2022 coroner’s inquests’ verdicts and recommendations

Review the Office of the Chief Coroner’s 2022 inquests’ verdicts and recommendations.

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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

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

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

(Original signed by: Foreperson)

The verdict was received on February 4, 2022
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:

Amend the Construction Regulations to include a mandatory requirement for training of Health and Safety Representatives who work on construction projects.
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.
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.
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.
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.
Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers).
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

Review the current Use of Force Model (2004) and related regulations, and consider de-emphasizing use of the term "force" and employing alternative terminology.
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.
Explore and research the availability and efficacy of additional less-lethal use of force options for officers.
For conductive energy weapons consider high visibility markings (colour) to differentiate them from firearms.

Directed to the Hamilton Police Service

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.
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.
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

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.
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.
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

Explore developing and providing all police recruits with additional de-escalation training.
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.
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:

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
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.
Where there is an existing threat assessment on file, provide contact information so that TBAT can discuss the assessment with the enquiring member.
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.
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.
Implement regular reviews to ensure the accuracy and reliability of the information in the records management system available to officers.
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.
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.
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.
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.
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.
Consider the circumstances of all police-related inquests as training scenarios.
Consider re-allocating more time to scenario-based de-escalation training during annual use of force certification at the OPP Academy.
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:

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.
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:

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Ensure that witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports.
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.
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.
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;
The results of the data collected on use of force incidents must be taught to all frontline police officers.
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
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.
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:

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:

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.
The Ontario Use of Force model shall be redesigned to highlight and emphasize the importance of de-escalation at all points during police interactions.
The OPC shall ensure that persons with lived experience are engaged in the development and delivery of de-escalation training.
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.
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:

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:

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.
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.
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.
Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones.
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.
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:

Improve mental health awareness of housing support personnel, and in particular, concerning the recognition of mental health crisis.
Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis.
Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants.
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”):

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.
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.
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.
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.
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.
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

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
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
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
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

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

Segregation

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.
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.
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

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
Review the process for obtaining inmates’ medical history from their next of kin when inmates are identified as potentially suicidal or violent.
Ensure all health care providers, including nurses, physicians, psychiatrists, and psychologists, are trained on the revised Recovery Plan policy.
Ensure that adequate staffing is provided at each institution to implement recovery plans.
Ensure that all health care staff are trained in suicide prevention policies and documentation.
Consider using specialized care units for inmates who have been removed from suicide watch.
Consider providing cognitive behavioural therapy, and/or other evidence-informed clinical interventions, for inmates who may be at risk of suicide.
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

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.
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.
Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders.

Health care records

Ensure that health care files at CECC are maintained in compliance with provincial policies and professional standards.
Ensure that health care professionals who provide care remotely have access to relevant information from an inmate’s health care file.
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
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
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

Ensure that security patrols are completed during shift changeovers.
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

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
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.
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.
Increase the physical space available for inmate programming at the CECC, including counselling.
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

Increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities.
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.
Seek and allocate adequate funding and resources to implement the above recommendations.

To the Office of the Coroner

Consider conducting inquests in a timely manner, within 24 months from the incident date.

June

Culleton, Carol
Kuzyk, Anastasia
Warmerdam, Nathalie

Names of the deceased: Culleton, Carol; Kuzyk, Anastasia; Warmerdam, Nathalie
Held at: 1 International Drive, Pembroke
From: June 6
To: June 28, 2022
By: Leslie Reaume, Presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Culleton
Given name(s): Carol
Age: 66

Date and time of death: September 22, 2015. Time of death could not be determined.
Place of death: Combermere, Ontario
Cause of death: upper airway obstruction
By what means: homicide

Surname: Kuzyk
Given name(s): Anastasia
Age: 36

Date and time of death: September 22, 2015. Time of death could not be determined.
Place of death: Wilno, Ontario
Cause of death: shotgun wound of the chest and neck
By what means: homicide

Surname: Warmerdam
Given name(s): Nathalie
Age: 48

Date and time of death: September 22, 2015. Time of death could not be determined.
Place of death: Foymount, Ontario
Cause of death: shotgun wound of the chest and neck
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on June 28, 2022
Presiding officer’s name: Leslie Reaume
(Original signed by presiding officer)

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

Inquest into the deaths of: Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam

Jury recommendations

To the Government of Ontario:

The Government of Ontario should:

Oversight and accountability

Formally declare intimate partner violence as an epidemic.
Establish an independent Intimate Partner Violence Commission dedicated to eradicating intimate partner violence (IPV) and acting as a voice that speaks on behalf of survivors and victims’ families, raising public awareness, and ensuring the transparency and accountability of government and other organizations in addressing IPV in all its forms. The Commissioner should have sufficient authority to ensure meaningful access to any person, document or information required to accomplish the Commission’s mandate. The Commission should be provided with adequate and stable funding to ensure effectiveness.
Engage in meaningful consultation with IPV stakeholders and experts in the field, to determine the mandate and responsibilities of the IPV Commission, which may include:
1. Driving change towards the goal of eradicating IPV in Ontario.
2. Evaluating the effectiveness of existing IPV programs and strategies, including the adequacy of existing funding.
3. Analyzing and reporting on all IPV-related issues with a view to improving awareness of IPV issues and potential solutions.
4. Advocating for survivors and their families having regard to addressing the systemic concerns of survivors navigating the legal system.

