Chronological listing of verdicts and recommendations

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.

January

Blumberg, Alexsey
Bondarevs, Aleksandrs
Fayzullo, Fazilov
Korostin, Vladimir

Names of the deceased: Blumberg, Alexsey; Bondarevs, Aleksandrs; Fayzullo, Fazilov; Korostin, Vladimir
Held at: remote inquest
From: January 31
To: February 4, 2022
By: Dr. John Carlisle, coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Blumberg
Given name(s): Alexsey
Age: 38

Date and time of death:  December 24, 2009 at 4:30 p.m.
Place of death: 2757 Kipling Avenue, Toronto
Cause of death: multiple injuries due to a fall from a suspended work platform
By what means: accident

Surname: Bondarevs
Given name(s): Alexsandrs
Age: 24

Date and time of death:  December 24, 2009 at 4:30 p.m.
Place of death: 2757 Kipling Avenue, Toronto
Cause of death: multiple injuries due to a fall from a suspended work platform
By what means: accident

Surname: Fazilov
Given name(s): Fayzullo
Age: 31

Date and time of death:  December 24, 2009 at 4:30 p.m.
Place of death: 2757 Kipling Avenue, Toronto
Cause of death: multiple injuries due to a fall from a suspended work platform
By what means: accident

Surname: Korostin
Given name(s): Vladimir
Age: 40

Date and time of death:  December 24, 2009 at 4:30 p.m.
Place of death: 2757 Kipling Avenue, Toronto
Cause of death: multiple injuries due to a fall from a suspended work platform
By what means: accident

(Original signed by: Foreperson)

The verdict was received on February 4, 2020
Coroner's name: Dr. John Carlisle​
(Original signed by coroner)

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

Inquest into the deaths of: Aleksey Blumberg, Aleksandrs Bondarevs, Fayzullo Fazilov and Vladimir Korostin

Jury recommendations
To the Ministry of Labour, Training and Skills Development:
  1. Amend the Construction Regulations to include a mandatory requirement for training of Health and Safety Representatives who work on construction projects.
  2. 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.
  3. Conduct scans of other jurisdictions’ use of emerging technologies and partnerships in the proactive reduction of workplace injuries and fatalities. Provide annual reports, accessible to the public, on ongoing research findings through the Chief Prevention Officer.
  4. Add a requirement under O. Reg. 213/91 for any supervisor of workers working at heights and/or using a supervisor to take the Working at Heights training under section 138.
  5. Chief Prevention Officer to track effectiveness of the Working at Heights training program through regular evaluations and public-facing reporting to demonstrate the relationship between the Working at Heights training program and falls from heights data generated through the Prevention Division. Make adjustments to program curriculum and delivery methods according to gaps and opportunities identified.
  6. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers).
  7. Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training.

February

MacDougall, Quinn Emerson

Surname: MacDougall
Given name(s): Quinn Emmerson
Age: 19

Held at:  25 Morton Schulman Avenue, Toronto (virtually)
From: February 28
To: March 11, 2022
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Quinn Emmerson MacDougall
Date and time of death:  April 3, 2018 at 4:23 p.m.
Place of death: Hamilton General Hospital, 237 Barton Street East, Hamilton, Ontario
Cause of death: gunshot wound of the torso (right chest)
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on March 11, 2022
Coroner's name: Dr. David Eden
(Original signed by coroner)

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

Inquest into the death of: Quinn Emerson MacDougall

Jury recommendations
Directed to the Ministry of the Solicitor General
  1. Review the current Use of Force Model (2004) and related regulations, and consider de-emphasizing use of the term "force" and employing alternative terminology.
  2. Review the current Use of Force Model (2004) and related regulations, and consider incorporating the concept of de-escalation expressly (both in terminology and visual representation) into the Model as a response option and/or goal.
  3. Explore and research the availability and efficacy of additional less-lethal use of force options for officers.
  4. For conductive energy weapons consider high visibility markings (colour) to differentiate them from firearms.
Directed to the Hamilton Police Service
  1. Explore the capability of the information management systems to “track” the deployment of alternative responses to assist a person in crisis and the outcomes. 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.
  2. Explore the capability of the information management systems to accurately capture the number of calls for service which are initially reported and dispatched as another type of call but are later assessed by the responding officers to be a call which has a significant person in crisis component. 
  3. Explore, with community mental health partners, the feasibility of extending the availability of Mobile Crisis Rapid Response Team (MCRRT) Units to 24 hours a day and of increasing the number of MCRRT units available to respond to calls at all times.
Directed to all Police Services in Ontario
  1. If none already exists, explore with community mental health partners, the feasibility of establishing and adequately resourcing joint mental health-police response teams to assist with person in crisis calls for service.
  2. If a police service has a joint mental health-police team, give studied consideration to implementing a police policy that provides, once police officers attending a call identify a potential mental health concern and provided it is safe to do so, that the joint mental health-police team should be engaged.
  3. Explore developing and providing all police officers with additional de-escalation training.
Directed to the Ontario Police College and the Ministry of the Solicitor General
  1. Explore developing and providing all police recruits with additional de-escalation training.
  2. Consider including conductive energy weapons training as part of the mandatory curriculum for police recruits at the Ontario Police College with a yearly re-certification.
  3. 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.

