coroner's inquest verdicts

Continue to train staff to identify and address suicidal ideations and risk factors (acute and chronic) associated with suicide. The ministry should explore the benefits and detriments of periodic re-screening for suicidal risk or mental health concerns akin to the admissions screenings to see if an inmates status has changed while in custody. It also ruled Don Mamakwa's death in 2014 had an . 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 . Develop workable practices to improve contact and connection of individual young people with safe adults in their circle of care, to reduce circumstances where children are absent and their whereabouts are unknown. She said: 'I consider that based on the evidence I have heard the failure to report the smear test accurately was a gross failure and the further assessments in both August and . For a free, no-obligation, initial discussion of how we may be able to help, please contact us today. 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. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. 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. Inform staff and affected personnel that resources are available to support them with respect to work related stress. Include coercive control, as defined in the. Implement the corporate health care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. Work with the Infrastructure Health and Safety Association to develop guidance material for employers and constructors on how to address the hazard of falling ice. The ministry should implement dedicated and centralized real time monitoring of cameras at. 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) This training should be designed and delivered by Indigenous people. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. In recognition of the important roles of family and Indigenous communities, offer to involve the family and the Indigenous community of a deceased Indigenous young person in the Pediatric Death Committee Review process where appropriate, having due regard to confidentiality concerns. Older verdicts and recommendations, and responses to recommendations are available by request by: e-mail: occ.inquiries@ontario.ca. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. Ensure that security patrols are completed during shift changeovers. The role of the coroner is to investigate sudden deaths that have been reported to them, and to hold inquests where appropriate. Develop an expert panel including Indigenous leaders, researchers, as well as leaders from other provincial child welfare ministries, such as British Columbias Ministry of Children and Family Development who can provide expertise on best practices to revise the child welfare funding formula to address the needs of Indigenous youth. The ministry should undertake a study to identify the effects of overcrowding, and other living conditions on inmate populations especially those with addictions and/or pre-existing mental illness and to take any appropriate corrective measures. . 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). That care and services must be provided using a trauma informed approach to ensure that individuals who have suffered complex traumas are not excluded from the services that may assist them. An 'investigation' is a new way a Coroner can handle a case that was introduced in reforms of the legislation in July 2013. Review policies to ensure the timely, reliable, consistent, and accurate dissemination of information, including the use of emergency alerts and media releases, where the police are aware of circumstances that could put the public in danger, and that the focus is on safety when developing policies regarding what information to share with whom and when. 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. The ministry should explore digital form tools that would ensure all required fields are completed. Consideration of streaming short video clips or other helpful information via the television screens on each living unit should also be given. 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. Inclusion of and consultation with Indigenous communities/agencies is essential. The jury hears evidence from witnesses under summons (same as a subpoena) in order to determine the facts of a death. Did you find what you were looking for? 4:33 p.m. - April 28, 2022. 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. Even in countries where the jury system is strong, the coroner's jury, which originated in medieval England, is a disappearing form. 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. These solutions should be communicated to relevant staff and stakeholders in a timely manner. Prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. Ensure that witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports. Any requests to obtain and use video or other recordings from the inquest shall be made to the Office of the Chief Coroner for their consideration. The ministry should provide educational opportunities to persons in custody and operational staff at correctional facilities about the Good Samaritan principles that it adopts in its operational policies and practices. These supports should account for the social barriers to accessing such supports within a custodial environment. In most cases, no further action is required, and the death can be registered as normal. 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. Develop further therapeutic activity programming for youth that reflects a wide variety of interests. Increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. 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). 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 Toronto Police Service should provide emergency task force (. mental health, interpreters etc. 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. In partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, establish multisectoral, multidisciplinary roundtables at local, regional, and provincial levels accessible to community members and service providers to problem-solve regarding service to young people with complex needs. Commission a study to examine the creation and implementation of a province-wide, civilian-led crisis intervention system to respond to persons in crisis, including mental health crisis. The ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive additional Indigenous cultural safety training. IV. mechanical devices, such as a pin, that can be inserted into a boom or crane to prevent movement into the prohibited zone. risk assessment training with the most up-to-date research on tools and risk factors. The ministry should update all forms to remove the term North American Indian in favour of First Nations/Inuit/Mtis on any admission or information forms used with people in custody. 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. As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights. Consider using specialized care units for inmates who have been removed from suicide watch. We recommend that significant and automatic fines should be levied against any company/constructor that fails to ensure that a dedicated Signaller be assigned to Hydro-vac crews and/or any crane operation when working in the vicinity of overhead powerlines. Funding for mobile tracking system alarms and other security supports for survivors of, Funding for services dedicated to perpetrators of, Develop a plan for enhanced second-stage housing for. 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. 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. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. In partnership and in consultation with First Nations, provide direct, sustainable, equitable, and adequate funding to First Nations for prevention services, cultural services, and Band Representative Services to service and support both on- and off-reserve First Nations children, youth and families involved in child welfare and in support of children and youth in need of mental health supports pursuant to a needs-based approach that meets substantive equality. The inquest heard from 278 witnesses and is estimated to have cost the taxpayer more than 6.5m. The Coroner is expected to open an inquest where there is reasonable suspicion that the deceased has died a violent or unnatural death, where the cause of death is unknown or if the deceased. It is recommended that the Ministry of Labour, Training & Skills Development take steps to amend the. 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. The implementation plan should be made public in order to ensure accountability. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. 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. 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. Inform staff of the LivingWorks Start online training on suicide prevention and provide them with information to register. Explore digitized records of over a century of coroner's records from Stark County, Ohio, available online . Explore developing and providing all police officers with additional de-escalation training. . Coroner's court returns verdict of medical misadventure after inquest into death of Linda Connell (41) five days after minor surgery to remove ovarian cyst The Ministry of the Solicitor General is committed to overall public safety and ensuring Ontarios communities are supported and protected by effective and accountable law enforcement, correctional services, death investigations, forensic science services, emergency management operations and animal welfare services. We recommend that an industry wide Hazard Alert be published, alerting end-users, and manufacturers of remote-control devices for booms and cranes, to the risk of inadvertent boom or crane movement associated to the OMNEX T300 Wireless Remote Control, or any similarly designed remote control used for boom or crane operation. 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. It would also provide a primary point of communication for emergency response and medical personnel. 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. Prioritizing the development of cross-agency and cross-system collaborative services. Peer support and appropriate circles of support. 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. Ensure that gaps or compliance issues identified during investigations into inmate deaths (including by Correctional Services Oversight and Investigations) are communicated and reinforced to relevant staff and healthcare providers. 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. Strengthen annual education for Crowns regarding applications for Dangerous and Long-term Offender designations in high-risk, Commission a comprehensive, independent, and evidence-based review of the mandatory charging framework employed in Ontario, with a view to assessing its effect on, Review and amend, where appropriate, standard language templates for bail and probation conditions in, plan for removal or surrender of firearms and the Possession and Acquisition License (, possibility of a "firearm free home" condition, past disregard for conditions as a risk factor, When evaluating the suitability of a prospective surety in. Prioritize continued efforts regarding bed shortages for female inmates. The ministry should engage with people with lived experience to develop enhanced supports for people in custody who witness a traumatic event. 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. The verdict means the jury confirms the death is suspicious, but is unable to reach any other verdicts open to them. That the use of paper green sheets be discontinued, that the booking process and prisoner management systems be digitized, and that documentation used for charges in court be separated from the documentation used to manage and care for individuals in custody. The same expert panel as noted above should provide recommendations to define outcome measures which clearly describe the successful progression of Indigenous youth through the welfare system to independence and adulthood. development of an integrated Plan of Care focused on the social determinants of health for the family and child that follows them through community services when they are in the community and also when they are in the care of a childrens aid society and incorporate the cultural and spiritual needs of the child; and. In addition to posting hazard alerts on the ministrys website, develop and implement a system of communication to distribute hazard alerts so that they are sent directly to constructors and employers. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. It should have no impact on Ontario Works or Ontario Disability Support Plan payments. It is recommended that the chief coroner take steps to expedite the hearing of coroners inquests, if feasible that they be held within three years. Implement recommendation #20 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. If there is no individual evaluation component, the ministry should consider implementing one. The Toronto Police Service should explore the ability to use audio/visual capabilities to have short notice assistance from external professionals e.g. Consider the viability of a requirement for dump trucks to be equipped with back-up cameras that provide 360 degree visibility. The relevant coroners office will contact you if this is the case. 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. 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. Consider an appropriate role for community members or organizations as part of the missing person investigation, or in a debrief with the missing person once the investigation is concluded. That the use of medically fragile flags be considered for the. Date of inquest. Provide adequate and sustainable funding and resources to ensure that a range of placement options and transition services, including independent and semi-independent living arrangements, are available for children and young people receiving services from childrens aid societies and Indigenous well-being agencies. Develop and deliver training for constables and sergeants on interpersonal skills, emotional intelligence, leadership, and team building. 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. Held at: TorontoFrom:June 29To: June 29, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Frank FerranteDate and time of death: July 28, 2015 at 8:34 p.m.Place of death:Southlake Regional Health Centre, 596 Davis Drive, NewmarketCause of death:heat strokeBy what means:accident, The verdict was received on June 29, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:YonanGiven name(s):MettiAge:66. responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth. Inquests for this area are normally held at Archbishops Palace, Maidstone unless stated otherwise. The Toronto Police Service should improve delivery of relevant information to the inner perimeter where crisis negotiations are taking place without unduly disrupting the negotiation process. Clarify the definition of accident in sections 52 and 53 of the, Consider studying the effectiveness of Albertas. 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. The ministry should develop training for correctional officers on strategies to work constructively with Indigenous men in custody, similar to the Biidaaban Kwewok and Biidaaban Niniwok Beginnings for Indigenous Women and Men training. Funding for services provided to survivors that allows for the hiring and retention of skilled and experienced staff so that they are not required to rely on volunteers and fundraisers in order to provide services to survivors. For conductive energy weapons consider high visibility markings (colour) to differentiate them from firearms. Coroners are independent judicial officers who investigate deaths reported to them. 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.

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