Consideration should be given to the United Kingdom’s Domestic Abuse Commissioner model in developing the mandate of the Commission.

Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system.
Immediately institute a provincial implementation committee dedicated to ensuring that the recommendations from this Inquest are comprehensively considered, and any responses are fully reported and published. The committee should include senior members of relevant ministries central to IPV and an equal number of community IPV experts. It should be chaired by an independent IPV expert who could speak freely on progress made on implementation.
Amend the Coroners Act to require the recipient of an inquest recommendation to advise the Office of the Chief Coroner if a recommendation is complied with or to provide an explanation if it is not implemented.

System approaches, collaboration and communication

Ensure that IPV issues are addressed using an all-of-government approach across ministries, and cooperate and coordinate with federal, provincial, and territorial partners in seeking to end IPV.
Require that all justice system participants who work with IPV survivors and perpetrators are trained and engage in a trauma-informed approach to interacting and dealing with survivors and perpetrators.
Explore incorporating restorative justice and community-based approaches in dealing with appropriate IPV cases to ensure safety and best outcomes for survivors.
Encourage that IPV be integrated into every municipality’s community safety and well-being plan.
Study the feasibility of, and implement if feasible, justice sector participants having access to relevant findings made in family and civil law proceedings for use in criminal proceedings, including at bail and sentencing stages. The study would, in part, inquire into the following:
1. The process to identify relevant findings and for sharing those findings with other justice participants.
2. Which justice participants should have access to the findings made by a civil or family court.
3. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents.
4. What permissible uses could be made of the documents and findings in a criminal proceeding.
5. models in other jurisdictions that identify relevant IPV cases in different courts
Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning.
Require all police services to immediately inform the Chief Firearms Officer (CFO) of IPV-related charges after they are laid, and provide any relevant records, including Firearms Interest Police information.
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 IPV stakeholders, including Probation, CFO, Crown’s offices, Ontario Court of Justice, Superior Court of Justice, correctional institutions and parole boards. Police services that wish to use their own RMS are to update IPV information into the Universal RMS.
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.
Review policies to ensure the timely, reliable, consistent, and accurate dissemination of information, including the use of emergency alerts and media releases, where the police are aware of circumstances that could put the public in danger, and that the focus is on safety when developing policies regarding what information to share with whom and when. Consideration should be given to disseminating information through alternative methods where cellular service is not consistently available.
Establish clear guidelines regarding the flagging of perpetrators or potential IPV victims in police databases, immediate dispatch and police access to the identities and contact information of potential targets, and how to notify those targets.

Funding

Recognize that the implementation of the recommendations from this Inquest, including the need for adequate and stable funding for all organizations providing IPV support services, will require a significant financial investment and commit to provide such funding.
Create an emergency fund, such as the “She C.A.N Fund”, in honour of Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam to support women living with IPV who are taking steps to seek safety. This fund should include the following:
1. Easy, low-barrier access for IPV survivors seeking to improve their safety.
2. referral to the fund through IPV service providers.
3. Small grants of up to $7,000.
4. It should have no impact on Ontario Works or Ontario Disability Support Plan payments.
5. Consideration for the needs of rural and geographically remote survivors of IPV.
6. Funding to be provided on an annualized basis, with adequacy assessed and considered after the first three years.
7. Inject a significant one-time investment into IPV related support services.
Realign the approach to public funding provided to IPV service providers with a view to removing unnecessary reporting obligations with a focus on service. Draw on best practices in Canada and internationally, and adopt and implement improved, adequate, stable, and recurring funding that incorporates the following:
1. IPV services are core programming and should receive annualized funding like other public services.
2. Service providers provide one annual report for all funders across government to account for the funds received, articulate results and highlight key challenges, learnings, and accomplishments.
3. Recognition that, in remote and rural areas, funding cannot be the per-capita equivalent to funding in urban settings as this does not take into account rural realities, including that:
  1. IPV is more prominent in rural areas
  2. economies of scale for urban settings supporting larger numbers of survivors
  3. the need to travel to access and provide services where telephone and internet coverage is not available
  4. the lack of public transit
  5. the cost of transportation for survivors and service providers.
4. Consideration of the remoteness quotient used to calculate funding in other social services, such as education and policing.
5. Enhanced funding for IPV service providers, including shelters, sexual assault support centres, victim services, and counselling services, considering urban and rural realities.
6. Designated funding for transportation for those receiving IPV-related support services where public transportation is inadequate or unavailable, such as in Renfrew County.
7. Funding to ensure mental health supports for IPV service providers, as well as timely access to trauma supports immediately following a traumatic event.
8. Funding for services provided to survivors that allows for the hiring and retention of skilled and experienced staff so that they are not required to rely on volunteers and fundraisers in order to provide services to survivors.
9. Funding for mobile tracking system alarms and other security supports for survivors of IPV.
10. Funding for counselling for IPV survivors.
11. Funding for services dedicated to perpetrators of IPV.
Develop a plan for enhanced second-stage housing for IPV survivors.
Fund for “safe rooms” to be installed in survivors’ homes in high-risk cases.

