Provide support for training and capacity building for childrens aid societies and licensed residential facilities to meet the consultation requirements with bands and First Nation communities under sections 72 and 73 of the. Work towards creating (including if necessary by making a request to the, developing a strategic plan; including review and potential amendments to missing persons investigations (, use of civilian support workers, civilians in duties not required for a sworn officer related to, maintenance and development of community partnerships and, in particular, the Indigenous community, partnerships with youth institutions and, in particular, child and youth mental health facilities, Review and revise the risk assessment process and policies that govern whether a missing person is classified as Level 1 or Level 2, as well as whether an urgent search is required. mechanical devices, such as a pin, that can be inserted into a boom or crane to prevent movement into the prohibited zone. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. The OCC distributes all verdicts and recommendations to organizations for them to implement, including: The OCC asks recipients to respond within six months to indicate if the recommendation(s) was implemented, and if not, the rationale for their position. Implement the Spirit Bear Plan through collaboration with. 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. Implement the National Action Plan on Gender-based Violence in a timely manner. 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. Time of death could not be determined.Place of death: Wilno, OntarioCause of death: shotgun wound of the chest and neckBy what means: homicide, Surname: WarmerdamGiven name(s): NathalieAge: 48, Date and time of death: September 22, 2015. The ministry should implement dedicated and centralized real time monitoring of cameras at. 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. Information on Coroners openings and hearings. Conduct a comprehensive, third-party audit of its health and safety system. the health care needs of the inmate population, compliance with provincial policies and professional standards, record keeping and communication of health care information, an audit of a meaningful selection of inmate health care files, interviews with health care staff to determine the causes of any deficiencies uncovered in the review. The committee should include senior members of relevant ministries central to, Require that all justice system participants who work with, Explore incorporating restorative justice and community-based approaches in dealing with appropriate. Consideration should be given to disseminating information through alternative methods where cellular service is not consistently available. 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. Be staffed 24 hours a day and 7 days a week. The ministry should investigate how security is assessed concerning spiritual elders, knowledge keepers, and traditional teachers. The inquest will then be adjourned to be resumed at a later date. 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. 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. Implement recommendation #35 from the Inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Risk assessments and risks of lethality are taken into account when making enforcement decisions. The Chief Coroner's Annual Reports cover matters that the Chief Coroner wishes to bring to the attention of the Lord Chancellor, and matters that the Lord Chancellor has asked the Chief Coroner to cover. For a young person in its program, engage with the guardian at the intake stage to set clear lines of responsibility regarding communication of information regarding the youth to those in the youths circle of care, including communication of self-harm attempts and leaving the property without permission. Consider extending the recommendations 10-22 to include all municipal police forces across Ontario. Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. What verdicts can a coroner give? The inquest heard from 278 witnesses and is estimated to have cost the taxpayer more than 6.5m. 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. The Toronto Police Service should explore the ability to use audio/visual capabilities to have short notice assistance from external professionals e.g. At the end of an inquest, the Coroner will read out a formal verdict to record: the identity of the deceased; how the death happened ; . The aim is to get all the facts about the circumstances of a death. For a free, no-obligation, initial discussion of how we may be able to help, please contact us today. The Government of Ontario should offer and arrange enhanced legal and mental health support for families of persons who die in a police encounter and ensure that those services are delivered in a timely and trauma-informed manner. Ensure that all safety plans are written down and shared with Lynwood staff, the young persons guardian, and other members of a young persons circle of care where appropriate and consistent with privacy legislation and rights. 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. Coroners will look to establish the medical cause of death. 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. 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. 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. There are many ways to contact the Government of Ontario. 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. 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. Study the feasibility of, and implement if feasible, justice sector participants having access to relevant findings made in family and civil law proceedings for use in criminal proceedings, including at bail and sentencing stages. Visual signage should be placed in the booking area and cell blocks. 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. 