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The purpose of an inquest is to establish who the deceased person was, and when, where and how they died. 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. The Toronto Police Service should continue to build a diverse. Older verdicts and recommendations, and responses to recommendations are available by request by: e-mail: occ.inquiries@ontario.ca. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. This training should be designed and delivered by Indigenous people. 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. The provision of therapeutic care. The content of such training to include: what cyanide is used for within the workplace and where it can be found, the method for identifying cyanide within the workplace, personal protective equipment and limitations associated with such equipment, the signs and symptoms of cyanide exposure, first aid / treatment procedures for people potentially exposed to cyanide. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services. The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. State detention includes people in immigration detention centres. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools. The ministry should take steps to actively promote awareness of information, services and programs available to persons in custody regarding opioid/other substance use. 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). 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. Encourage all fixed term Nurse Practitioners at the, Reinstate funding for an embedded Kawartha Lakes Police Service detachment inside the Central East Correctional Centre. And people detained in hospital under the Mental Health Act. 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. Conclusions (verdicts) At the end of the Inquest, the Coroner can give the following Conclusions about the death: Natural causes Accident or misadventure Suicide The 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. Develop and deliver training for constables and sergeants on interpersonal skills, emotional intelligence, leadership, and team building. 08:52, 2 MAR 2023. The ministry should ensure that all staff be trained regarding crisis and incident response and management. That access to electronic health records be provided to all paramedics in Ontario, and if such access is available, that Superior North. The ministry shall treat people in custody on remand as presumed to be innocent. Distribute current contact information for ORNGE, air ambulance to all remote workplaces including but not limited to the mining, forestry, and construction industries. Greater use of court-ordered language ensuring alleged and convicted offenders will not reside in homes that have firearms. 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. Review the current Use of Force Model (2004) and related regulations, and consider de-emphasizing use of the term "force" and employing alternative terminology. The ministry should amend its policies and practices for admissions officer/. 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. The ministry should ensure that healthcare and correctional staff at correctional facilities receive additional training about building rapport and resolving challenging encounters with persons in custody. It would also provide a primary point of communication for emergency response and medical personnel. Coroners are independent judicial officers who investigate deaths reported to them. The jury must deliver a verdict answering the five questions regarding the death: who (identity of the deceased) when (date of death) where (location of death) how (medical cause of death) Provide enhanced police training in addressing mental health-related situations and crises, including awareness education in recognizing and identifying situations where mental illness may play a role. Ensure that health care transfer summaries are completed in compliance with provincial policies when inmates are transferred between institutions. Create guidelines for staff in making decisions regarding whether to issue, review, revoke, or add conditions to. Within 6 months of the jurys verdict, strike a task force to review, report on, and initiate changes to: funding, accountabilities, and timely access to care for all community-based mental health services that receive funding from the Government of Ontario, available resources and supports for family members and/or caregivers of patients and community services receiving mental health services, how family members and/or caregivers and community services can provide support and/or information about patients when patient consent is not provided, address what information can be shared from family members and other stakeholders, align services and community agencies to better share information about individuals with mental health concerns in the community, Establish further study and review of the criteria and training associated with the, mandatory refresher training for emergency room physicians and psychiatrists in the province of Ontario on when and how to use the Form 1 options associated with mental health, the assessment of Box A and Box B criteria for psychiatric evaluation and involuntary detention, to determine how best to ensure collateral information from family members and relevant community services information can be included as part of the process for determining appropriate treatment options. The ministry should require all forms related to the admissions of inmates to be completed in full, including review and signature by a sergeant (or their designate). 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. It is their duty to find out the medical cause of the death if it is not known, and to enquire about the cause of it if it was due to violence or was otherwise unnatural. 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. Require primary actors involved in a major incident to conduct a formal de-brief and write a report identifying lessons learned and recommendations for improvement, if appropriate. 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. Start grassroots Safe Spaces program that businesses can participate in where survivors can feel safe and ask for information (. The Coroner investigates deaths in order to establish who . incorporate the approach of minimizing the risk of hanging in the designing and planning of the bookshelves in all units. 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. It simply aims to gather information in order to answer these questions. Inclusion of and consultation with Indigenous communities/agencies is essential. 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. Develop and implement a new approach to public education campaigns to promote awareness about, Complete a yearly annual review of public attitudes through public opinion research, and revise and strengthen public education material based on these reviews, feedback from communities and experts, international best practices, and recommendations from the Domestic Violence Death Review Committee (, Use and build on existing age-appropriate education programs for primary and secondary schools, and universities and colleges. The ministry should adopt Good Samaritan principles in operational policies and practices to encourage persons in custody to call for help or try to help another person suspected of being in medical distress or come forward with information about drugs within the institution, without being subjected to any institutional misconduct proceedings for possession or use of contraband. Derbyshire Police. Utilize the resources generated by the Ministry of Labour, Immigration, Training and Skills Development and Infrastructure Health & Safety Association to develop a comprehensive safety plan for when a skid steer (owned or operated by Green Star or one of its employees) is in use at a construction site. 