April

Santos, Fernando

Surname: Santos
Given name(s): Fernando
Age: 59

Held at:  25 Morton Schulman Avenue, Toronto
From: April 4
To: April 7, 2022
By: Dr. Robert Boyko
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Fernando Santos
Date and time of death:  January 23, 2018 at 3:38 p.m.
Place of death: 1575 Lakeshore Road West, Mississauga
Cause of death: blunt force trauma of the torso
By what means: accident

(Original signed by: Foreperson)

The verdict was received on April 7, 2022
Coroner's name: Dr. Robert Boyko
(Original signed by coroner)

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

Inquest into the death of: Fernando Santos

Jury recommendations

No recommendations.

Saidi, Babak

Surname: Saidi
Given name(s): Babak
Age: 43

Held at:  Ottawa
From: April 20
To: April 29, 2022
By: Dr. Bob Reddoch
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Babak Saidi
Date and time of death:  December 23, 2017 at 11:30 a.m.
Place of death: Morrisburg, Ontario
Cause of death: gunshot wounds to the right shoulder and right side of the back.
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on April 29, 2022
Coroner's name: Dr. Bob Reddoch
(Original signed by coroner)

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

Inquest into the death of: Babak Saidi

Jury recommendations
To the Ontario Provincial Police:

The Ontario Provincial Police (OPP) should:

  1. Develop, establish, and provide regular training to OPP officers on a policy addressing the planning and approach to arrests of individuals in potentially higher risk circumstances (the “policy”), which should include the following considerations:
    1. circumstances in which the policy is applicable, including when an individual would be considered potentially dangerous
    2. involving a supervising officer in the planning of the arrest, when possible
    3. completing an arrest decision tool, which may include a checklist of criteria
    4. how and when to contact the OPP Threat and Behavioural Analysis Team (TBAT) for information and assistance
    5. how to identify possible factors that could complicate an arrest, such as possible mental health issues, unpredictability, past incidents with police, and violent history
  2. 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. In the case of high risk and dangerous subjects, consider the application of Situation Mission Execution Administration Command & Communication (SMEAC) adapted for arrest planning.
  3. Where there is an existing threat assessment on file, provide contact information so that TBAT can discuss the assessment with the enquiring member.
  4. Deliver training to frontline officers on the purpose of the Crime Abatement Program, the information included in Crime Abatement Program records, and how to access such records.
  5. 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.
  6. Implement regular reviews to ensure the accuracy and reliability of the information in the records management system available to officers.
  7. Ensure that any arrest planning course delivered by the OPP Academy includes training on how to assess and integrate the strengths and weaknesses of frontline officers at the planning, briefing, and execution stages of an arrest.
  8. Develop a mandatory training course for sergeants delivered by the OPP Academy pertaining to their role in leadership and mentorship, regarding planning, briefing, and execution stages of an arrest.
  9. Provide dedicated mandatory mental health training as part of the annual block training delivered to officers through the OPP Academy. Ensure that appropriate “people-first language” (type of linguistic prescription which puts a person before a diagnosis, describing what a person “has” rather than asserting what a person “is”) is embedded into the training.
  10. 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 OPP officers.
  11. Develop and deliver training for constables and sergeants on interpersonal skills, emotional intelligence, leadership, and team building. This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools.
  12. Consider the circumstances of all police-related inquests as training scenarios.
  13. Consider re-allocating more time to scenario-based de-escalation training during annual use of force certification at the OPP Academy.
  14. Post the verdict and recommendations of this inquest on the OPP Connections system, or otherwise distribute the verdict and recommendations to OPP officers. If possible, share with other Canadian police services.
To the Ministry of the Solicitor General

The Ministry of the Solicitor General should:

  1. Revise the provincial Use of Force Model (2004) as soon as possible. In particular, the Model should explicitly include an emphasis on de-escalation as a foundational principle, and de-escalation techniques should be embedded within the Model.
  2. Consider renaming the Model to better reflect the range of tools and techniques available to officers.

