coroner's inquest verdicts

Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. A coroner is an independent judicial office holder. 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. Create guidelines for staff in making decisions regarding whether to issue, review, revoke, or add conditions to. 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. 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 Coroner's officer will usually inform interested parties to the Inquest who is to give evidence at the hearing. In addition, such education should be repeated quarterly. What verdicts can a coroner give? Reconvene one year following the verdict to discuss the progress in implementing these recommendations. Be staffed 24 hours a day and 7 days a week. Time of death could not be determined.Place of death: Foymount, OntarioCause of death: shotgun wound of the chest and neckBy what means: homicide, The verdict was received on June 28, 2022Presiding officers name: Leslie Reaume(Original signed by presiding officer). 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. The purpose of an inquest is to establish who the deceased person was, and when, where and how they died. 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. There must be special recognition of the unique challenges Black people who also have serious mental health issues face when they come into contact with police. Report to the Thunder Bay Police Services Board on the above. To use any such collected information to assess the effectiveness of the deployed alternative responses, to identify the potential for the improvement of future responses and outcomes, and to support any request for additional resources. All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. The ministry should conduct a comprehensive and ongoing process of engagement with patients in its custody in the development of healthcare strategy, policy and delivery. 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. Held at: SudburyFrom:June 13To: June 16, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Ronald LepageDate and time of death:April 6, 2017 at 9:12 p.m.Place of death:Health Sciences North, 41 Ramsey Lake RoadCause of death:blunt force/crush injury to abdomen and pelvisBy what means:accident, The verdict was received on June 16, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:BlairGiven name(s):Delilah SophiaAge:30. 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 coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . Refer to the mining legislative review committee the consideration of amendments to Ontario Regulation 854, Mines and Mining Plants (the Regulation) that would: Require the following precautions be taken should a worker perform maintenance work in an area in which the work may reasonably be expected to expose the worker to a material containing cyanide at concentrations that may endanger the worker. This training should be designed and delivered by Indigenous people. The ministry should retrofit all units within. 42. 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. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care. (Note: this is included in both mining industry and Ministry of Labour section). The ability to respond immediately with risk management services in collaboration with. The ministry should consult with the Ministry of the Attorney General to determine a process for obtaining summary information about upcoming court appearances for persons in custody and prospective length of time in custody, and rapidly provide this information to health care and programming staff. The. 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. Where gaps exist, the ministry should explore and research means to increase actual programing at Detention and Correctional Centres: Analysis of data collection or research of Indigenous core or other programing should include identification of gaps, steps taken to resolve gaps, improvements and best practices; This analysis and research should be reported, maintained and disseminated to Ontario`s correctional Institutions, service providers and for use with consultation with First Nation, Metis and Inuit community; The ministry should consider evaluating and modifying their policies on allowing volunteers into the facility that have a criminal record. Nine jurors reached unanimous decisions on all but one of the 14 questions at the inquests into Britain's worst sporting disaster. Consideration for the needs of rural and geographically remote survivors of. . Improve public awareness and knowledge of community-based supports for persons experiencing mental health issues should target young people, and utilize channels of communication that are accessible and suitable for youth. The inquest heard from 278 witnesses and is estimated to have cost the taxpayer more than 6.5m. Where possible and financially feasible, connect young people with external resources that could provide additional opportunities, including but not limited to sport, land-based learning, culture, art, and other pursuits that will assist in developing a forward pathway. Roger and Bradley Stockton crashed on the second lap of last year's final sidecar race. There are many ways to contact the Government of Ontario. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented. Sources of Evidence and Disclosure . 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. Programs are funded at a level that anticipates an increased stream of referrals. 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. The ministry should take immediate steps to improve opportunities for persons in custody to access recreation and exercise facilities and programs. whether the missing person is an Indigenous youth. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. Establish clear guidelines regarding the flagging of perpetrators or potential, Recognize that the implementation of the recommendations from this Inquest, including the need for adequate and stable funding for all organizations providing, Create an emergency fund, such as the She C.A.N Fund, in honour of Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam to support women living with. All correctional staff and nurses have full access to, All correctional staff and nurses perform a thorough review of. The ministry shall treat people in custody on remand as presumed to be innocent. Held at:SudburyFrom: August 29To: September 2, 2022By: Dr. David Cameron, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Richard Raymond PigeauDate and time of death: October 20, 2015 at 12:06 p.m.Place of death:3259 Skead Road, Skead, ON, P0M 2Y0 1660 Level, 1660-021 RampCause of death:crush-type blunt force injuries to torsoBy what means:accident, The verdict was received on September 2, 2022Presiding officer's name: Dr. David Cameron(Original signed by presiding officer), Surname: GordonGiven name(s): JacobAge:24. Implement the Spirit Bear Plan through collaboration with. This can be: accident/misadventure unlawful killing natural causes. Led by the Chippewas of Georgina Island First Nation, support the development and delivery of a case study training module for childrens aid societies and residential service providers regarding the lessons arising from Devon Freemans life and death and incorporate information from the Narrative document (with the exclusion of personal identifiers or information that may identify individuals or otherwise assign blame). Names of the deceased: Mamakwa, Donald; McKay, Marlon RolandHeld at: Thunder BayFrom: October 11To:November 4, 2022By:Dr.David Cameron, presiding officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:MamakwaGiven name(s): DonaldAge:44, Date and time of death: August 3, 2014 at 12:03 a.m.Place of death:Thunder Bay Police ServiceCause of death:ketoacidosis, complicating diabetes mellitus, chronic alcoholism, and septicemiaBy what means:undetermined, Surname:McKayGiven name(s):Marlon RolandAge:50, Date and time of death: July 20, 2017 at 1:34 a.m.Place of death: Thunder Bay Regional Health CentreCause of death:hypertensive heart diseaseBy what means: natural, The verdict was received on November 4, 2022Coroner's name:Dr.David Cameron(Original signed by coroner). 