Education and training

Develop and implement a new approach to public education campaigns to promote awareness about IPV, including finding opportunities to reach a wider audience in rural communities. These messages should promote broad recognition of how to seek support, risk factors, and warning signs of IPV, community and bystander engagement, be accessible in multiple languages and in multiple formats, and ensure that rural residents can identify themselves in the messaging and materials.
Complete a yearly annual review of public attitudes through public opinion research, and revise and strengthen public education material based on these reviews, feedback from communities and experts, international best practices, and recommendations from the Domestic Violence Death Review Committee (DVDRC) and other IPV experts.
Use and build on existing age-appropriate education programs for primary and secondary schools, and universities and colleges. Such programs should include: violence prevention, recognizing healthy and abusive relationships, identifying subtle indicators of coercive control, understanding risk factors (such as stalking, fear caused by IPV, strangulation, threats to kill), managing and processing feelings, dispute resolution, community and bystander obligations, the need for safety planning and risk management, and the unique experiences in rural and urban settings.
Ensure teachers are trained to deliver the IPV-related curriculum and utilize IPV professionals regularly to provide support for the delivery of primary, secondary, and post-secondary programming.
Develop a roster of resources available to support classroom teachers in the delivery of primary, secondary, and post-secondary programming where local IPV professionals are not available.
Review existing training for justice system personnel who are within the purview of the provincial government or police services.
Provide professional education and training for justice system personnel on IPV-related issues, which should include:
1. Annual refresher courses.
2. risk assessment training with the most up-to-date research on tools and risk factors.
3. Trauma-informed practices, including an understanding of why survivors may recant or may not cooperate with a criminal investigation, best practices for managing this reality, and investigation and prosecution of perpetrators.
4. Crisis management training.
5. The availability and use of weapons prohibition orders in IPV cases.
6. Meaningful screening of sureties.
7. Greater use of court-ordered language ensuring alleged and convicted offenders will not reside in homes that have firearms.
8. Indicators of IPV including coercive control, and awareness of risk factors for lethality (including destruction of property, especially by fire, harm to pets, strangulation, criminal harassment, stalking, sexual violence, and threatening police).
9. Unique rural factors.
10. Firearm risks, including the links between firearm ownership and IPV.
11. Opportunities for communities, friends, and families to play a role in the prevention and reporting of IPV.
Provide specialized and enhanced training of police officers with a goal of developing an IPV specialist in each police detachment.
Track whether mandated IPV-related professional education and training is completed by all justice system personnel.

Measures addressing perpetrators of IPV

Establish a province-wide 24/7 hotline for men who need support to prevent them from engaging in IPV.
Provide services aimed at addressing perpetrators of IPV that should include:
1. An approach that is not one-size-fits-all.
2. A variety of group-based interventions augmented with individual counseling and case management sessions to assess and manage risk and to supplement services, as needed, to address individual needs.
3. Peer support and appropriate circles of support.
4. Prioritizing the development of cross-agency and cross-system collaborative services.
5. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services.
6. The ability to respond immediately with risk management services in collaboration with IPV service providers.
7. Being accessible by clients voluntarily and via referral, and not just through the criminal justice system.
8. Programs are funded at a level that anticipates an increased stream of referrals.
9. Make in-custody IPV programs available in the community as well so that offenders can complete programs started in custody.
10. Conducting audits of PARs and other perpetrator intervention programs for efficacy, consistency, and currency.
11. Increasing program availability and develop flexible options for IPV perpetrators on remand, serving sentences, and in the community.
Recognize the specialized knowledge and expertise of IPV service providers involved in perpetrator intervention and support the development of workforce capacity within the sector by developing and providing competency-based training opportunities. Service contracts should include funding for supervision and ongoing professional development, and mental health support.
Address barriers and create opportunities and pathways to services for IPV perpetrators that can be accessed in the community. Referrals to service providers should be made as early as possible and should be repeatedly and persistently offered to both engage perpetrators and reinforce the need for perpetrators to be accountable for their abusive behaviours.
Improve the coordination of services addressing substance use, mental health, child protection, and IPV perpetration, and encourage cross-agency service provision and case management.
As new services are funded, include aims and outcomes associated with building an underlying network of specialized services to address IPV perpetration and developing messaging around its availability.
Ensure that IPV-related public education campaigns address IPV perpetration and should include men’s voices, represent men’s experiences, and prompt men to seek help to address their own abusive behaviours. They should highlight opening the door to conversations about concerning behaviours.
Endeavour to minimize destabilizing factors for perpetrators of IPV that increase risk, correlates of IPV, and barriers for survivors to leave violence. Specific consideration should be given to financial instability, housing insecurity, and mental health issues, including addictions treatment options, and how these factors and potential solutions are affected by rural contexts.