May

Ekamba, Marc Diza

Surname: Ekamba
Given name(s): Marc Diza
Age: 22

Held at:  Toronto
From: May 16
To: June 3, 2022
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Marc Diza Ekamba
Date and time of death: March 20, 2015 at 10:53 p.m.
Place of death: 3070 Queen Frederica Drive, Mississauga, Ontario
Cause of death: multiple gunshot wounds
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on June 3, 2022
Coroner's name: Dr. David Eden
(Original signed by coroner)

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

Inquest into the death of: Marc Diza Ekamba

Jury recommendations
To all Ontario police services:
  1. Improve knowledge and awareness for police communicators, call takers, and dispatchers of the signs of mental health crisis, and ensure that communicators are trained to ask questions directed at determining whether a call involves a mental health crisis.
  2. Ensure that police officers responding to a mental health crisis are aware that police have responded previously to incidents involving the same parties, and facilitate access for responding officers to significant information regarding previous calls.
  3. Ensure that all police officers who interact directly with the public are provided with the four-day mental health training currently provided to incoming police officers in their first year of service. Regular refresher training on mental health issues should be provided to all police officers who interact with the public.
  4. Ensure that police officers can accurately identify their own Mental Health Act options and explain options available to complainants when a mental health issue is the basis for criminal conduct.
  5. Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (OPC), and engage with the OPC on its experience with the training and its potential implementation.
  6. Ensure that persons with lived experience from peer-run organizations are directly involved in the development and delivery of both mental health crisis and de-escalation training.
  7. Mandate that all police service officers receive annual implicit bias and cultural competency training to address stereotyping of Black people, and the existing research on anti-Black racism in policing.
  8. Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations.
  9. Develop and implement a pilot project to explore the feasibility of dispatching crisis support workers to mental health service calls that do not require police involvement, similar to Peel Regional Police Mental Health Strategies.
  10. Create emotionally supportive debrief sessions for police officers at the division or platoon level for those involved in critical incidents resulting in serious bodily harm or death, with regard for the Special Investigations Unit investigative process.
  11. Ensure that witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports.
  12. Police services and police services boards shall establish standing or advisory committees on race and impartial policing and on mental health in order to meet with representatives of peer-run organizations and members of affected communities on an ongoing basis to discuss concerns and facilitate solutions.
  13. 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.
  14. Police services and police services boards shall establish permanent data collection and retention systems to record race, mental health issues, and other relevant factors on use of force incidents. The data should be standardized, disaggregated, tabulated and publicly reported. The data should include age, gender, perceived race, and officer perception of whether the individual has any mental health issues;
  15. The results of the data collected on use of force incidents must be taught to all frontline police officers.
  16. 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:
    1. develop an objective methodology to measure and evaluate police service performance on use of force
    2. take corrective action to address systemic discrimination
    3. provide clear and transparent information to the public on biased and discriminatory use of force
  17. Training for new officers should be amended so that the question of the suspect’s mental health be as prominent in their considerations as the criminal activity they have committed.
  18. Training should be given to establish who should lead the call when dealing with a potentially violent incident or crisis.

    All Ontario police services should seek and allocate funding and resources adequate to implement the above recommendations.
To the Peel Regional Police:
  1. Re-evaluate the capacity of Community Outreach and Support and Mobile Crisis Rapid Response teams to meet the growing need for these services in the Region of Peel.

