The Office of the Chief Coroner (OCC) for Ontario provides death investigations and inquests, when necessary, to ensure that no death is overlooked, concealed or ignored. The OCC use the findings to generate recommendations to help improve public safety and prevent future deaths in similar circumstances. The OCC distributes all verdicts and recommendations to organizations for them to implement, including:

  • agencies
  • associations
  • government ministries
  • other identified organizations may be identified in the recommendations

The OCC asks recipients to respond within six months to indicate if the recommendation(s) was implemented, and if not, the rationale for their position.

The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Older verdicts and recommendations, and responses to recommendations are available by request by:

You can also access verdicts and recommendations using Westlaw Canada.

November

Jeffrey, Mark King

Surname: Jeffrey
Given name(s): Mark King
Age: 34

Held at:  Toronto
From: November 22
To: December 1, 2021
By: Dr. Steven Bodley
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Mark King Jeffrey
Date and time of death:  June 29, 2015 at 4:07 p.m.
Place of death: Beaver Creek Institution, 2000 Beaver Creek Drive, Gravenhurst
Cause of death: Hanging
By what means: Suicide

(Original signed by: Foreperson)

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
  1. Correctional Services of Canada should:
    1. make the Anijaarniq: A Holistic Inuit Strategy publicly available
    2. ensure that Correctional Services of Canada staff are aware of the Anijaarniq Strategy and that it is implemented properly
  2. In recognition of the dislocation that Inuit face in custody, steps should be taken to ensure that Inuit serving their federal sentence, who wish to do so, maintain their family and community relationships to support them on their healing journey. In circumstances where an Inuk is unable to connect with their loved ones, with the authorization of the Inuk serving their federal sentence, Correctional Services of Canada should make best efforts to:
    1. engage in relationship-building with Inuit communities and organizations to establish partnerships that will help ensure that Inuit in custody are able to connect with their loved ones
    2. contact the local parole offices where possible, where the Inuk’s loved ones are located and/or an Inuit organization to attempt to establish contact with the loved ones
    3. explore ways in which the “Government of Canada” identifier that appears on the telephone be adjusted to ensure that it does not impact loved ones and cause them not to respond
  3. To recognize that Inuit in minimum security custody require Inuit-specific services, employment of Inuit staff at Inuit Centres of Excellence (as outlined in Anijaarniq) should be increased to meet the needs of Inuit in custody. This will include:
    1. engaging Inuit Elders and Inuit Liaison Officers at Inuit-designated facilities to determine what additional supports may be required
    2. making best efforts to ensure additional Inuit Elders and Inuit Liaison Officers are hired at Inuit- designated facilities
    3. making best efforts to ensure that the services of Inuit Elders and Inuit Liaison Officers are adequate at both medium and minimum security facilities
    4. ensuring that Regional Headquarters and/or National Headquarters will be made aware when there is insufficient Inuit staff and/or Elders on site when the regular Inuit staff/Elders are off work, or away from their work sites
    5. leveraging technology to provide Inuit in custody increased access to Inuit Elders and Inuit Liaison Officers
  4. Correctional Services of Canada should conduct a feasibility study about:
    1. moving the Inuit Centre of Excellence from Gravenhurst to an institution closer to Ottawa, Ontario
    2. increasing capacity for Inuit serving their federal sentence to serve their sentence in an existing Institution in Inuit Nunangat
  5. Correctional Services of Canada should explore ways to address the delays in payment to Inuit / Indigenous Elders and Inuit / Indigenous people who provide services to Correctional Services of Canada and for travel expenses. Efforts should be made to align payment schedules more closely with community standards (i.e. same day honoraria and compensation when bookings are cancelled).
  6. Correctional Services of Canada should conduct a feasibility study into establishing a s. 81 Healing Lodge in Ontario and the establishment of Healing Lodges for Inuit in Inuit Nunangat and/or in southern Canadian Cities where there are established Inuit communities, such as Ottawa.
  7. Correctional Services of Canada should develop training and education for competencies in Correctional Services of Canada staff knowledge of s. 81 Healing Lodges.
  8. In collaboration with Indigenous communities and organizations, Correctional Services of Canada should update Commissioner’s Directive 702 to include:
    1. distinguish between the realities of First Nations, Inuit and Métis people
    2. reflect that Elders and Indigenous Liaison Officers shall be on Case Management Teams for Indigenous people in custody who request their services or have an established relationship in place, and their views shall be accurately reflected in recommendation and decision-making documentation
    3. provide further particulars related to Indigenous Social History factors including how the factors are to be understood, applied, and reflected in recommendation and decision-making processes
    4. reflect that culturally appropriate/restorative alternatives such as resolution/Healing Circles and Elders should be considered before an increase to security classification and/or a transfer recommendation is made
