disclosure of information about a perpetrators history of, Explore the implementation of electronic monitoring to enable the tracking of those charged or found guilty of an. When a worker experiences a medical issue in the workplace, the possibility that the medical event is due to a workplace hazard should always be considered. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. This will require consultation with and inclusion of a diverse group of Indigenous communities/agencies, in recognition of the fact that Indigenous cultures/traditions/ways of being are not monolithic and that Thunder Bay is home to Indigenous peoples from across the North who possess a spectrum of cultural values/languages/ways of being. 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. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. The Regulation would require that, in such circumstances: impermeable personal protective equipment to be used and there be a process for verifying or confirming the use of the required personal protective equipment before work is performed in the area, the flushing of cyanide-containing material from lines, titrations to ensure cyanide content in any debris or materials in the area is below a set threshold (, lock out and tag out procedures are to be developed and implemented, workers required or assigned to work in the area have received cyanide awareness training and proper removal of. 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. 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. 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. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. An an inquest is purely a fact-finding hearing; nobody is on trial. Consideration of the remoteness quotient used to calculate funding in other social services, such as education and policing. The ministry should ensure that Indigenous Liaison Officer (, The ministry should create policy and direction that recognizes the role and function of, Spiritual Elders, knowledge keepers and helpers should be provided honoraria or some form of financial compensation for the important work they are conducting as part facilitating their access to their spiritual rights or as part of culturally relevant programing, and that the Ministry should revise both health and. 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. 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. Consider applying other ministry resources to support health care staff recruitment at the, Monitor how often inmates on suicide watch at the, Ensure that if any inmates on suicide watch at the, Provide an anonymized public report on the number of inmates on suicide watch at the. That the Ministry of Health immediately address patient flow at the Thunder Bay Regional Health Sciences Center emergency department to address police and ambulance off-load delays and code black events. Develop strategies on prescribing and dispensing medications in a manner that would assist with protecting patients from being coerced into diverting the medication to other inmates. Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. 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 Coroner can hold an inquest even if the death happened abroad. Office opening hours are Monday to Thursday, 8am to 4pm, and . 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 Section 9: Giving Evidence As a witness you are not on trial, you are there to assist the court The Coroner decides which witnesses should attend, and in what order they are called. Deliver training to frontline officers on the purpose of the Crime Abatement Program, the information included in Crime Abatement Program records, and how to access such records. Constructors, employers and supervisors shall ensure that workers are not endangered by cell phone use on construction projects. Sources of Evidence and Disclosure . Establish an independent Intimate Partner Violence Commission dedicated to eradicating intimate partner violence (, Driving change towards the goal of eradicating. all health care staff will have access to, Develop an action plan to ensure that there is adequate physical space at the, Upgrade the physical infrastructure at the, Increase the physical space available for inmate programming at the. These supports should account for the social barriers to accessing such supports within a custodial environment. 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. The Chief Firearms Officer should work with appropriate decision-makers to: The Information and Privacy Commissioner of Ontario should: Surname:McKayGiven name(s):GabrielAge:36. This would include training, equipment or work processes and the continued availability of safety data sheets. Make adjustments to program curriculum and delivery methods according to gaps and opportunities identified. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. Develop further therapeutic activity programming for youth that reflects a wide variety of interests. A-Z of records. Ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the. 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. 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. Explore developing and providing all police recruits with additional de-escalation training. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing. 17 June 2022 . These solutions should be communicated to relevant staff and stakeholders in a timely manner. . Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training. 