    Peel Regional Police should seek and allocate funding and resources adequate to implement the above recommendations.
To the Ministry of the Solicitor General:
  1. The Ontario Use of Force model should be renamed to accurately capture the intent and purpose of the model, which is a guide to police engagement with the public rather than to suggest that force is inherent in police interactions.
  2. The Ontario Use of Force model shall be redesigned to highlight and emphasize the importance of de-escalation at all points during police interactions.
  3. The OPC shall ensure that persons with lived experience are engaged in the development and delivery of de-escalation training.
  4. The OPC shall ensure that affected communities and persons with lived experience be directly engaged in the development and delivery of anti-bias training. The OPC should ensure that community organizations who represent persons with lived experience are engaged in this work.
  5. Revise the use of force report form to require officers to document de-escalation techniques used.
To the Ministry of the Solicitor General and Peel Regional Police:
  1. There must be special recognition of the unique challenges Black people who also have serious mental health issues face when they come into contact with police. 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 Ministry of the Solicitor General and Peel Regional Police should seek and allocate funding and resources adequate to implement the above recommendations.
To the government of Ontario:
  1. 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. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience.
  2. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. Measures to improve public awareness should be developed in consultation with content experts and community organizations that represent persons with lived experience.
  3. Improve public awareness of both policing and non-policing community-based crisis responses to mental health crisis. Efforts to improve public awareness of these options should be developed in consultation with content experts and community organizations that represent persons with lived experience.
  4. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones.
  5. 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.
  6. 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.

    The Government of Ontario should allocate funding and resources adequate to implement the above recommendations.
To Peel Housing Corporation:
  1. Improve mental health awareness of housing support personnel, and in particular, concerning the recognition of mental health crisis.
  2. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis.
  3. Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants.
  4. Review and improve training to housing support personnel on cultural competency, anti-Black racism, implicit bias, mental health and its intersectional nature.

    Peel Housing Corporation should seek and allocate funding and resources adequate to implement the above recommendations.

Veillette, Jean Hervé

Surname: Veillette
Given name(s): Jean Hervé
Age: 48

Held at:  25 Morton Shulman Ave Toronto (virtually)
From: May 16
To: May 18, 2022
By: Dr. Bob Reddoch
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jean Hervé Veillette
Date and time of death: January 17, 2019 at 1:21 a.m.
Place of death: Ottawa Hospital General Campus
Cause of death: hanging
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on May 18, 2022
Coroner's name: Dr. Bob Reddoch
(Original signed by coroner)

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

Inquest into the death of: Jean Hervé Veillette

Jury recommendations
Directed to the Ministry of the Solicitor General (“the ministry”):
  1. The ministry should review and if necessary consider enhancing the mechanisms for ensuring that all staff receive their suicide awareness training in accordance with the timelines set out in policy.
  2. The ministry should review the suicide awareness training to ensure that it includes a robust individual evaluation component for comprehension of the course materials. If there is no individual evaluation component, the ministry should consider implementing one.
  3. When operationally feasible, the ministry should run the scenario-based CPR / First Aid training in settings that simulate real-life emergencies as closely as possible.
  4. If not already provided, the ministry should explore the availability of substance abuse treatment programs for all Ontario detention centres such as Narcotics Anonymous, and if not available, explore alternatives to that.
  5. 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 inmate’s status has changed while in custody.
  6. In any new detention centre builds, consideration should be given in the design to allow for timely access for emergency personnel.

Rajendiran, Arun Kumar
Tavernier, Darrel
Kelly, Stephen

Names of the deceased: Rajendiran, Arun Kumar; Tavernier, Darrel; Kelly, Stephen
Held at: Toronto
From: May 30
To: June 13, 2022
By: Dr. Robert Reddoch, coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Rajendiran
Given name(s):Arun Kumar
Age: 25

Date and time of death:  November 12, 2014 at 8:16 p.m.
Place of death: Central East Correctional Centre, Lindsay, Ontario
Cause of death: hanging
By what means: suicide

Surname: Tavernier
Given name(s): Darrel
Age: 42

Date and time of death:  January 1, 2018 at 8:37 a.m.
Place of death: Ross Memorial Hospital, Lindsay, Ontario
Cause of death: hanging
By what means: suicide

Surname: Kelly
Given name(s): Stephen
Age: 62

Date and time of death:  May 18, 2019 at 9:10 a.m.
Place of death: Ross Memorial Hospital, Lindsay, Ontario
Cause of death: hanging
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on June 13, 2022
Coroner's name: Dr. Robert Reddoch
(Original signed by coroner)

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

Inquest into the deaths of: Arun Kumar Rajendiran, Darrel Tavernier and Stephen Kelly

Jury recommendations
To the Ministry of the Solicitor General (SOLGEN)