    5. recognize that Elders and Indigenous Liaison Officers support the mental health of Indigenous people in custody and also offer spiritual supports
  9. When a s. 81 transfer decision is being contemplated, Correctional Services of Canada should work collaboratively with the Healing Lodge to ensure that an Indigenous person’s Healing Plan is not interrupted. The Healing Lodge’s views on whether the individual can be supported by their programming should inform decision-making.
  10. Correctional Services of Canada should provide the full range of effective therapeutic interventions for Inuit inmates are considered and based on self-identified needs, which may include Inuit-specific supports to include carving, Healing Circles, counseling with Elders, etc.
  11. The Anijaarniq: A Holistic Inuit Strategy must be co-developed, co-implemented and co-managed by Correctional Services of Canada and Inuit governments, Inuit land claim organizations and Inuit communities. This will include:
    1. creating a collaborative working group that includes stakeholders from Inuit land claims, Inuit governments and Inuit organizations to develop a better understanding of the distinct needs of Inuit in federal custody and developing a strategic implementation plan on how to address these needs
    2. the development of a mutually agreed upon implementation plan, accountability framework and shared responsibilities that will identify contributions and advancements by all parties engaged in the working group
    3. Inuit Centres of Excellence producing an annual report on the results of the Anijaarniq strategy for the Inuit governments, Inuit land claim organizations and Inuit organizations
  12. When an impactful recommendation or decision (security reclassification, transfer, etc.) is being made and/or delivered to an Inuk, Correctional Services of Canada should ensure that wraparound supports – such as Elders, Inuit/Indigenous Liaison Officers, health care, etc. – are offered within a reasonable time frame that the information is shared with the individual. Virtual alternatives should be considered if in-person staff is not available.
  13. Correctional Services of Canada explore ways in which to better understand and meaningfully address the relevant barriers to recruiting Inuit Elders, Inuit Liaison Officers and Inuit staff for Inuit Centres of Excellence, such as the possibility of Correctional Services of Canada providing the following employment supports for its Inuit staff, including Inuit contractors:
    1. relocation supports
    2. accommodation supports
    3. counselling supports
    4. transportation supports
    5. seniority incentives
    6. multi-year contracts
    7. offer services virtually where applicable (Elders can work from home)
  14. Training at Inuit Centres of Excellence must include all staff that are involved with Inuit offenders, including but not limited to parole officers, correctional staff, decision-makers, program and intervention staff. All training for staff must be documented and recorded and kept on personnel files. Training must be ongoing and require recertification training, if required, on an annual basis. This mandatory training must include:
    1. Inuit specific cultural awareness training that is an annual and multi-day training, including Mental Health First Aid for Inuit
    2. addictions training including drug awareness training
    3. training on the history of colonialism and the impacts of trauma and intergenerational trauma, and anti-racism training, including anti-bias training
    4. complete case notes/Offender Management System (OMS) document entry trainings with a focus on demonstrating how Indigenous Social History factors, and decisions like R. v. Ipeelee and the Gladue principles are applied.
  15. In collaboration with mental health practitioners, including Indigenous health practitioners, Correctional Services of Canada should:
    1. identify whether suicide prevention tools should be updated to take into account Indigenous Social History factors and Indigenous realities including suicide rates, recognizing that the suicide rates of Inuit are amongst the highest in the country
    2. develop and deliver training related to identifying and responding to suicidality in their peers
    3. develop practices that promote scientific-based and holistic responses to drug use
  16. Orientation training should be provided to Inuit Elders and Inuit Liaison Officers with respect to the OMS. This training should include:
    1. information on how to review entries made by staff to ensure that events and interactions are accurately reflected
    2. information on how Inuit Elders, with the assistance of Inuit Liaison Officers, are to enter information into the OMS to ensure that their views are recorded and accurately reflected
  17. In order to commemorate the life of Mark Jeffrey, and his dedication and advocacy toward Inuit in custody, including his role as Chairperson of the Inuit Inmate Committee and Chairperson of the Carving Shed, work with the Inuit population at Beaver Creek Institution and other interested parties to develop a memorial in his honour.
  18. When an incompatibility exists between an Inuk and a non-Inuk and a transfer is being contemplated, additional or specific consideration should be given to the individual who has established community and cultural connections at Beaver Creek Institution or another Inuit Centre of Excellence.
  19. With respect to recommendations and decisions being made about individuals in custody, any conversations and investigations occurring must be clearly documented and provided to the individual in custody to ensure that their procedural fairness rights are not violated.