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 witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports. To the Ministry of the Solicitor General and Windsor Police Service, Surname:OgundipeGiven name(s):VictorAge:41. When the coroner's jury could not determine a cause of death, an "_" will appear in the verdict category. Court listings are held in the Avon Coroner's Court, Old Weston Road, Flax Bourton, Bristol BS48 1UL At this time Jury inquests are being held at Ashton Court Mansion House, Ashton Court Estate, Long Ashton, Bristol, BS41 9JN These listings are subject to change. Designated funding for transportation for those receiving, Funding to ensure mental health supports for. An 'investigation' is a new way a Coroner can handle a case that was introduced in reforms of the legislation in July 2013. The ministry should conduct regular reviews to ensure its complement of nurses is sufficient to allow thorough assessments of each Inmate. Show entries Revise the use of force report form to require officers to document de-escalation techniques used. 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. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care. To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. The inquest into father and son Roger and Bradley Stockton, who died in a sidecar crash June 10 2022, closed this afternoon. Inclusion of and consultation with Indigenous communities/agencies is essential. The inquest would be held in the district where the death occurred. In consultation with organizations like Hamilton Childrens Aid Society and other agencies servicing high-risk youth, develop a joint process whereby, Establish the role of an Indigenous Liaison within the. Consider engaging the private sector to assist in developing recruitment and retention strategies and provide current labour market data and analysis. Identify all ongoing construction projects involving Claridge Homes group of companies in Ontario and conduct proactive inspections of those sites. 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. These would keep Indigenous youth within their local community and connected to family, culture, and local supports. 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. Held at:25 Morton Schulman Avenue, TorontoFrom:April 4To:April 7, 2022By:Dr.Robert Boykohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Fernando SantosDate and time of death: January 23, 2018 at 3:38 p.m.Place of death:1575 Lakeshore Road West, MississaugaCause of death:blunt force trauma of the torsoBy what means:accident, The verdict was received on April 7, 2022Coroner's name:Dr.Robert Boyko(Original signed by coroner), Surname:SaidiGiven name(s):BabakAge:43. This may be done through by creating a mailing list of employers, constructors and trade unions, in the construction sector or in consultation with the Infrastructure Health and Safety Association, or such other partners as may assist with the development and implementation of the system. 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. Require all police services to immediately inform the Chief Firearms Officer (, Create a Universal RMS records management system accessible by all police services (including federal, provincial, municipal, military and First Nations) in Ontario, with appropriate read/write access to all. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. The ministry shall implement a policy requiring the inclusion of a letter describing what is contained in the return of property of an individual that has died in custody. Explore developing and providing all police officers with additional de-escalation training. 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 . Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. Coroners will look to establish the medical cause of death. 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. Tailboard meetings/forms must be completed. Ensure existing policy and guidelines require probation officers to follow through on enforcement of non-compliance by requiring delivery and documentation of clear instructions regarding expectations to supervised offenders in a way that allows for direct and progressive enforcement decisions. Improve public awareness of both policing and non-policing community-based crisis responses to mental health crisis. 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. Review existing training for justice system personnel who are within the purview of the provincial government or police services. This should be a focus for performance management and quality assurance processes. Understanding any impacts after an order for such technology expires. Specifically, they should consider the length or passage of time since a volunteer had any criminal convictions and the nature of the criminal conviction to determine criteria that would increase Indigenous volunteers participation in Indigenous programing and to provide peer resources in an effective way. In consultation with civil society child rights experts and Indigenous rights experts, undertake a Child Rights Impact Assessment with respect to all proposed regulations made under and amendments to the. The inspections should focus on assessing whether projects are organized in a manner that ensures safety of all workers. We, the jury, wish to make the following recommendations: Surname:MacDougallGiven name(s):Quinn EmmersonAge:19. Held at:TimminsFrom: December 12To: December 20, 2022By:Dr.David Eden, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Denis Stanley JosephMilletteDate and time of death: June 3, 2015Place of death:Detour Lake MineCause of death:acute cyanide intoxicationBy what means:accident, The verdict was received on December 9, 2022Presiding officer's name:Dr.David Eden(Original signed by presiding officer). This includes education of workers, availability and maintenance of rescue equipment (. 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. Promote and utilize the participation of young people and youth-driven practices in services, tools and programs, such as: the Wise Practices resources and Life Promotions toolkit by Indigenous youth, that are about their own wellness and make space for the young people to put into practice tips and ideas from those services, tools and programs. Which justice participants should have access to the findings made by a civil or family court. Develop and implement a plan to cap the length of time for fixed term employment status, and roll over into full time status (for correctional officers and nursing staff). The Board will consider yearly public reports setting out the initiatives taken by the Board, the progress of those initiatives and an expected timeline for completion of the initiatives. It should have no impact on Ontario Works or Ontario Disability Support Plan payments. Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system. 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. Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors. The number of jurors generally ranges from 6 to 20. Use or continue to utilize neutral, descriptive language to describe young people who leave their place of residence without permission. Acknowledgement of i) and ii) by the competent assistant. While recognising that inquests must be . They contact the survivor to inform her of the offenders living situation, any conditions or limitations on his movement or activities, and what she should do in the event of a possible breach by the offender. 12/09/2022. 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. Reconvene one year following the verdict to discuss the progress in implementing these recommendations. The provision of medical care including the appropriate dispensing of medications to participants in the program, in recognition that participants may face barriers in accessing medical care and carrying out treatment plans independently. This training should also include periodic or ongoing refresher training. Coroner's Officers are police officers who work under the direction of the coroner and liaise with bereaved families, the emergency services, government agencies, doctors, hospitals and funeral directors. You can also access verdicts and recommendations using Westlaw Canada. Message from HM Acting Senior Coroner for the City of Brighton & Hove Although the Government has eased most coronavirus restrictions, a number of measures will still be in place at Woodvale Coroner's Court to ensure the continued . Seek and allocate adequate funding and resources to implement these recommendations. 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. The Coroner cannot make any decisions as to civil or criminal liability, but at the end of an inquest hearing a decision will be made on where, when, and how the person has died. The 74,160 records in this database were extracted from the Cook County Coroner's Inquest Records. Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. 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. The ministry should use the Indigenous led study to create and implement a policy on using Indigenous cultural practices as solutions to combating the opioid crisis at. Inquests. That the Thunder Bay Police Service ensure that the Reconciliation training currently being undertaken by the service is not a one-time training course, but rather provided as continuous training over the course of an officers career and that the police service consult with Indigenous Nations. The. Explore digitized records of over a century of coroner's records from Stark County, Ohio, available online . For young people in care, engage with any outside service provider at the intake stage to set clear lines of responsibility regarding communication of information regarding the young person to those in the youths circle of care, including communication of self-harm attempts and leaving the property without permission. 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. Coroner's verdict in inquest into . When a community prescription for an opioid medication is discontinued or amended by a. Consider extending the recommendations 10-22 to include all municipal police forces across Ontario. Regular meetings between mine emergency response team and. A coroner's inquest . A British coroner will hear about the final hours of Amy Winehouse's life at the inquest into the soul diva's death. Ensure that security patrols are completed during shift changeovers. 08:52, 2 MAR 2023. Coverage of cellular networks, particularly in remote and rural regions. To ensure open and full communication, data collection, knowledge, and relationship-building regarding the children, youth, and families transferred to ongoing service, consider implementing a one care team per family system with consideration to the file loads of workers. Coroner's Officer. Ensure that the employer properly identifies and reviews all potential chemical hazards at the mine site including, but not limited to, the dangers of cyanide. An inquest jury examining the cases of two Oji-Cree men has released 35 recommendations after a four-week hearing in Thunder Bay, Ont. The ministry should develop guidance to determine criteria by which. The ministry should explore digital form tools that would ensure all required fields are completed. The ministry should collaborate with the London Middlesex Medical Officer of Health in developing its harm reduction strategies. 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. The ministry should ensure that correctional officers investigate cell change requests immediately, and grant same immediately, where merited. 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. Review the process for obtaining inmates medical history from their next of kin when inmates are identified as potentially suicidal or violent. Consider conducting an ice management campaign for large construction projects in Eastern Ontario. 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. That the use of medically fragile flags be considered for the. When operationally feasible, the ministry should run the scenario-based. models in other jurisdictions that identify relevant. The ministry should ensure that pending the admissions process and related mental health assessments, Inmates are placed in a temporary housing unit without a cellmate. There are many ways to contact the Government of Ontario.