Central East Correctional Centre (CECC) Health Care Review

  1. Ensure that the SOLGEN Corporate Health Care Unit conducts a comprehensive review of the quality of health care at the CECC. The review should assess:
    1. the health care needs of the inmate population
    2. compliance with provincial policies and professional standards
    3. record keeping and communication of health care information
  2. The methodology for the CECC health care review should include:
    1. an audit of a meaningful selection of inmate health care files
    2. interviews with health care staff to determine the causes of any deficiencies uncovered in the review
  3. The CECC health care review team should complete an action plan to address and support the results of the review, including:
    1. the health care needs of the inmate population
    2. the quality of health care at CECC
    3. compliance with provincial policies and professional standards
    4. staff competency
  4. The CECC health care review and action plan should be prioritized, and efforts be made to complete the review and the action plan by the end of 2022.

Health care staffing

  1. Prioritize the Health Care Performance and Planning Unit’s analysis of recruitment challenges for correctional health care staff.
  2. Ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the CECC.
  3. Consider engaging the private sector to assist in developing recruitment and retention strategies and provide current labour market data and analysis.
  4. Consider applying other ministry resources to support health care staff recruitment at the CECC.

Segregation

  1. Monitor how often inmates on suicide watch at the CECC are held in conditions of segregation and ensure this information is made available to correctional and healthcare staff.
  2. Ensure that if any inmates on suicide watch at the CECC are being held in segregation, the conditions of their confinement are promptly altered so that they no longer constitute segregation.
  3. Provide an anonymized public report on the number of inmates on suicide watch at the CECC who have been held in conditions of segregation. The public report should be issued every six months and should include the following information:
    1. why each inmate was held in conditions of segregation (for example: inmate’s refusal to comply, lack of physical space to accommodate time out of cell, inadequate staffing, etc.)
    2. duration of each period of segregation
    3. measures taken to alter the inmate’s conditions of confinement so that they no longer constitute segregation

Suicide prevention

  1. Revise the provincial policy on recovery plans for inmates who are removed from suicide watch. The revisions should require correctional institutions to ensure that:
    1. one or more staff member is designated to develop a recovery plan when an inmate is removed from suicide watch
    2. one or more staff member is designated to oversee the plan and ensure it is implemented
    3. placement of inmates in recovery is reviewed with health care staff and this review is documented
    4. The recovery plan is available for health care and operational staff
  2. Review the process for obtaining inmates’ medical history from their next of kin when inmates are identified as potentially suicidal or violent.
  3. Ensure all health care providers, including nurses, physicians, psychiatrists, and psychologists, are trained on the revised Recovery Plan policy.
  4. Ensure that adequate staffing is provided at each institution to implement recovery plans.
  5. Ensure that all health care staff are trained in suicide prevention policies and documentation.
  6. Consider using specialized care units for inmates who have been removed from suicide watch.
  7. Consider providing cognitive behavioural therapy, and/or other evidence-informed clinical interventions, for inmates who may be at risk of suicide.
  8. Conduct a review of the safety features designed into the CECC and conduct repairs to any features that are found to be currently out of standard, specifically, to repair any light fixtures that are not situated flush with the ceilings as originally installed, to ensure they cannot be used as anchor points.

Investigation and communication

  1. Implement the corporate health care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. These reviews should analyze relevant health care files and assess quality of care. The reviewers should work with the local health care team to identify gaps and find solutions. These solutions should be communicated to relevant staff and stakeholders in a timely manner.
  2. 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.
  3. Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders.

Health care records

  1. Ensure that health care files at CECC are maintained in compliance with provincial policies and professional standards.
  2. Ensure that health care professionals who provide care remotely have access to relevant information from an inmate’s health care file.
  3. Ensure that CECC health care files are regularly audited. These audits should include:
    1. internal audits by a health care manager or designate
    2. external audits by the Corporate Health Care Unit
  4. Ensure that the planned Electronic Medical Record (EMR) system is implemented at the CECC. The EMR system should:
    1. be available to all health care staff at the point of care
    2. be accessible throughout the institution
    3. ensure that health care professionals who provide care remotely have complete access to inmates’ health care files
    4. include methods of communicating health care orders electronically
  5. Ensure that psychiatrists who provide services at the CECC are advised of the purpose for reviewing and signing daily mental health assessment forms. Any significant change in the daily mental health assessment forms should be flagged and reported to the psychiatrist in a timely manner.