Moffat, Aaron

Surname: Moffat
Given name(s): Aaron
Age: 32

Held at:  Toronto
From: November 15
To: November 19, 2021
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Aaron Moffat
Date and time of death:  February 3, 2018 at 6:20 a.m.
Place of death: Bluewater Health
Cause of death: Hypoxic-ischemic encephalopathy due to hanging
By what means: Suicide

(Original signed by: Foreperson)

The verdict was received on November 19, 2021
Coroner's name: Dr. David Eden
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Aaron Moffat

Jury recommendations
To the Ministry of the Solicitor General:

Methadone treatment and opioid withdrawal

  1. The Ministry of the Solicitor General’s Correctional Service’s (ministry) policy on methadone maintenance treatment require that all inmates on community methadone maintenance treatment should receive continuity of care with every effort made to provide daily dispensing of methadone within 24 hours of incarceration, without any gaps in care, to avoid opioid withdrawal and ensuing physical and psychological distress that accompanies opioid withdrawal.
  2. The ministry policy on opioid withdrawal require that opioid withdrawal should be considered a significant contributing factor of patient distress, including distress that can contribute to suicidal ideation and suicidal behaviours and attempts.
  3. The ministry’s policy on withdrawal require that in the event the individual does not receive continuity of methadone within 24 hours, an inmate must be clinically reassessed for opioid withdrawal, on an ongoing basis, and provided pharmacologic options for the treatment of withdrawal symptoms. The pharmacologic management of opioid withdrawal should be monitored for adequate response.
  4. The ministry should consider auditing incarceration facilities that engage with an external service to provide Opioid Agonist Treatment (OAT) to ensure a formal written agreement detailing the expectations and responsibilities of both the institution and the service be executed, including scope of service, hours of service, on-call expectations, timelines for responding to calls and agreement to adhere to ministry OAT policies.
  5. The ministry’s policies should include regular assessments of jail cell infrastructure to identify and reduce potential anchor points.

Suicidality

  1. The ministry change its Interim Health Care Part A form so that the section on suicidality removes the word specify and replaces it with specify and explore and document detailed assessment in Health Care Part D. The ministry will provide training to all its nurses on the expectations with respect to this change.
  2. The ministry amend the COWS form so that the suicide screening section include a tick box for health care professionals completing this form to document that they have completed the screening on this specific section.
Other recommendations specific to the Sarnia Jail:

Methadone treatment and opioid withdrawal

  1. The Sarnia Jail, in consultation with the primary care practitioners, develop a strategy to ensure timely access including treatment continuity to OAT including methadone. If an external service is engaged to provide OAT, a written agreement detailing the expectations and responsibilities of both the Sarnia Jail and the service be executed, including scope of service, hours of service, on-call expectations, timelines for responding to calls and agreement to adhere to ministry OAT policies.
  2. Until an agreement with the Sarnia Jail and the OAT service provider is established which outlines a protocol addressing communication, the Sarnia Jail’s Health Care Unit is to create a written direction for health care professionals at the Sarnia Jail in respect of communications for the purposes of obtaining methadone prescription. The direction is to require health care professionals at the Sarnia Jail to accurately document in the Health Care Record D all attempts to contact the Sarnia Jail on-contract physician and/or the OAT provider and to follow up with the Sarnia Jail on- contract physician and/or OAT provider every 2 hours if a response is not received; and if there are any communication issues escalate to the health care manager.
  3. The Sarnia Jail’s on-contract primary care physician must be able to prescribe methadone to ensure treatment continuity.

Mental health services

  1. The Sarnia Jail conduct a needs assessment to determine a schedule for mental health nurses that best addresses the needs of patients in the Sarnia Jail. The assessment may conclude a need for extended hours (into the evenings or weekends).
  2. The Sarnia Jail should consider a 24/7 on-call mental health care professional to ensure continuity of mental health needs of the individual are adequately addressed and advocated for.

October

Picanco, Michael

Surname: Picanco
Given name(s): Michael
Age: 35

Held at:  Toronto
From: October 25
To: October 27, 2021
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Michael Picanco
Date and time of death:  Pronounced on July 25, 2014 at 12:45 a.m. (presumed to have occurred at approximately 2:30 p.m. on July 24, 2014
Place of death: 24 Venn Crescent, Toronto
Cause of death: Crush asphyxia due to trench collapse on a construction site
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on October 27, 2021
Coroner's name: Dr. David Eden
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Michael Picanco

Jury recommendations
The Government of Ontario
  1. The Government of Ontario shall specify a date forthwith for the new amendments adding subsections 5.1, 5.2 and 5.3 to section 8 of the Occupational Health and Safety Act, 1990 (OHSA) to come into force. This amendment requires that the constructor or employer shall ensure health and safety representatives receive training that enables them to exercise their powers and perform their duties effectively (OHSA, s. 8(5.1-5.3)).
  2. The Government of Ontario should consider new amendments to the OHSA in regards to requiring a health and safety representative for workplaces that have less than six workers.
  3. The Government of Ontario shall amend s. 10(5) of the Coroner’s Act, 1990 to provide that an inquest must be held as soon as practicable, and if possible, within 24 months of the date of death.
Utility Force Inc.
  1. Utility Force shall conduct a comprehensive review of their health and safety program and policy to ensure compliance with OHSA regulations.
  2. Utility Force shall train all employees in trenching and excavation safety awareness upon hiring.
  3. Utility Force shall conduct refresher training and relevant toolbox talks to remind employees, and reinforce the importance, of safe practices.
  4. Utility Force shall ensure that the appropriate equipment is available for use prior to starting a job, including but not limited to providing an adequate trench box and/or shoring materials.
  5. Utility Force shall ensure all appropriate equipment is used and safety practices are followed at each jobsite.
Field Visits
  1. When issuing an order for compliance, Ministry of Labour, Training and Skills Development (MLTSD) inspectors shall conduct a check on the parties to note if there is a history of non-compliance.
  2. The MLTSD should implement a progressive disciplinary response when multiple non-compliance orders are found.
  3. The MLTSD should conduct a review of the employer’s occupational health and safety program and policy and employee orientation when multiple non-compliance orders are found.
  4. MLTSD inspectors shall conduct more frequent proactive visits, without notice, to an employer’s jobsites when they have previously been found in violation of OHSA Regulations.
  5. The MLTSD should consider posting all orders and charges together with any subsequent dispositions, convictions and/or sentences imposed relating to any constructors and/or employers, and press releases for the public to access.
Mandatory Training
  1. The MLTSD shall introduce mandatory and dedicated training courses for:
    1. trench and excavation safety awareness for workers who may perform and/or supervise such work
    2. the right to refuse unsafe work without reprisal or fear of reprisal
  2. The MLTSD should consider introducing worker certification for items 14.i. and 14.ii. that would be required as proof of competency on relevant jobsites.
MLTSD and Infrastructure Health and Safety Association
  1. Consider further strategies to engage with small construction contractors to ensure they have access to adequate training resources for their employees.