Intervention

Explore amending the Family Law Act, following meaningful consultation with stakeholders, including survivors and IPV service providers, to provide authority to order counselling for the perpetrator where IPV findings are made by the family court.
Investigate and develop a common framework for risk assessment in IPV cases, which includes a common understanding of IPV risk factors and lethality. This should be done in meaningful consultation and collaboration with those impacted by and assisting survivors of IPV, and consider key IPV principles, including victim-centred, intersectional, gender-specific, trauma-informed, anti-oppressive, and evidence-based approaches.
Co-train justice system personnel and IPV service providers on the risk assessment framework and tools so that there is a common understanding of the framework and tools for those who support or deal with survivors.
Ensure that survivor-informed risk assessments are incorporated into the decisions and positions taken by Crowns relating to bail, pleas, sentencing, and eligibility for Early Intervention Programs.
Clarify and enhance the use of high-risk committees by:
1. Strengthening provincial guidelines by identifying high-risk cases that should be referred to committee.
2. Identifying and including local IPV service providers that are in a position to assist with case identification, safety planning, and risk management - consideration should be given to including IPV service providers supporting perpetrators.
3. Ensuring that involved IPV service providers at high-risk committees are given the necessary information to facilitate their active participation, subject to victim consent where applicable.
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. Crowns should also consider a history of IPV whether or not convictions resulted when determining whether early intervention is appropriate.

Safety

Study the best approach for permitting disclosure of information about a perpetrator’s history of IPV and the potential risk to new and future partners who request such information, with a view to developing and implementing legislation. In doing so, study Clare’s law in the United Kingdom and similar legislation in Saskatchewan, Alberta and Manitoba, Bill 274 (Intimate Partner Violence Disclosure Act, 2021), and any other relevant legislation and policy. In the interim, develop a draft policy that can address this issue.
Set up IPV Registry for repeat IPV offenders similar to the Sex Offender Information Registry Act registry.
Explore the implementation of electronic monitoring to enable the tracking of those charged or found guilty of an IPV-related offence and enable the notification of authorities and survivors if the individual enters a prohibited area relating to a survivor. In determining the appropriateness of such a tool in Ontario, monitor the development of programs utilizing such technology in other provinces, with specific consideration given to:
1. Coverage of cellular networks, particularly in remote and rural regions.
2. Storage rules and protocols for tracking data.
3. Appropriate perpetrator programs and supports needed to accompany electronic monitoring.
4. Whether the tool exacerbates risk factors and contributes to recidivism.
5. Understanding any impacts after an order for such technology expires.
6. Frequency and impact of false alarms.
7. The appropriateness of essential services being provided by private, for-profit partners.
Start grassroots “Safe Spaces” program that businesses can participate in where survivors can feel safe and ask for information (e.g. pamphlets and handouts from women’s shelters, VWAP and men’s programs).
In referrals made by the OPP to Victim Services, ensure adequate information is provided, including relevant history, safety concerns and known risk factors.
Ensure that OPP conduct a study on improving tactical response timelines as it applies to rural environments generally and in IPV cases in particular.
Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services.
Set up satellite offices for police officers to work safely and comfortably to spread police resources more evenly over wide rural areas (e.g. consider asking schools and municipal governments to provide office space).
Enhance court supports for IPV survivors and develop an IPV-focused model for criminal courts similar to the Family Court Support Worker Program. Consideration should be given to the independent legal advice program for survivors of sexual violence as a model for IPV survivors.
Encourage Crowns to consult with the Regional Designated High-Risk Offender Crown for any case of IPV involving a high-risk offender that may meet the criteria for Dangerous or Long-term Offender designations.
Crowns should actively oppose variation requests to have firearms returned for any purpose, such as hunting.
Strengthen annual education for Crowns regarding applications for Dangerous and Long-term Offender designations in high-risk IPV cases.
Commission a comprehensive, independent, and evidence-based review of the mandatory charging framework employed in Ontario, with a view to assessing its effect on IPV rates and recidivism, with particular attention to any unintended negative consequences.
Conduct study of judges’ decisions in IPV cases and track in longitudinal studies for recividism, violence escalation, and future victims.
Review and amend, where appropriate, standard language templates for bail and probation conditions in IPV cases, and develop a framework for identifying the appropriate conditions based on level of risk in collaboration with stakeholders, including judges, justices of the peace, police, probation, crown attorneys, the CFO, and community providers with subject matter expertise in IPV risk management. The following factors should be considered:
1. enforceability
2. plan for removal or surrender of firearms and the Possession and Acquisition License (PAL)
3. residence distance from victims
4. keeping probation aware
5. safety of current and previous victims
6. possibility of a "firearm free home" condition
7. past disregard for conditions as a risk factor
Require that primary actors advise the CFO in a timely manner of expected and changed residential addresses of individuals who have been placed under weapons conditions.
When evaluating the suitability of a prospective surety in IPV cases, Crowns should make inquiries as to whether residential sureties have firearms in their home or a PAL.
Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented.
Ensure that Probation Services reviews and, if necessary, develops standardized protocols and policies for probation officers with respect to intake of IPV offenders and with respect to victim safety.
Review the mandate of Probation Services to prioritize:
1. condition compliance
2. victim safety
3. offender rehabilitation
Require that probation officers, in a timely manner, ensure:
1. There is an up-to-date risk assessment in the file.
2. 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.
3. They contact the survivor to inform her of the offender’s 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.
4. Regular contact with survivors to receive updates, provide information regarding the offender’s residence and locations frequented, and any changes to such circumstances, and seek input from survivors and justice system personnel before making decisions that may impact her safety.
5. Improved supervision of high-risk perpetrators released on probation, including informed decision-making when applying or seeking to modify conditions that impact the survivor’s needs and safety.
6. Risk assessments and risks of lethality are taken into account when making enforcement decisions.
Ensure existing policy and guidelines require probation officers to follow through on enforcement of non-compliance by requiring delivery and documentation of clear instructions regarding expectations to supervised offenders in a way that allows for direct and progressive enforcement decisions. This should be a focus for performance management and quality assurance processes.
Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. Consideration should be given to two-way information sharing including of case notes, and opportunities to order treatment in institutions for those with existing probation orders who are on remand.

