2022 coroner’s inquests’ verdicts and recommendations

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

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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.

August

Wettlaufer, Alexander Peter

Surname: Wettlaufer
Given name(s): Alexander Peter
Age: 21

Held at: Toronto, virtually
From: August 22
To: August 26, 2022
By: Dr. Bonnie Goldberg, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Alexander Peter Wettlaufer
Date and time of death: March 14, 2016 at 1:21 a.m.
Place of death: Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto
Cause of death: gunshot wounds to chest
By what means: undetermined

(Original signed by: Foreperson)

The verdict was received on August 26, 2022
Presiding officer's name: Dr. Bonnie Goldberg
(Original signed by presiding officer)

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

Inquest into the death of: Alexander Peter Wettlaufer

Jury recommendations

The Toronto Police Service

The Toronto Police Service should improve delivery of relevant information to the inner perimeter where crisis negotiations are taking place without unduly disrupting the negotiation process.
The Toronto Police Service should provide emergency task force (ETF) teams with technology to enhance sound capture for use whenever negotiating from a safe distance interferes with the negotiator’s ability to hear the subject.
The Toronto Police Service should consider the use of dedicated negotiators.
The Toronto Police Service should continue to explore the feasibility of implementing body-worn cameras for all ETF officers, and in the interim consider the feasibility of audio recording ETF occurrences from the beginning of the event.
The Toronto Police Service should explore the ability to use audio/visual capabilities to have short notice assistance from external professionals e.g. mental health, interpreters etc.
The Toronto Police Service should continue to build a diverse ETF that represents the communities they serve.
The Toronto Police Service should review research and studies in regard to use of non-lethal tools to incapacitate a subject in possession of a firearm.

The Solicitor General of Ontario

The Solicitor General of Ontario should study the phenomenon of individuals attempting to induce police officers to use lethal force, to improve best police practices across the province.
The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model.
The Solicitor General of Ontario should provide oversight on the mandatory annual training curriculum and number of hours that are provided by local police services e.g. crisis resolution and suicide prevention.

The Government of Ontario

The Government of Ontario should enhance supports for families of persons who die in a police encounter, and ensure that those services are delivered in a timely and trauma-informed manner.

Pigeau, Richard

Surname: Pigeau
Given name(s): Richard
Age: 54

Held at: Sudbury
From: August 29
To: September 2, 2022
By: Dr. David Cameron, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Richard Raymond Pigeau
Date and time of death: October 20, 2015 at 12:06 p.m.
Place of death: 3259 Skead Road, Skead, ON, P0M 2Y0 1660 Level, 1660-021 Ramp
Cause of death: crush-type blunt force injuries to torso
By what means: accident

(Original signed by: Foreperson)

The verdict was received on September 2, 2022
Presiding officer's name: Dr. David Cameron
(Original signed by presiding officer)

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

Inquest into the death of: Richard Pigeau

Jury recommendations

To: The Ministry of the Attorney General (MAG)

It is recommend that MAG examine the feasibility of applying the funds paid into the Ontario Victims’ Justice Fund towards defraying the costs incurred by a deceased’s family members to attend and meaningfully participate in the inquest process as parties.

To: The Ministry of Labour, Immigration, Training and Skills Development (MLITSD) and The Ministry of the Solicitor General (SolGen)

It is recommended that the MLITSD and SolGen work together to examine the feasibility and creation of an office or a program expansion of an office, such as the Office of the Chief Coroner, to provide family members of a workplace death assistance in navigating the inquest process and assisting in accessing grief and counselling services.