Sanchez, Jesus Revilla

Surname: Sanchez
Given name(s): Jesus Revilla
Age: 38

Held at:  Virtually at 25 Morton Shulman Ave, Toronto
From: October 18
To: October 19, 2021
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jesus Revilla Sanchez
Date and time of death:  December 5, 1996 at 11:35 p.m.
Place of death: Perth Great War Memorial Hospital, Perth
Cause of death: Multiple trauma
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on October 19, 2021
Coroner's name: Dr. Geoffrey Bond
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Jesus Revilla Sanchez

Jury recommendations
To: Ministry of Labour, Training and Skills Development

Amend the Notice of Project requirement in the Construction Regulation to require constructors to identify high risk hazards that will be present at the workplace (for example, fall hazards).

Steinfort, Allan

Surname: Steinfort
Given name(s): Allan
Age: 53

Held at:  Marriott Courtyard, Kingston
From: October 13
To: October 14, 2021
By: Dr. Bob Reddoch
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Allan Steinfort
Date and time of death:  August 7, 2018 at 3:06 p.m.
Place of death: Kingston General Hospital
Cause of death: Hanging
By what means: Suicide

(Original signed by: Foreperson)

The verdict was received on October 14, 2021
Coroner's name: Dr. Bob Reddoch
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Allan Steinfort

Jury recommendations
To the Solicitor General:

The coroner's jury recommends the following:

  1. It is recommended that access to records concerning medical, mental health and previous incarcerations are easily accessed at the time of assessment by an appropriate professional.
  2. It is recommended that a mental health assessment must be completed by a qualified professional in a timely fashion.

It is recommended that the Brief Jail Mental Health Screen Form (2005) be updated to reflect current mental health protocols.

Robertson, Barry

Surname: Robertson
Given name(s): Barry
Age: 31

Held at:  Toronto
From: October 6
To: October 8, 2021
By: Dr. Bob Reddoch
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Barry Robertson
Date and time of death:  March 26, 2012, at 12:18 a.m.
Place of death: The Ottawa Hospital, Civic Campus
Cause of death: Electrocution
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on October 8, 2021
Coroner's name: Dr. Bob Reddoch
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Barry Robertson

Jury recommendations
To the Ministry of Labour, Training and Skills Development and the Infrastructure Health and Safety Association:
  1. In safety courses for construction workers who may operate in the vicinity of power lines or conductors, consider including a special emphasis on teaching the need for a dedicated signaller for all crews. It is recommended to emphasize the extra caution when working close to the power lines. The signaller(s) or the dedicated spotter(s) should have sufficient knowledge and control of the situation.
  2. Consider incorporating a hands-on simulation to demonstrate various ways this hazard may present in an ever-changing workplace – including risk assessment, the appropriate equipment required for the job given the potential hazards present, signaller, emergency protocols, and only trained individuals should be operating the equipment, with no interchange of the duties.
  3. Consider emphasizing the requirement for workers to stop working, step back and re-assess the work being done once a new hazard presents itself. Create a safe environment for the employees to identify risks and hazards and voice their concerns about safety.
  4. The Ministry of Labour, Training and Skills Development should consider endorsing recommendations 1, 2 and 3.
To the Infrastructure Health and Safety Association
  1. With respect to constructors and employers who work close to active power lines, including use of a Hydrovac truck while doing construction:
    Explore the literature and data to determine if the below points would assist in increasing the safety of workers, who are completing construction tasks near live power lines:
    • installing rubber mats under workers
    • using overhead wrap around the live cable wires
    • adding signage to warn of the potential danger
    • adding visual indicators or flags that will show where the limit of the approach begins
    • equipping each construction site with an automated external defibrillator (AED) onsite and training each person on the construction site on how to use the AED
    • using an insulated boom rather than an uninsulated boom on the job site
To Hydro Ottawa and similar electrical companies:
  1. Provide documented information to contractors and subcontractors on the hazards of the job including power line height and voltage.
  2. Increase site visits of the active job sites to ensure compliance.
  3. Review contractors’/sub-contractors’ safety-related training records and the company’s health and safety policy and procedures to ensure they are up-to-date and sufficiently meet safety requirements.
  4. Perform an annual assessment and orientation refresher with long-standing contractors.
  5. Assess the protocols in determining when to turn off the power lines for contracted jobs; when possible, turn off the power.
  6. Review and assess the protocol to have the electrical company called before 911 emergency personnel in the event of an incident to avoid delay of assistance.