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). It is recommended that the Ministry of Labour, Training & Skills Development take steps to amend the. Regular meetings between mine emergency response team and. They must be treated as such, including refraining from using the term offender. Employers shall create and implement a policy on the appropriate use of cell phones and mobile devices at construction projects that includes methods for complying with 1(a) and 1(b). Health and safety representatives are selected in a manner that ensures independence. 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. The ministry should ensure that all staff be trained regarding crisis and incident response and management. Ensure that police officers responding to a mental health crisis are aware that police have responded previously to incidents involving the same parties, and facilitate access for responding officers to significant information regarding previous calls. Which justice participants should have access to the findings made by a civil or family court. Held at: Thunder BayFrom:June 13To: June 13, 2022By:Dr.Steven Bodleyhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Gabriel McKayDate and time of death:November 6, 2017 at 11:20 p.m.Place of death:St. Josephs Care Group, 35 Algoma Street North, Thunder Bay, OntarioCause of death:complications related to a severe brain injury sustained as the result of a workplace fall suffered September 14, 2016By what means:accident, The verdict was received on June 13, 2022Coroner's name:Dr.Steven Bodley(Original signed by coroner), Surname:LepageGiven name(s):RonaldAge:59. 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. 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. Provide frequent training to all workers to familiarize them with the hot weather plan/heat response plan and the dangers of working in high heat environments. Consider including a case study focused on falling ice in excavations in future inspector training material. 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. It is recommended that construction associations, including without limitation those listed at subparagraph 2.1, incorporate and promote a best practice for dump truck operators exiting haulage trucks to adhere to the following steps: position wheel chocks in appropriate locations, refrain from placing yourself between tires and/or axles, 2.1 Infrastructure Health and Safety Association. 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. Inject a significant one-time investment into, Realign the approach to public funding provided to. 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. 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. 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 The Ministry of Labour shall review and consider whether to amend. The ministry should seek funding to implement these recommendations. 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 ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody. The revised risk assessment factors, as well as search urgency factors, should be evidenced-based and clearly defined. The reviewers should work with the local health care team to identify gaps and find solutions. Clarify and enhance the use of high-risk committees by: Strengthening provincial guidelines by identifying high-risk cases that should be referred to committee. 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. Conduct scans of other jurisdictions use of emerging technologies and partnerships in the proactive reduction of workplace injuries and fatalities. Review the process for obtaining inmates medical history from their next of kin when inmates are identified as potentially suicidal or violent. This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities. 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. 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. We recommend that a public awareness campaign be developed that highlights the dangers of working in proximity to overhead power lines and provides information on how members of the public can report seemingly unsafe or non-compliant practices. 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. 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 educational opportunities should be provided upon intake and at least once a month in a group setting, and the contact information for healthcare workers should be provided to persons in custody if they would like to get more information. The ministry shall treat people in custody on remand as presumed to be innocent. Designate an employee to manage this plan, monitor the weather, ensure compliance with the plan and maintain records. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. We recommend that tailboard documents should be standardized, regulated, and include a section that addresses possible encroachment of overhead powerlines of the minimum distance permitted under Section 188 (2) of Regulation 213/91 for Construction Projects. However, the Coroner may decide to hold an inquest to establish the facts. These would keep Indigenous youth within their local community and connected to family, culture, and local supports. 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. Make adjustments to program curriculum and delivery methods according to gaps and opportunities identified. models in other jurisdictions that identify relevant. 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. Provide professional education and training for justice system personnel on. 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. In any new detention centre builds, consideration should be given in the design to allow for timely access for emergency personnel. Improve mental health awareness of housing support personnel, and in particular, concerning the recognition of mental health crisis. It is recommended that all mine and metallurgical sites where cyanide is present conduct periodic simulation exercises of cyanide exposure events as a means to promote preparedness by testing policies and plans, standard operating procedures, and personnel training. Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. 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. The appropriateness of essential services being provided by private, for-profit partners. The Office of the Chief Coroner (OCC) for Ontario provides death investigations and inquests, when necessary, to ensure that no death is overlooked, concealed or ignored. 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. The ministry should ensure and enforce thorough training that: All correctional staff read the unit notification cards of the inmates in their unit at the start of their work shift (immediately following shift change) and whenever an inmate returns to the unit from court or other external location. 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. Half day. 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. The relevant coroners office will contact you if this is the case. 17 June 2022 . All health and safety representatives are competent and aware of their duties and responsibilities. Sources of Evidence and Disclosure . 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. In recognition of the shortage of beds in detox/treatment (rehabilitation) facilities in the City of Thunder Bay, the number of beds in such programs should be increased to adequately meet the needs of the community. Name of deceased. If the examination shows death to have been a natural one, there may be no need for an inquest and the Coroner will send a form to the registrar of deaths so that the death can be registered by the relatives and a certificate of burial issued by the registrar. An inquest is not a trial and does not assign blame or liability. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. Consideration of streaming short video clips or other helpful information via the television screens on each living unit should also be given. Tailboard meetings/forms must be completed. State detention includes people in immigration detention centres. The ministry should analyze the data they collect to determine where there are gaps in service delivery of programs at particular institutions. The ministry should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. The Coroner's officer will usually inform interested parties to the Inquest who is to give evidence at the hearing. Recommend training programs be reviewed on an ongoing basis to maximize employees comprehension of content. 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. . . Inform staff of the LivingWorks Start online training on suicide prevention and provide them with information to register. Unfortunately, we cannot provide any additional information other than what is on the Court List. Re-evaluate the capacity of Community Outreach and Support and Mobile Crisis Rapid Response teams to meet the growing need for these services in the Region of Peel. Review whether one on one supervision needs to be provided to individuals in custody who pose particularly high risk, such as individuals who expressed suicidal ideation. The coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . Establish policies making clear that, absent exceptional circumstances, those assessed as high risk or where the allegations involve strangulation should not qualify for early intervention. The death of Daniel Robert NELSON was drug related. Consider re-allocating more time to scenario-based de-escalation training during annual use of force certification at the, Post the verdict and recommendations of this inquest on the. Review whether the policy for the care and handling of individuals in custody needs to be clarified, particularly in relation to which individuals in custody should be considered high risk. In jury inquests, the coroner directs the jury on matters of law and the jury decides the appropriate verdict . 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 Toronto Police Service should continue to explore the feasibility of implementing body-worn cameras for all. The ministry should explore safer alternatives to wooden pencils being provided to Inmates. All site supervisors are competent and aware of their duties and responsibilities. Openings. 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. Take all reasonable measures to ensure workers are educated, understand and avoid the hazard. 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. To improve outcomes for First Nations children and youth, empower and seek to fund bands and First Nation communities and affiliated stakeholders (such as the Association of Native Child and Family Services Agencies of Ontario) to collect data and analyze data to determine whether, and to what extent, child welfare interventions and services are improving outcomes for children and youth. 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. Ensure all health care providers, including nurses, physicians, psychiatrists, and psychologists, are trained on the revised Recovery Plan policy. The Senior Coroner for this area is Patricia Harding. 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. Peer support and appropriate circles of support. The hazard alert should identify cyanide, in all of its forms, as a potential workplace hazards. Task analysis safety card form to be reviewed and signed off by supervisor prior to the work commencing, to ensure it has been properly and thoroughly completed. Details of upcoming Openings, Inquest Hearings, Pre-Inquest Reviews, Documentary Inquests and Adjournments. 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. 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. An inquest has heard of the final moments before a father and son died racing together in last year's TT. 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. provide mandatory standardized training bi-annually on de-escalation strategies and empathy for community mental health-related situations. The role of the coroner is to investigate sudden deaths that have been reported to them, and to hold inquests where appropriate.
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