Ensure that the employer continues to properly identify and review Potential Chemical Hazards of cyanide at the mine site and modify the training, procedures and medical response as required. The relevant coroners office will contact you if this is the case. 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. 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. In most cases, no further action is required, and the death can be registered as normal. When operationally feasible, the ministry should run the scenario-based. 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. 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. The ministry should collaborate with the London Middlesex Medical Officer of Health in developing its harm reduction strategies. 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. Greater use of court-ordered language ensuring alleged and convicted offenders will not reside in homes that have firearms. 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. 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. Prioritizing the development of cross-agency and cross-system collaborative services. Include coercive control, as defined in the. The revisions should require correctional institutions to ensure that: one or more staff member is designated to develop a recovery plan when an inmate is removed from suicide watch, one or more staff member is designated to oversee the plan and ensure it is implemented, placement of inmates in recovery is reviewed with health care staff and this review is documented, The recovery plan is available for health care and operational staff. They must be treated as such, including refraining from using the term offender. Review the mandate of Probation Services to prioritize: Require that probation officers, in a timely manner, ensure: There is an up-to-date risk assessment in the file. The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody. Names of the deceased: Culleton, Carol; Kuzyk, Anastasia; Warmerdam, NathalieHeld at:1 International Drive, PembrokeFrom:June 6To: June 28, 2022By:Leslie Reaume, Presiding officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname: CulletonGiven name(s): CarolAge:66, Date and time of death: September 22, 2015. Names of the deceased: Rajendiran, Arun Kumar;Tavernier, Darrel; Kelly, StephenHeld at:TorontoFrom:May 30To: June 13, 2022By:Dr.Robert Reddoch, coroner for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:RajendiranGiven name(s):Arun KumarAge:25, Date and time of death: November 12, 2014 at 8:16 p.m.Place of death: Central East Correctional Centre, Lindsay, OntarioCause of death:hangingBy what means:suicide, Surname:TavernierGiven name(s):DarrelAge:42, Date and time of death: January 1, 2018 at 8:37 a.m.Place of death: Ross Memorial Hospital,Lindsay, OntarioCause of death:hangingBy what means:suicide, Surname:KellyGiven name(s):StephenAge:62, Date and time of death: May 18, 2019 at 9:10 a.m.Place of death: Ross Memorial Hospital,Lindsay, OntarioCause of death:hangingBy what means:suicide, The verdict was received on June 13, 2022Coroner's name: Dr.Robert Reddoch(Original signed by coroner), Central East Correctional Centre (CECC) Health Care Review. 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. 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. Implement recommendation #6 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. Inject a significant one-time investment into, Realign the approach to public funding provided to. The ministry should provide education opportunities to persons in custody on the following topics: illicit opioid/other drugs available/in circulation, mental and physical health risks of using illicit opioid/other drugs, safe drug-use practices, including never to inject, smoke or ingest drugs alone, the risks of mixing illicit opioid/other drugs with prescription drugs. The 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. This may be done through by creating a mailing list of employers, constructors and trade unions, in the construction sector or in consultation with the Infrastructure Health and Safety Association, or such other partners as may assist with the development and implementation of the system. A requirement that all skid steer operators regularly clean and clear debris from the windows of the skid steer to ensure maximum visibility. 2022 coroners inquests verdicts and recommendations, other identified organizations may be identified in the recommendations. 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. Consider renaming the Model to better reflect the range of tools and techniques available to officers. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. 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. There are no 'parties' and the Coroner does not make . All health and safety representatives are competent and aware of their duties and responsibilities. In December a coroner . For young people in care, engage with any outside service provider at the intake stage to set clear lines of responsibility regarding communication of information regarding the young person to those in the youths circle of care, including communication of self-harm attempts and leaving the property without permission. All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. how to prevent heat stress and other heat related illnesses that may arise from working in high temperature conditions, and. . If you are thinking about challenging a coroner's decision, it is important that you seek specialist advice as soon as possible. The Coroner usually conducts the inquest alone but will sometimes sit alongside a jury. For conductive energy weapons consider high visibility markings (colour) to differentiate them from firearms. 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. The training should address: understanding how emotional prejudice impacts decision making, tactics/solutions for mitigating the harmful impact of stereotyping on health and criminal justice outcomes, That both services consult with Indigenous Nations, Provincial Territorial Organizations (. The ministry should engage with people with lived experience to develop enhanced supports for people in custody who witness a traumatic event. Review, in consultation with stakeholders, the discretionary nature of inquests into the deaths of children in care and consider advocating for legislative change requiring said deaths to be the subject of mandatory inquests. Inquests. 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 implementation plan should be made public in order to ensure accountability. 