To the Chief Firearms Officer:

The Chief Firearms Officer should work with appropriate decision-makers to:

Review the mandate and approach of the CFO’s Spousal Support line to:
1. Change its name to one that better reflects its purpose. It should be clear that it is broadly accessible and not limited to a particular kind of relationship.
2. Be staffed 24 hours a day and 7 days a week.
3. Be publicized to enhance public awareness, and become better known among policing partners possibly through All Chiefs’ bulletins.
Create guidelines for staff in making decisions regarding whether to issue, review, revoke, or add conditions to PALs to ensure consistency among staff and through time. Particular attention should be paid to red flags and risk factors around IPV, including where there is no conviction.
Require that a PAL is automatically reviewed when someone is charged with an IPV-related offence.
Require PAL applicants and holders to report to the CFO in a timely manner any change in information provided in application and renewal forms submitted to the CFO, including when an individual with weapons restrictions comes to reside in their home.
Amend PAL application and renewal forms to require identification as a surety.

To the Office of the Chief Coroner

The Office of the Chief Coroner should:

Ensure that the DVDRC reviews its mandate with a view to enhancing its impact on IPV and provide the DVDRC with improved supports.
Ensure DVDRC annual reports are published online in a timely manner.
Ensure that DVDRC reports and responses to recommendations are publicly available and will continue to be available without charge.
Consider adopting Femicide as one of the categories for manner of death.

To the Information and Privacy Commissioner of Ontario

The Information and Privacy Commissioner of Ontario should:

Working together with the DVDRC, justice partners and IPV service providers, develop a plain language tool to empower IPV professionals to make informed decisions about privacy, confidentiality, and public safety.

To the Government of Canada

The Government of Canada should:

Explore adding the term “Femicide” and its definition to the Criminal Code to be used where appropriate in the context of relevant crimes.
Consider amendments to the Dangerous Offender provisions of the Criminal Code, or the inclusion of a new classification of Offender under the Criminal Code, that better reflects the realities of IPV charges and takes into account risk factors for serious violence and lethality in an IPV context.
Undertake an analysis of the application of s. 264 of the Criminal Code with a view to evaluating whether the existing factors adequately capture the impact on survivors. Consider the removal of the subjective requirement that the action causes the victim to fear for their safety.
Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing.
Implement the National Action Plan on Gender-based Violence in a timely manner.
Establish a Royal Commission to review and recommend changes to the Criminal Justice system to make it more victim-centric, more responsive to root causes of crime and more adaptable as society evolves.
Include “coercive control”, as defined in the Divorce Act, as a criminal offence on its own or as a type of assault under s. 265 of the Criminal Code.

To the parties to this inquest

The parties to this inquest should:

Reconvene one year following the verdict to discuss the progress in implementing these recommendations.

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

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.
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
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.
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.
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.

Blair, Delilah Sophia

Surname: Blair
Given name(s): Delilah Sophia
Age: 30

Held at: Windsor
From: June 20
To: June 30, 2022
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Delilah Sophia Blair
Date and time of death: May 21, 2017 at 8:58 p.m.
Place of death: Windsor Regional Hospital Ouellette Campus
Cause of death: hanging
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on June 30, 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: Delilah Sophia Blair

Jury recommendations

To the Ministry of the Solicitor General (the ministry) and/or South West Detention Centre (SWDC):

The term “SWDC/ministry” means “SWDC and the ministry”