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. Explore developing and providing all police officers with additional de-escalation training. These solutions should be communicated to relevant staff and stakeholders in a timely manner. The Government of Ontario should enhance supports for families of persons who die in a police encounter, and ensure that those services are delivered in a timely and trauma-informed manner. Which justice participants should have access to the findings made by a civil or family court. 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. This should incorporate recognition of the historical and ongoing traumas faced by Indigenous communities and adequate cultural competency to provide care/services in a manner that recognizes these traumas. Prepare and distribute a hazard alert about the hazards of cyanide in the workplace. Ensure that witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports. Section 14.6 states the following: We call upon Correctional Service Canada and provincial and territorial services to provide intensive and comprehensive mental health, addictions, and trauma services for incarcerated Indigenous women, girls, and. 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. 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. Explore the capability of the information management systems to accurately capture the number of calls for service which are initially reported and dispatched as another type of call but are later assessed by the responding officers to be a call which has a significant person in crisis component. All physician assistants and doctors ensure that workplace hazards are incorporated into the assessment of any medical emergency. Provide direct, sustainable, equitable, and adequate joint funding from the named Ministries and Government of Canada to First Nations, off-reserve Indigenous service providers, and non-Indigenous service providers serving off-reserve First Nations children, youth and families to increase the capacity for collaboration in the provision of child welfare and mental health services. Full Hearing. Continue to prioritize the recruitment, hiring, and retention of workers with First Nations identity and from other equity-deserving groups, recognizing skills related to Indigenous knowledge and cultural identity alongside traditional mainstream credentials. 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 (. 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. The revised risk assessment factors, as well as search urgency factors, should be evidenced-based and clearly defined. Held at:Ottawa (virtual)From: October 11To: November 10, 2022By:Dr. Geoffrey Bond, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Olivier BruneauDate and time of death: March 23, 2016 at 8:08 a.m.Place of death:Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, OntarioCause of death:blunt force chest injuryBy what means:accident, The verdict was received on November 10, 2022Presiding officer's name:Dr. Geoffrey Bond(Original signed by presiding officer), Surname:DhindsaGiven name(s):VikramAge:34. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones. 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. Held at: 25 Morton Shulman Ave Toronto (virtually)From:May 16To: May 18, 2022By:Dr.Bob Reddochhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Jean Herv VeilletteDate and time of death:January 17, 2019 at 1:21 a.m.Place of death:Ottawa Hospital General CampusCause of death:hangingBy what means:suicide, The verdict was received on May 18, 2022Coroner's name:Dr.Bob Reddoch(Original signed by coroner). Consider adopting Femicide as one of the categories for manner of death. 17 June 2022 . 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. Take all reasonable measures to ensure workers are educated, understand and avoid the hazard. In consultation with residential homes and child and youth mental health facilities like Lynwood, develop a common joint responsibility protocol governing the process, roles and responsibilities when it comes to searching for youth who have left congregate settings without permission. The Coroner can hold an inquest even if the death happened abroad. 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. Assess the feasibility and impact of establishing a mental health advocate role (or enhancing the abilities of social workers) to be the point person helping patients and families coordinate mental health services: this advocate assists with scheduling follow-up sessions after appointments; check-ins, and visits; support after medication changes; recommends community services; collecting collateral information from relevant parties, based on demand and proper funding, this advocate will be required to manage multiple concurrent cases effectively within a framework of flagging and following up with the highest-risk outpatients, consistently offer a family meeting within 48-72 hours of hospital admission, regardless of the patients status in hospital, to collect collateral information, documented offer of a meeting with family members or support team occurs prior to discharge from hospital to ensure a patient with mental health issues has support, provide mental health services 24 hours a day to better assist communities by expanding self-help services to those in need through online, hybrid, or in-person supports, The Ministry of the Solicitor General (ministry) should review the Offender Tracking Information System. The Ministry of Labour shall review and consider whether to amend. Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing. 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. That a Task Force be developed with a mandate to establish a sobering centre in Thunder Bay. Checklists and plan for ensuring all safety and medical equipment is readily available and in working order. 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. . The ministry should amend its policies and practices for admissions officer/. If you are thinking about challenging a coroner's decision, it is important that you seek specialist advice as soon as possible. To ensure the safety of children in care, train staff to ensure that, to the extent a youths file is transferred from one staff member to another, all information relating to a young persons suicidal behaviour and ideation is clearly flagged in transfer discussions or communications between staff. 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. Implement the National Action Plan on Gender-based Violence in a timely manner. Prioritize developing and implementing a long-term plan to establish adequate housing for male/female inmates. The ministry should ensure that all staff be trained regarding crisis and incident response and management. . Fund for safe rooms to be installed in survivors homes in high-risk cases. The ministry should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. 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. Conduct a review and consider the role of jailers, the level of supervision given to individuals in custody, and training given to staff in that role, and in particular: Review the level of staffing, and consider a policy that links the number of staff to the number of prisoners, similar to the Ontario Provincial Polices standard of using one guard for seven individuals in custody.

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