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 inquest into the Lakanal House fire in the London borough of Southwark on 3 July 2009 began on 14 January and ended on March 28 2013. . 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. Continue to train staff to identify and address suicidal ideations and risk factors (acute and chronic) associated with suicide. Rename crisis hotline services and create awareness campaigns to educate the public about their existence to make the public aware that these services are available before a person reaches the point of crisis. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. 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. The ministry should embrace an evidence-based approach to harm reduction in a manner that protects the mental and physical health of persons in custody. When operationally feasible, the ministry should run the scenario-based. The inquest will then be adjourned to be resumed at a later date. The ministry shall consult with an expert in trauma-informed care to review the current care programs to provide specific suggestions for institutional changes to promote trauma informed practices within the detention centre. IV. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented. That bystander training be provided to police officers so that officers feel more comfortable addressing inappropriate behavior by colleagues. This shall include adequate training and resources for all care providers and all staff within MAPs so that individuals with a likelihood of violent behaviour as a result of trauma are still able to receive care and services from the. How is it different from an inquest? The dangers of working in proximity to overhead powerlines, even when no work on overhead power lines is intended. 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. These reviews should analyze relevant health care files and assess quality of care. To support ongoing consultation, communication, and transparency between the Society and the bands and First Nations communities of the children and youth it serves, the Society shall reach out to those bands and First Nation communities and offer to develop a communication protocol and offer to initiate quarterly reviews regarding all children receiving services from the Society. 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. 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. Consideration should be given to two-way information sharing including of case notes, and opportunities to order treatment in institutions for those with existing probation orders who are on remand. This increase shall: Not come as an alternative to the creation of a sobering centre, in recognition of the fact that these institutions would provide different services. Mandate that all police service officers receive annual implicit bias and cultural competency training to address stereotyping of Black people, and the existing research on anti-Black racism in policing. Clarify the definition of accident in sections 52 and 53 of the, Consider studying the effectiveness of Albertas. 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. It is recommended that the North Bay Police Service and the North Bay Police Services Board consider policy and training amendments that require officers to notify Emergency Medical Services (, It is recommended that the North Bay Police Service and the North Bay Police Services Board consider steps that are required to ensure that, It is recommended that the North Bay Police Service, the North Bay Police Services Board and the Special Investigations Unit, review the process for data extraction from a Conducted Energy Weapon (, Assessthe feasibility of requiring a constructors supervisor (as required by section 14 of, Post in a conspicuous place the name of the current constructors supervisor, Require a written delegation of supervisory authority, Review the supervisor awareness training required by section 2 of. Improve mental health awareness of housing support personnel, and in particular, concerning the recognition of mental health crisis. 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. When the coroner's jury could not determine a cause of death, an "_" will appear in the verdict category. Once the ministry completes the consultations on tear-resistant sheets and blankets, if there are viable options, the ministry endeavor to implement the use of such bedding in all provincial institutions. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. A list of the inquests scheduled for hearing in the Oxford Coroner's Court. Mandatory use of a signaller when operating a skid steer. This includes: familiarity with the act and the regulations that apply to the work, ability to identify and address workplace hazards. Implement more rigorous and thorough assessment of potential and current employees. Please note inquests can be changed at the last minute, please check before attending. 4:33 p.m. - April 28, 2022. The ministry should ensure that people in custody have access to a reliable means of initiating an emergency medical response. In conjunction with recommendation number12, the ministry should abandon the use of the title, Native Inmate Liaison Officer, and move toward the exclusive use of the title, Indigenous Liaison Officer.. 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 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. Held at:WindsorFrom: September 12To: September 23, 2022By: Dr. Daniel L. Ambrosini, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Matthew MahoneyDate and time of death: Pronounced deceased at 9:39 a.m. on March 21st, 2018Place of death:Windsor Regional Hospital (Ouellette Campus)Cause of death:multiple gunshot woundsBy what means:homicide, The verdict was received on September 23, 2022Presiding officer's name: Dr. Daniel L. Ambrosini(Original signed by presiding officer). The circumstances in which judges can lead inquests and details of notable inquests overseen by a judge. The ministry should collaborate with the London Middlesex Medical Officer of Health in developing its harm reduction strategies. 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. Coroners will look to establish the medical cause of death. how to prevent heat stress and other heat related illnesses that may arise from working in high temperature conditions, and. Consider including a case study focused on falling ice in excavations in future inspector training material. All physician assistants and doctors are trained on all medical equipment available at the worksite. 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. However, the Coroner may decide to hold an inquest to establish the facts. 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. In order to promote, protect, and prioritize worker health and safety, road-resurfacing contracts should be reviewed with attention to how time limits on construction work and limits on allowable lane closures are established. The 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 To Green Star Grading & Sodding Construction Ltd. (Green Star): Surname:SoaresGiven name(s):RicardoAge:32. 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. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. Amend the notification requirements in section 7.1 of the Construction Regulations to include a signed and dated attestation that the work platforms will be installed, inspected, tested and maintained in accordance with the applicable regulations, including sections 139 and 139.1. 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.