August

Peltier, Carl

Surname: Peltier
Given name(s): Carl
Age: 54

Held at: Little Current
From: August 9
To: August 10, 2021
By: Dr. Steven Bodley
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Carl James Isaiah Peltier
Date and time of death:  August 21, 2017 at 4:38 p.m.
Place of death: Health Sciences North, Sudbury
Cause of death: Crushing chest injury with compressional asphyxia caused by collapsed trusses
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on August 10, 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: Carl Peltier

Jury recommendations
  1. That the provincial government and the Ministry of Labour Training and Skills Development (MOLTSD) make a concerted effort to reach out to small construction crews (1-5 workers) to assist their employees with their personal obligations to promote safety as laid out in Occupational Health and Safety Act (OHSA) and its regulations.
  2. That the provincial government and the MOLTSD explore the creation of training modules for supervisors and crew members involved in the erection of trusses under OHSA and its regulations.
  3. That the provincial government and the MOLTSD continue to explore making the complexity of the project instead of the dollar value of the project the prerequisite for the requirement to file a Notice of Project under Section 5 of the Construction Regulation under OHSA.
  4. That Professional Engineers Ontario should consider providing specific installation/bracing guidelines with the engineered drawings in regards to the installation of trusses.

 

July

Zaraeeneh, Ali

Surname: Zaraeeneh
Given name(s): Ali
Age: 25

Held at: Toronto
From: July 26
To: August 3, 2021
By: Dr. Mara Goldstein
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ali Zaraeeneh
Date and time of death:  December 13, 2017 at 10:47 p.m.
Place of death: 1520 Major Mackenzie Drive West, Vaughan
Cause of death: Perforating gunshot wounds of head
By what means: Homicide

(Original signed by: Foreperson)

The verdict was received on August 3, 2021
Coroner's name: Dr. Mara Goldstein
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Ali Zaraeeneh

Jury recommendations
To the Ontario College of Family Physicians:
  1. It is recommended that family physicians provide improved education and support to families with respect to accessing the Form 2 process under the Mental Health Act.
  2. It is recommended that family physicians improve their awareness of their authority to initiate the Form 1 process under the Mental Health Act.
  3. It is recommended that family physicians enhance their awareness of community resources available to assist families struggling to support a loved one who is experiencing mental health challenges.
  4. It is recommended that family physician practice groups practice within a collaborative care model, with access to advice and consultation from dedicated psychiatrists.
  5. It is recommended that family physicians facilitate access to assertive multidisciplinary mental health outreach teams for people experiencing, or at great risk of experiencing, their first episode of psychotic symptoms. It is recommended that coverage and access to these teams be enhanced.
  6. It is recommended that family physicians follow up and record attempted contact with patients, who they have seen regarding possible mental health concerns, to ensure recommendations were acted upon.
To the Ontario Hospital Association:
  1. It is recommended that emergency departments within hospitals facilitate access to assertive multidisciplinary mental health outreach teams for people experiencing, or at great risk of experiencing, their first episode of psychotic symptoms. It is recommended that coverage and access to these teams be enhanced.
  2. It is recommended that emergency departments within hospitals follow up with individuals following discharge from an emergency department visit in which a referral for mental health was made. The attempt at contact should be documented in the individuals’ files.