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

It is recommended that the MLITSD expedite the amendment to the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 854 (Mines and Mining Plants) proposed by the Mining Legislative Review Committee related to management of change processes.
It is recommended that the MLITSD examine the feasibility of amending the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 854 (Mines and Mining Plants) to mandate the use of seatbelts in mobile mining equipment in underground mines.
It is recommended that the MLITSD take steps to coordinate a risk assessment of the possible risks associated with door ajar interlock systems and subsequent loss of control on underground mining load haul dump machines in use today
It is recommended that the MLITSD take steps to amend the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 854 (Mines and Mining Plants) to mandate that all new underground mining load haul dump machines be equipped with door ajar and unbuckled seatbelt alarm systems.
It is recommended that the MLITSD take steps to amend the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 854 (Mines and Mining Plants) to mandate that all underground mining load haul dump machine currently in use be retrofitted with door ajar and unbuckled seatbelt alarm systems.
It is recommended that MLITSD take steps to amend the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 854 (Mines and Mining Plants) to mandate that all mobile mining equipment be used in accordance with any operating manuals issued by equipment manufacturers as found in O. Reg. 213/91 at 5.93(3) unless any deviation from the operating manual has first been appropriately risk assessed.
It is recommended that the MLITSD and equipment manufacturers take the steps to coordinate a risk assessment of the possible risks associated with machine steering controls mounted on doors in underground mining load haul dump machines in use today.
It is recommended that the MLITSD and equipment manufacturers, assess the feasibility of integrating a sensor into the operator’s seat that would be part of the operator presence system.

To: The Chief Prevention Officer of the Ministry of Labour, Immigration, Training and Skills Development

It is recommended that the Chief Prevention Officer of the MLITSD take steps to examine the feasibility of creating a reporting and/or notification system to promote the rapid sharing of information between mine operators and equipment manufacturers related to mobile equipment high potential risk incidents such that information could be shared expeditiously to proactively prevent the occurrence of similar events at other mines.

To: Caterpillar of Canada Corporation (CAT)

It is recommended that CAT take steps to assess the hazard of loss of control on underground LHDs when the door opens on a STIC steer equipped machine during operation. Specifically, to address a transmission shift to neutral and steer lockout.
It is recommended that CAT explore relocation of the door latching mechanism in order to make it more visible to the operator of LHD equipment, such as flipping the hinges and the latch to opposite sides.
It is recommended that CAT assess the risks and feasibility of allowing the orientation of the operator’s seat to swivel in order to allow operator to have more maneuverability to view the striker.

To: Glencore Corporation

It is recommended that training related to the management of change process take place on a regular basis (annual as a minimum) to ensure that all employees are continually informed as to what requires the initiation of the management of change process.

September

Gordon, Jacob

Surname: Gordon
Given name(s): Jacob
Age: 24

Held at: Toronto
From: September 6
To: September 9, 2022
By: Dr. Mary Beth Bourne, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jacob Gordon
Date and time of death: November 24^th, 2015 at 10:23 a.m.
Place of death: Mackenzie Richmond Hill Hospital, 10 Trench Street, Richmond Hill
Cause of death: electrocution
By what means: accident

(Original signed by: Foreperson)

The verdict was received on September 9, 2022
Presiding officer's name: Dr. Mary Beth Bourne
(Original signed by presiding officer)

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

Inquest into the death of: Jacob Gordon

Jury recommendations

Infrastructure Health and Safety Association

We recommend that an industry wide Hazard Alert be published, alerting end-users, and manufacturers of remote-control devices for booms and cranes, to the risk of inadvertent boom or crane movement associated to the OMNEX T300 Wireless Remote Control, or any similarly designed remote control used for boom or crane operation.
We recommend that all construction projects that utilize booms or cranes in proximity to overhead power lines, be required to make a written request to the owner of the power lines, to facilitate compliance with sections 187 and 188 of Regulation 213/91 for Construction Projects.
We recommend that locates in the vicinity of power lines should include underground, on grade, and above grade utilities or hazards, as well as current, voltage and distance from grade to the high-power line.

Ministry of Labour, Immigration, Training and Skills Development and Infrastructure Health and Safety Association and Provincial Labour-Management Health and Safety Committee for Construction (PLMHSC)

We recommend that the PLMHSC, study, examine, and report on the feasibility of amending the Act to require that all remote controls used to operate booms or cranes in the proximity of overhead power lines have a 3-position switch (“deadman switch”) or other approved failsafe mechanism to prevent unexpected movement of the boom or crane.
We recommend that where a construction project involves work in proximity to overhead power lines and equipment that has the potential to contact overhead power lines such as a boom or a crane is being operated, the PLMHSC, study, examine, and report on the feasibility of amending the Act to require the use of any, or all, of the following protective measures:
1. emerging technologies, like an electro magnetic sensor to prevent a boom or crane from entering the prohibited zone (disabling controls).
2. mechanical devices, such as a pin, that can be inserted into a boom or crane to prevent movement into the prohibited zone.
3. Insulated booms and cranes.
4. Signaller be equipped with a remote e-stop.