Indigenous people must be able to access spiritual rights as well as programs with regularity and without unreasonable delay. Specifically, the the ministry should:
1. ensure that all Native Inmate Liaison Officer/Indigenous Liaison Officer (NILO/ILO) positions are adequately funded and strive to achieve more equitable remuneration so that they can recruit, retain, and keep NILO/ILO staff in full time, permanent positions. Remuneration should include payment for
  1. paid time off
  2. benefits, that include access to an employee assistance program
  3. opportunities for support following traumatic incidents
2. create policy and direction that recognizes the role and function of NILO/ILO staff as central to the delivery of Indigenous spiritual, cultural access and for health and wellness
3. consider increasing NILO/ILO staff at each detention centre to meet the needs of Indigenous people in custody.
The ministry should ensure that spiritual elders, knowledge keepers, and helpers are provided honoraria or financial compensation for their important work delivering cultural programming and access to their spiritual rights. Compensation should include:
1. fee/honoraria for services
2. cost of transportation to facility
3. cost of medicines or supplies required to facilitate service.
The ministry should revise both health and NILO/ILO policy to recognize cultural and spiritual support as a fundamental health care right to all.
The ministry should consider contracting Elder positions in addition to NILO positions at all provincial facilities. Any such position(s) should take into account similar factors for remuneration as recommended for NILO/ILO above.
The ministry should investigate how security is assessed concerning spiritual elders, knowledge keepers, and traditional teachers.
The ministry should engage in community consultation on the development of Indigenous core programming with Indigenous leadership including First Nation, Métis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres.
The ministry and the SWDC management should make concerted efforts to work with NILO to build relationships with Indigenous communities and organizations that are local to the facility.
The ministry should update all forms to remove the term “North American Indian” in favour of First Nations/Inuit/Métis on any admission or information forms used with people in custody.
The ministry shall support the National Inquiry into Missing and Murdered Indigenous Women and Girls' Call to Justice 14.6 as it applies to provincial corrections services. Section 14.6 states the following:
- We call upon Correctional Service Canada and provincial and territorial services to provide intensive and comprehensive mental health, addictions, and trauma services for incarcerated Indigenous women, girls, and 2SLGBTQQIA people, ensuring that the term of care is needs-based and not tied to the duration of incarceration. These plans and services must follow the individuals as they reintegrate into the community.
The SWDC/ministry shall ensure that all correctional officers are trained on the importance of inmate care plans.
The SWDC/ministry shall ensure that if a person in custody self-identifies as Indigenous, that this fact is included on the inmate care plan.
The SWDC shall make best efforts to ensure the Managed Clinical Care Unit (formerly known as the Female Mental Health Unit) is directly supervised.
When designing new correctional facilities, the ministry shall:
1. minimize the construction of indirect supervision units
2. consider needs-based housing for women and woman-identifying mental health clients
3. incorporate the approach of minimizing the risk of hanging in the designing and planning of the bookshelves in all units.
The SWDC/ministry shall review the bookshelves in the Managed Clinical Care Unit (formerly known as the Female Mental Health Unit) to determine whether they should be retrofitted to reduce suicide risk.
The ministry shall consult with the federal government and other provinces and territories to determine if there is bedding that is less susceptible to tearing for use by persons in custody not on suicide watch.
Once the ministry completes the consultations on tear-resistant sheets and blankets, if there are viable options, the ministry endeavor to implement the use of such bedding in all provincial institutions.
The ministry shall update policy so that phone calls by persons in custody are not referred to as a privilege.
The SWDC shall ensure that, where a person in custody does not have a calling card and can only make collect calls, the facilitation of requests of such calls shall be treated as a priority, including taking steps to ensure that the person in custody is able make this contact.
The SWDC/ministry should increase Indigenous-specific training to all frontline workers. Training should try to achieve culturally appropriate and trauma-informed models of care specifically for Indigenous people in custody and be adequately resourced.
The SWDC/ministry should continue to encourage staff participation in Indigenous ceremony and celebrations to promote better understanding of the strengths of Indigenous cultural practices.
The SWDC/ministry shall ensure that, where a person in custody identifies the existence of other health records, the SWDC/ministry should seek that person’s consent to obtain them.
The SWDC/ministry should incorporate substantive feedback from persons in custody in determining health care services.
The ministry should consult with the Ministry of the Attorney General to determine a process for obtaining summary information about upcoming court appearances for persons in custody and prospective length of time in custody, and rapidly provide this information to health care and programming staff.
The SWDC/ministry shall ensure that persons in custody are screened for suicide risk one month following admission as well as after any significant life event, where known (such as sentencing).
The SWDC/ministry shall ensure that there is timely assessment and intervention focused on a comprehensive addictions treatment plan and addictions-specific support for people remanded into custody, including a plan that will continue in the community when the person is released.
The ministry should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. The ministry should also consider what, if any, supports or agencies that are local to the bereaved can be referred, or assist the family, in receiving the news.
The ministry shall implement a policy requiring the inclusion of a letter describing what is contained in the return of property of an individual that has died in custody.
The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody.
The SWDC/ministry shall include automated external defibrillators in nurses’ equipment for emergency response (e.g. emergency bag/crash cart).
The SWDC/ministry shall ensure that the first sergeant responding to a medical emergency is responsible for ensuring that a 911 knife is brought to the scene of the emergency.
The SWDC/ministry shall ensure that, where rotational unlock is necessary, correctional officers and sergeants may consult with the multidisciplinary team and others, including NILOs, to maximize the number of persons in custody who may be out of their cell concurrently.
The SWDC/ministry shall ensure that correctional officers who work on ranges designated for women shall have mandatory specialized training in gender, mental health, and Indigenous realities.
The SWDC shall ensure all inmate requests by people in custody are delivered to a sergeant, who must ensure follow-up in writing within 72 hours. For any requests that are denied or delayed more than 72 hours, an explanation shall be provided to the person in custody. Any requests delayed more than 72 hours, the Sergeant or designate shall notify his/her supervisor who shall take steps to respond.
The ministry shall actively facilitate “meaningful social interaction” and prioritize face-to-face and direct human contact without physical barriers, empathetic exchange, and sustained social interaction.
The ministry shall consult with an expert in trauma-informed care to review the current care programs to provide specific suggestions for institutional changes to promote trauma informed practices within the detention centre.
The ministry shall treat people in custody on remand as presumed to be innocent. They must be treated as such, including refraining from using the term “offender”.
The ministry shall ensure that wherever a serious mental illness is suspected or identified through mental health screening, that the person in custody will not be placed in conditions of segregation.