Security patrols

  1. Ensure that security patrols are completed during shift changeovers.
  2. Ensure that correctional staff at the CECC conduct regular cell checks to remove contraband items, including excess clothing and bedsheets.
To the Government of Ontario and SOLGEN
  1. Upgrade the infrastructure at the CECC to ensure that an EMR system can be properly implemented. This includes ensuring that:
    1. all health care staff will have access to EMRs
    2. EMRs can be accessed throughout the CECC, including in the health care unit, video treatment units and the G wings of the living units
  2. Develop an action plan to ensure that there is adequate physical space at the CECC to comply with the legal prohibition against segregation for inmates with serious mental illnesses or elevated suicide risk.
  3. Upgrade the physical infrastructure at the CECC to ensure that inmates with serious mental illness or elevated suicide risk can have the amount of meaningful social interaction and time out of their cells that is required by law.
  4. Increase the physical space available for inmate programming at the CECC, including counselling.
  5. Explore options for privacy screens or barriers around toilets in cells to avoid the need for inmates to fashion their own privacy sheets.
To the Government of Ontario
  1. Increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities.
  2. Consider retroactive compensation for the security clearance review period for those candidates that successfully obtain security clearance and sign an employment agreement with the CECC. Ensure this policy is made known to the candidates at the outset of the recruiting process.
  3. Seek and allocate adequate funding and resources to implement the above recommendations.
To the Office of the Coroner
  1. Consider conducting inquests in a timely manner, within 24 months from the incident date.

June

McKay, Gabriel

Surname: McKay
Given name(s): Gabriel
Age: 36

Held at: Thunder Bay
From: June 13
To: June 13, 2022
By: Dr. Steven Bodley
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Gabriel McKay
Date and time of death: November 6, 2017 at 11:20 p.m.
Place of death: St. Joseph’s Care Group, 35 Algoma Street North, Thunder Bay, Ontario
Cause of death: complications related to a severe brain injury sustained as the result of a workplace fall suffered September 14, 2016
By what means: accident

(Original signed by: Foreperson)

The verdict was received on June 13, 2022
Coroner's name: Dr. Steven Bodley
(Original signed by coroner)

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

Inquest into the death of: Gabriel McKay

Jury recommendations

No recommendations.

Lepage, Ronald

Surname: Lepage
Given name(s): Ronald
Age: 59

Held at:  Sudbury
From: June 13
To: June 16, 2022
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ronald Lepage
Date and time of death: April 6, 2017 at 9:12 p.m.
Place of death: Health Sciences North, 41 Ramsey Lake Road
Cause of death: blunt force/crush injury to abdomen and pelvis
By what means: accident

(Original signed by: Foreperson)

The verdict was received on June 16, 2022
Coroner's name: Dr. Geoffrey Bond
(Original signed by coroner)

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

Inquest into the death of: Ronald Lepage

Jury recommendations
  1. It is recommended that the Ministry of Labour, Training & Skills Development take steps to amend the Occupational Health and Safety ActR.S.O. 1990,c. O.1, Regulation 213/91 “Construction Projects”, section 102 to include a dump-truck with its dump box and other implements raised.
  2. 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:
    1. lower the dump box
    2. engage the brakes
    3. position wheel chocks in appropriate locations
    4. refrain from placing yourself between tires and/or axles
     
    • 2.1 Infrastructure Health and Safety Association
      Public Service Health and Safety Association
      Provincial Labour Management Health and Safety Committee
      Construction Safety Association of Ontario
      Ontario General Contractors Association
      Ontario Good Roads
      Ontario Trucking Association
      Ontario Dump Truck Association
      Ontario Road Builders Association
  3. It is recommended that the chief coroner take steps to expedite the hearing of coroner’s inquests, if feasible that they be held within three years.
  4. It is recommended that the Ministry of Labour, Training and Skills Development take steps to amend the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 213/91 “Construction Projects”, to add that a requirement that employers shall conduct a risk assessment of the workplace for the purpose of identifying, assessing and managing hazards, and potential hazards, that may expose a worker to injury or illness.
    • 4.1 It is recommended that employers, constructors, supervisors ensure that any hazard identified in risk assessments be relayed to workers together with the associated level of risk.
  5. That the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, be amended to promote first aid training for all workers on mining property.