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. The Solicitor General of Ontario should study the phenomenon of individuals attempting to induce police officers to use lethal force, to improve best police practices across the province. Police services and police services boards shall consult with third-parties, including individuals from the Black community, Black advocacy community organizations, persons with lived experiences from peer-run organizations, and appropriate content experts, and: develop an objective methodology to measure and evaluate police service performance on use of force, take corrective action to address systemic discrimination, provide clear and transparent information to the public on biased and discriminatory use of force. The ministry should explore digital form tools that would ensure all required fields are completed. The inquest jury consists of five people selected by the coroner's constable from a list of jurors from the community. Conduct a comprehensive, third-party audit of its health and safety system. Signaller be equipped with a remote e-stop. It is recommended that the Ministry of Labour, Training & Skills Development take steps to amend the. Call us on 020 7632 4300 or make an enquiry online. support for the development of programs that are flexible and able to respond to a range of needs including chronic and acute needs in a range of health and well-being domains. This includes: familiarity with the act and the regulations that apply to the work, ability to identify and address workplace hazards. 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. 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. Hearings. Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system. 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. Physicians should be encouraged to communicate with a patients community health care providers when discontinuing or amending a prescription for an opioid medication, when consent is provided by the patient. Encourage all fixed term Nurse Practitioners at the, Reinstate funding for an embedded Kawartha Lakes Police Service detachment inside the Central East Correctional Centre. The inquest will then be adjourned to be resumed at a later date. To ensure the safety and ongoing wellness of the children in its care, where a youth has disclosed suicidal behaviours or ideation, make best efforts to bring together all those involved in a youths circle of care to discuss and assess the youths situation and participate in safety planning for the youth (including the youths self-identified support, youths guardian, First Nation if applicable, medical team, supportive community members and family where appropriate). Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants. Explore the possibility of developing and including crisis intervention training as part of the mandatory curriculum for police recruits at the Ontario Police College and the requirement that all officers re-qualify at a determined interval. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. The data should be standardized, disaggregated, tabulated and publicly reported. The ministry should implement dedicated and centralized real time monitoring of cameras at. Mandatory skid steer operation certification and re-certification process. Regular refresher training on mental health issues should be provided to all police officers who interact with the public. Consider conducting an ice management campaign for large construction projects in Eastern Ontario. The Toronto Police Service should continue to explore the feasibility of implementing body-worn cameras for all. The availability and use of weapons prohibition orders in. Ensure that security patrols are completed during shift changeovers. Name of deceased. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented. All the latest inquests including openings from Derby Coroners' Court. In recognition of the fact that law enforcement agencies in the City of Thunder Bay lack the appropriate training, cultural competency, and resources to provide appropriate services to individuals suffering from alcohol/substance use disorder and/or chronic housing insecurity, work to ensure that community-based programs which provide outreach and services to such individuals are maintained and continued, including and not limited to: the Care Bus, operated by NorWest Community Health Centre, the WiiChiiHehWayWin street outreach initiative, operated by Matawa First Nations Management. 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. The ministry should amend its policies and practices for admissions officer/. Ensure all health care providers, including nurses, physicians, psychiatrists, and psychologists, are trained on the revised Recovery Plan policy. 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. Inquests should be completed within 24 months from the incident date unless the circumstances warrant additional time. 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. In order to support fulsome assessment, information sharing within the child welfare system and ensuring a holistic approach to caring for children and young people, develop future amendments to. The site also provides information on how to request copies of the original files. The purpose of an inquest is to establish who the deceased person was, and when, where and how they died. It is recommended that the Ministry of Labour, Training and Skills Development take steps to amend the. Coroners will look to establish the medical cause of death. That an accessible sobering centre with a locally developed model of care appropriate to meet the needs of Thunder Bay and surrounding communities be established. 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. Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders. In addition, such education should be repeated quarterly. Firearm risks, including the links between firearm ownership and, Opportunities for communities, friends, and families to play a role in the prevention and reporting of, Provide specialized and enhanced training of police officers with a goal of developing an, Establish a province-wide 24/7 hotline for men who need support to prevent them from engaging in, Provide services aimed at addressing perpetrators of. the cost of transportation for survivors and service providers. Refresher training should be delivered annually. Specifically, they should consider the length or passage of time since a volunteer had any criminal convictions and the nature of the criminal conviction to determine criteria that would increase Indigenous volunteers participation in Indigenous programing and to provide peer resources in an effective way. BBC Radio Sussex. The orientation should include hazards, work processes and medical issues, that may be unique to that work site. The dangers of working in proximity to overhead powerlines, even when no work on overhead power lines is intended. 