To the Windsor Police Service:

The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons’ directives.

Ferrante, Frank

Surname: Ferrante
Given name(s): Frank
Age: 44

Held at: Toronto
From: June 29
To: June 29, 2022
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Frank Ferrante
Date and time of death: July 28, 2015 at 8:34 p.m.
Place of death: Southlake Regional Health Centre, 596 Davis Drive, Newmarket
Cause of death: heat stroke
By what means: accident

(Original signed by: Foreperson)

The verdict was received on June 29, 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: Frank Ferrante

Jury recommendations

Ministry of Labour, Training and Skills Development (MLTSD):

Continue working with the Ministry's partners to provide public awareness campaigns and educational materials relating to:
1. Highlighting the dangers and risks associated with working in high temperatures
2. How workers should prepare themselves to safely work in high temperatures
3. How employers should prepare their workers and their job sites to ensure safe working conditions during periods of high temperatures,
4. how to prevent heat stress and other heat related illnesses that may arise from working in high temperature conditions, and,
5. how to identify and address the precursors to heat stress, and other heat related illnesses that may arise from working in high temperature conditions.
Continue working with their partners to provide timely alerts, reminders and warnings to the public about the dangers of working in high temperature conditions on days when the temperatures reach dangerous levels.
Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors.
Continue working with partners to provide public awareness campaigns and educational materials in a greater variety of media formats (billboards, bus shelters, etc.) and in a greater variety of languages.

Rainbow Exterior Wrap and General Contracting:

Utilizing the resources publicly provided by the MLTSD, WSIB and IHSA, draft a hot weather plan/heat response plan.
Designate an employee to manage this plan, monitor the weather, ensure compliance with the plan and maintain records.
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.
Provide training to workers on the signs and symptoms of heat stress and heat stroke, how to prevent heat-related illness and first aid steps to be taken should a worker believe they or their co-worker are showing signs of such illness.
Prior to commencing work, survey worksites where high temperatures are a concern and ensure that every reasonable precaution is taken to protect workers from heat stress and heat related illnesses.

Lam Renovations:

Develop health and safety materials and for all workers and train workers, including temporary workers, on health and safety protocols prior to them undertaking any work.
Utilizing the resources publicly provided by the MLTSD, WSIB and IHSA, draft a hot weather plan/heat response plan.
Designate an employee to manage this plan, monitor the weather, ensure compliance with the plan and maintain records.
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.
Provide training to workers on the signs and symptoms of heat stress and heat stroke, how to prevent heat-related illness and first aid steps to be taken should a worker believe they or their co-worker are showing signs of such illness.
Prior to commencing work, survey worksites where high temperatures are a concern and ensure that every reasonable precaution is taken to protect workers from heat stress and heat related illnesses.

July

Yonan, Metti

Surname: Yonan
Given name(s): Metti
Age: 66

Held at: North York
From: July 18
To: July 18, 2022
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Metti Yonan
Date and time of death: November 28, 2014 at 12:40 p.m.
Place of death: Sunnybrook Hospital, 2075 Bayview Avenue, North York
Cause of death: blunt force crushing injuries to the torso that caused extensive internal hemorrhage
By what means: accident

(Original signed by: Foreperson)

The verdict was received on July 18, 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: Metti Yonan

Jury recommendations

To the Ministry of Labour, Immigration, Training and Skills Development:

Continue working with the ministry’s partners to create educational materials that highlight the dangers associated with skid steer work and the risks of being struck by a skid steer.
Mandatory skid steer operation certification and re-certification process.

To Green Star Grading & Sodding Construction Ltd. (“Green Star”):

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. Said plan should include (but not be limited to):
1. A mandatory mechanical safety review that each skid steer operator must complete each day, prior to commencing work. Said plan should include checking that the back-up alarm on the skid steer is operational.
2. A requirement that all skid steer operators regularly clean and clear debris from the windows of the skid steer to ensure maximum visibility.
3. Mandatory use of a signaller when operating a skid steer.
4. Prohibiting the use of skid steers in reverse unless it is operationally necessary.
Educate any worker who is to work for or on behalf of Green Star at a construction site where a skid steer is in use (including those who operate skid steers) regarding the risks and dangers associated with working on or near a skid steer and ensure that they are familiar with the aforementioned safety plan. Said education and instruction should occur prior to the commencement of work on any site where a skid steer is anticipated to be in operation. In addition, such education should be repeated quarterly.