June

Wright, Bradley

Surname: Wright
Given name(s): Bradley
Age: 55

Held at: Virtually - 25 Morton Shulman Avenue, Toronto
From: June 23
To: June 25, 2021
By: Dr. Steven Bodley
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Bradley Wright
Date and time of death:  April 2, 2018 at 2:43 p.m
Place of death: 56 Ambrosia Terrace Trenton
Cause of death: Multiple injuries due to a fall of ground from a collapsed trench
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on June 25, 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: Bradley Wright

Jury recommendations
Ministry of Labour, Training and Skills Development (MLTSD)
  1. Amend the Construction regulations to include:
    1. Mandatory training on trenching regulations for all workers who are required to dig or enter a trench.
    2. Mandatory training of all supervisors, or workers functioning in a supervisory role, on the regulations governing any anticipated construction activities specific to their worksite(s). For example, if trenching is anticipated to be necessary, they should be completely prepared to offer guidance to workers who will be entering the trench.
  2. Consider strategies for partnering with municipal building departments to provide constructors with information about the applicable regulations when they apply for building permits.
  3. Consider adding an alternative quantitative methodology for identification of soil type to the existing qualitative methodology in O. Reg. 213/91 -Sec 226 to reduce ambiguity in selection of soil type when quantitative information is available.
MLTSD and Infrastructure Health and Safety Association
  1. Conduct a comprehensive review of current strategies for engaging with constructors and their employees. Develop and implement more effective strategies to ensure that these companies and workers:
    1. are aware of their legal obligations and rights under the OHSA and construction regulations
    2. are aware of and have access to resources to help identify and eliminate hazards at their workplaces
    3. are aware of and have access to training resources to protect the health and safety of workers.
City of Quinte West and the Association of Municipalities of Ontario
  1. Encourage communication between building inspectors and their managers about workplace hazards observed during building inspections. Inspectors should be encouraged to reflect on and report situations where workers are potentially at risk from hazards or incomplete application of construction regulations. Managers and inspectors should work together to promote safety on these worksites and communicate any concerns to the workplace parties and/or MLTSD when appropriate.
  2. Consider the provision of OHSA and construction regulation training to building inspectors and their managers to educate them on safe working conditions and to be able to identify unsafe working conditions.
  3. Consider a change to the way developers install municipal services, such that the connection for sewer pipes are higher than the current practice and separated from the other services such as hydro and gas connections. This would allow constructors of new homes to avoid dangerously deep trenches when connecting site services.

Dakaj, Ismet

Surname: Dakaj
Given name(s): Ismet
Age: 46

Held at: Virtually - 25 Morton Shulman Avenue, Toronto
From: June 8
To: June 11, 2021
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ismet Dakaj
Date and time of death:  Approximately 8:19 a.m., June 27, 2014
Place of death: Derry Rd. construction site, Milton
Cause of death: Blunt force injuries of the head, neck and torso as a consequence of being run over by a dump truck
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on June 11, 2021
Coroner's name: Dr. David Eden
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Ismet Dakaj

Jury Recommendations
To the Ministry of Labour, Training and Skills Development (MLTSD)

Proposed legislative amendments

  1. Review s. 104 of Regulation 213/91 (“The Regulations”) under the Occupational Health and Safety Act (OHSA) to eliminate potentially inconsistent language concerning the reversing of vehicles on worksites (i.e. “no practical alternative” v. “as little as possible”). Legislate a requirement that for projects meeting this requisite standard, and where a construction vehicle’s predominant mode of operation will be reversing, MLTSD pre-approval and ongoing oversight is required.
  2. Amend s. 106 of the regulations to clarify that vehicles cannot reverse unless the driver maintains constant sight of the signalperson — otherwise, the driver must immediately stop the vehicle.
  3. Amend s. 106(2) of the regulations to require that all workers on a construction site must maintain at least two meters distance from any moving construction vehicle.
  4. Regularly review the maximum penalty(s) that may be imposed upon a corporation pursuant to section s. 66(2) of the OHSA to ensure they still satisfy the underlying principles of sentencing under the act. Study the appropriateness of imposing a minimum fine for OHSA violations directly resulting in the death of a construction worker. Study the appropriateness of imposing a minimum fine for other OHSA violations of s. 106 such as instances where a signaller is performing multiple functions.