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. To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. TT sidecar driver had passenger's dog tag - inquest. . 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. Create guidelines for staff in making decisions regarding whether to issue, review, revoke, or add conditions to. The audit should be independent and should result in an action plan that must be submitted to the. An an inquest is purely a fact-finding hearing; nobody is on trial. 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. The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model. The ministry should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. What permissible uses could be made of the documents and findings in a criminal proceeding. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones. 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. 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. Make adjustments to program curriculum and delivery methods according to gaps and opportunities identified. Include the development of strategic partnerships between the sobering centre, managed alcohol programming, medical providers, all subsidized housing providers and community care teams to provide and facilitate appropriate discharge planning for individuals who are to be released from the centre. As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights. 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. Most medical treatment-related Inquest hearings are held in public, usually without a jury, and the Coroner decides the verdict having heard all the necessary evidence. This should be a focus for performance management and quality assurance processes. The ministry should explore the feasibility of creating and implementing a plan for mental health assessments to be completed by a qualified professional within six hours of the admission, and for all other admissions procedures to be completed within 24 hours of the inmates admission. 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. 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. In jury inquests, the coroner directs the jury on matters of law and the jury decides the appropriate verdict . 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. 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. Continue working with the Ministry's partners to provide public awareness campaigns and educational materials relating to: Highlighting the dangers and risks associated with working in high temperatures, How workers should prepare themselves to safely work in high temperatures. It is recommended that training related to the management of change process take place on a regular basis (annual as a minimum) to ensure that all employees are continually informed as to what requires the initiation of the management of change process. This would both provide a warning and a specific ongoing reminder to any person entering such areas. 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. The ministry should investigate how security is assessed concerning spiritual elders, knowledge keepers, and traditional teachers. Older verdicts and recommendations, and responses to recommendations are available by request by: occ.inquiries@ontario.ca 1-877-991-9959 You can also access verdicts and recommendations using Westlaw Canada. Foster and support the co-development of life promotion programs such as Promote Life Together between Indigenous and non-Indigenous stakeholders to establish and develop meaningful programs and services, with an emphasis on the inclusion and engagement of Indigenous stakeholders from inception. 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. Amend the Construction Regulations to include a mandatory requirement for training of Health and Safety Representatives who work on construction projects. Continue to follow the international Cyanide Management Code. The verdict means the jury confirms the death is suspicious, but is unable to reach any other verdicts open to them. . That the sobering center meet the criteria for the designation of an alternate level of care by the Ministry of Health to permit paramedics to transport patients to the sobering center rather than an emergency room. 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. Require all police services to immediately inform the Chief Firearms Officer (, Create a Universal RMS records management system accessible by all police services (including federal, provincial, municipal, military and First Nations) in Ontario, with appropriate read/write access to all. The Ministry of Labour shall review and consider whether to impose a renewal requirement on Common Core Underground Certification. 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. When will a death be reported to the Coroner? The arresting officers and jailers must clearly indicate/communicate verbally and with diverse signage the procedures and rights of people in custody. (Note: this is included in both mining industry and Ministry of Labour section). 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. 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. This will be referred to as the inquest 'conclusion' or 'verdict.' If the cause remains in doubt after a post mortem, an inquest will be held. Risk assessments and risks of lethality are taken into account when making enforcement decisions. Said plan should include (but not be limited to): A mandatory mechanical safety review that each skid steer operator must complete each day, prior to commencing work. Explore and research the availability and efficacy of additional less-lethal use of force options for officers. Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a pilot project. Ensure that police officers can accurately identify their own, Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (. It should have no impact on Ontario Works or Ontario Disability Support Plan payments. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers). 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. Coroner's Duties The office of coroner became constitutional with statehood in 1818. Details of upcoming Openings, Inquest Hearings, Pre-Inquest Reviews, Documentary Inquests and Adjournments. The ministry should advocate for total compensation offered to nurses and healthcare staff be competitive with that in non-correctional settings. 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.