Soares, Ricardo

Surname: Soares
Given name(s): Ricardo
Age: 32

Held at: Toronto
From: July 25
To: July 27, 2022
By: Bonnie Goldberg, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ricardo Soares
Date and time of death: November 17, 2017 at 2:37 p.m.
Place of death: Ford Drive near Kingsway Drive, Oakville
Cause of death: blunt force injuries to the head, chest and abdomen
By what means: accident

(Original signed by: Foreperson)

The verdict was received on July 18, 2022
Presiding officer's name: Bonnie Goldberg
(Original signed by presiding officer)

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

Inquest into the death of: Ricardo Soares

Jury recommendations

To The Ministry of Labour, Immigration, Training and Skills Development

Amend the Construction Regulations (O. Reg. 213/91) to include the following requirements:
1. Construction projects should be planned and organized so that no cellular phones or similar cellular devices shall be used on the worksite except in case of an emergency or where use is restricted to occur inside of a designate structure, stationary vehicle, or other designated area away from any area in which construction work is occurring or ongoing.
2. Constructors, employers and supervisors shall ensure that workers are not endangered by cell phone use on construction projects.
3. Employers shall create and implement a policy on the appropriate use of cell phones and mobile devices at construction projects that includes methods for complying with 1(a) and 1(b).
4. Employers shall ensure that workers are trained on the cell phone policy.
Consider an amendment to section 106 of O. Reg. 213/91 that requires employers to ensure that vehicle operators, in addition to the signaler, as required by law, have received adequate oral and written instruction on their duties including safety requirements.
Consider the viability of a requirement for dump trucks to be equipped with back-up cameras that provide 360 degree visibility.

Regional Municipality of Halton

In order to promote, protect, and prioritize worker health and safety, road-resurfacing contracts should be reviewed with attention to how time limits on construction work and limits on allowable lane closures are established.

Fermar Paving Limited

Advise all workers that they should report health and safety concerns to their health and safety representative, joint health and safety committee, to Fermar’s Health and Safety Department, or directly to the Ontario Health and Safety Act’s Health and Safety Contact Centre.

Updated: August 17, 2022

Published: March 14, 2022

2022 coroner’s inquests’ verdicts and recommendations

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Chronological listing of verdicts and recommendations

January

Blumberg, AlexseyBondarevs, AleksandrsFayzullo, FazilovKorostin, Vladimir

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:

February

MacDougall, Quinn Emerson

Inquest into the death of: Quinn Emerson MacDougall

Jury recommendations

Directed to the Ministry of the Solicitor General

Directed to the Hamilton Police Service

Directed to all Police Services in Ontario

Directed to the Ontario Police College and the Ministry of the Solicitor General

April

Santos, Fernando

Inquest into the death of: Fernando Santos

Jury recommendations

Saidi, Babak

Inquest into the death of: Babak Saidi

Jury recommendations

To the Ontario Provincial Police:

To the Ministry of the Solicitor General

May

Ekamba, Marc Diza

Inquest into the death of: Marc Diza Ekamba

Jury recommendations

To all Ontario police services:

To the Peel Regional Police:

To the Ministry of the Solicitor General:

To the Ministry of the Solicitor General and Peel Regional Police:

To the government of Ontario:

To Peel Housing Corporation:

Veillette, Jean Hervé

Inquest into the death of: Jean Hervé Veillette

Jury recommendations

Directed to the Ministry of the Solicitor General (“the ministry”):

Rajendiran, Arun KumarTavernier, DarrelKelly, Stephen

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

Jury recommendations

To the Ministry of the Solicitor General (SOLGEN)

To the Government of Ontario and SOLGEN

To the Government of Ontario

To the Office of the Coroner

June

Culleton, CarolKuzyk, AnastasiaWarmerdam, Nathalie

Inquest into the deaths of: Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam

Jury recommendations

To the Government of Ontario:

To the Chief Firearms Officer:

To the Office of the Chief Coroner

To the Information and Privacy Commissioner of Ontario

To the Government of Canada

To the parties to this inquest

McKay, Gabriel

Inquest into the death of: Gabriel McKay

Jury recommendations

Lepage, Ronald

Inquest into the death of: Ronald Lepage

Jury recommendations

Blair, Delilah Sophia

Inquest into the death of: Delilah Sophia Blair

Jury recommendations

To the Ministry of the Solicitor General (the ministry) and/or South West Detention Centre (SWDC):

To the Windsor Police Service:

Ferrante, Frank

Inquest into the death of: Frank Ferrante

Jury recommendations

Ministry of Labour, Training and Skills Development (MLTSD):

Rainbow Exterior Wrap and General Contracting:

Lam Renovations:

July

Yonan, Metti

Inquest into the death of: Metti Yonan

Jury recommendations

To the Ministry of Labour, Immigration, Training and Skills Development:

Soares, Ricardo

Inquest into the death of: Ricardo Soares

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

Rajendiran, Arun Kumar
Tavernier, Darrel
Kelly, Stephen

Culleton, Carol
Kuzyk, Anastasia
Warmerdam, Nathalie