Proposed legislative additions

  1. Mandate under the OHSA and/or its Regulations that all construction vehicles, including dump trucks, on a construction site must be equipped with a properly functioning back-up camera.
  2. Mandate under the OHSA and/or its Regulations that workers on construction sites must be provided, understand and formally acknowledge written documentation of all existing safety and communication protocols on a worksite. Similarly, risk management strategies and evaluations, as currently contemplated under the OHSA, must be formalized, reduced to writing and readily accessible to all workers.
  3. Mandate under the OHSA and/or its Regulations that constructors and employers must hold and document regularly scheduled safety meetings incorporating all workers, employees and/or additional parties who may reasonably be expected to attend at or near a construction site, including third-parties (e.g. pay-duty police officers). A site orientation package listing all existing safety requirements and protocols must be provided to attendees.
  4. Mandate under the OHSA and/or its Regulations that all drivers operating a construction vehicle acknowledge in writing the requirements enumerated in ss. 104-106 of the Regulations.
  5. Mandate under the OHSA and/or its Regulations that signage including ss. 104-106 be posted on site in areas where vehicles may be regularly operated in reverse.
  6. Mandate under the OHSA and/or its Regulations that work on a construction site deemed to require pay-duty officers shall not commence until the pay-duty officers are in place in strict accordance with a pre-established, documented safety and communications plan established by the employer/constructor.
  7. In consultation with the Infrastructure Health & Safety Association (IHSA), draft standardized training materials for signalpersons and traffic control persons. Mandate the provision of this training, and periodic refreshment thereof, to signalpersons and traffic control persons by their respective constructor, employer and/or supervisor, as applicable, and in accordance with site-specific requirements prior to the commencement of any work. Documentation of training completion to be maintained on site.

Additional recommendations

  1. Incorporate safe construction vehicle reversing practices, including the proper use of signalpersons on construction sites, into the standardized DZ licensing curriculum.
  2. Issue forthwith a province-wide bulletin and/or public awareness campaign — specifically targeting construction workers and heavy equipment operators — reemphasizing the requirements and importance of ss. 104-106 of the Regulations.
To the Ministry of the Solicitor General
  1. Minister of the Solicitor General to amend s. 10(5) of the Coroners Act to provide that an inquest must be held as soon as practicable.
To New Alliance and or other constructor and/or employer
  1. Constructor/employer to implement, monitor and enforce existing OHSA Regulations, specifically relating to reversing vehicles, safe signaling and on-site communication protocols.
  2. Constructor/employer to continually monitor and revise signalperson, driver and traffic control training in accordance with ministry standards, supplemented as required to meet site-specific requirements.
  3. Constructor/employer to develop protocols as part of the safety plan for safe, consistent communication with third-parties – including the police and other organizations – who may reasonably be expected to interact with site workers in the execution of their duties.
  4. Constructor/employer to develop protocols as part of the safety plan that ensure that new hires, particularly from temporary agencies, meet all Ministry of Labour standards (i.e. are competent as defined in the Regulations) prior to commencing work of any kind on the site.
  5. Constructor/employer to develop protocols as part of the safety plan that ensure a designated stop point with clear signage/markings where construction vehicles enter/intersect a public roadway.
  6. Constructor/employer to develop as part of the safety plan to provide radios to both drivers and signalers where reversing is used as the method of transport.
  7. Constructor/employer to post signage in multiple accessible locations containing Whistleblower contact information for workers.
To police services in Ontario
  1. Amend the pay-duty policies of all police services in Ontario to require that any employer or constructor requesting pay duty officers to attend at or near a construction worksite submit to the relevant police service a current Traffic Control Plan and a copy of the employer or constructor’s current traffic control and signaller protocols.
  2. Amend the pay-duty policies of all police services in Ontario to include a provision that any pay duty officer attending at or near a construction worksite in a pay-duty capacity must be fully informed prior to arrival of the employer/constructor’s current traffic control and signaller protocols, as updated by the employer/constructor.