Ministry of Labour, Immigration, Training and Skills Development and Infrastructure Health and Safety Association

We recommend that a public awareness campaign be developed that highlights the dangers of working in proximity to overhead power lines and provides information on how members of the public can report seemingly unsafe or non-compliant practices.

Ministry of Labour, Immigration, Training and Skills Development Infrastructure Health and Safety Association and Provincial Labour-Management Health and Safety Committee for Construction

We recommend that Occupational Health and Safety be amended to allow Health and Safety representatives and Joint Health and Safety committees authority to keep confidential the name of any workers who report unsafe conditions.
We recommend that the frequency of required refresher courses/training for Constructors, Employers, Supervisors, and Workers, who work in proximity to overhead power lines and operate equipment that has the potential to contact overhead power lines, be increased to once a year. Topics covered in the refresher should include, among other things:
1. The dangers of working in proximity to overhead powerlines, even when no work on overhead power lines is intended.
2. The requirements for compliance with Occupational Health and Safety Act and Sections 187 and 188 of Regulation 213/91 for Construction Projects, and resources to assist with compliance.
3. The Internal Responsibility System, with an emphasis on the importance of promoting a no-blame workplace safety culture that encourages an open relationship to discuss workplace safety.
4. Tailboard meetings/forms must be completed prior to setup or starting any work.

We recommend that significant and automatic fines should be levied against any company/constructor that fails to ensure that a dedicated Signaller be assigned to Hydro-vac crews and/or any crane operation when working in the vicinity of overhead powerlines.
We recommend that tailboard documents should be standardized, regulated, and include a section that addresses possible encroachment of overhead powerlines of the minimum distance permitted under Section 188 (2) of Regulation 213/91 for Construction Projects

Mahoney, Matthew

Surname: Mahoney
Given name(s): Matthew
Age: 33

Held at: Windsor
From: September 12
To: September 23, 2022
By: Dr. Daniel L. Ambrosini, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Matthew Mahoney
Date and time of death: Pronounced deceased at 9:39 a.m. on March 21st, 2018
Place of death: Windsor Regional Hospital (Ouellette Campus)
Cause of death: multiple gunshot wounds
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on September 23, 2022
Presiding officer's name: Dr. Daniel L. Ambrosini
(Original signed by presiding officer)

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

Inquest into the death of: Matthew Mahoney

Jury recommendations

Directed towards the Ontario Ministry of Health

For the purpose of assisting clinicians in directing patients to receive timely mental health services and promoting accountability of community mental health services, a direction requiring that all hospital and community-based mental health services that receive funding from the Government of Ontario:
1. collect and publish monthly non-identifying data regarding:
  1. wait times for treatment (i.e., actual receipt of mental health services by mental health professionals as opposed to waiting times for intake) and patient volumes
  2. days and hours of mental health services provided
2. provide the resources to allow hospitals and community-based mental health services to provide this data
3. increase mental health awareness and promotion of initiatives within communities to address the lack of familiarity of services and options available for persons and families dealing with mental health situations
Within 6 months of the jury’s verdict, strike a task force to review, report on, and initiate changes to:
1. funding, accountabilities, and timely access to care for all community-based mental health services that receive funding from the Government of Ontario
2. available resources and supports for family members and/or caregivers of patients and community services receiving mental health services
3. how family members and/or caregivers and community services can provide support and/or information about patients when patient consent is not provided
4. address what information can be shared from family members and other stakeholders
5. align services and community agencies to better share information about individuals with mental health concerns in the community

The task force should focus these reviews on the most vulnerable patients, particularly those diagnosed with moderate to severe mental illness, especially schizophrenia and/or schizophrenia-related disorders.

Establish further study and review of the criteria and training associated with the Mental Health Act and report on recommendations to address:
1. mandatory refresher training for emergency room physicians and psychiatrists in the province of Ontario on when and how to use the Form 1 options associated with mental health
2. the assessment of Box A and Box B criteria for psychiatric evaluation and involuntary detention
3. to determine how best to ensure collateral information from family members and relevant community services information can be included as part of the process for determining appropriate treatment options

Directed to the Government of Ontario

The Government of Ontario should offer and arrange enhanced legal and mental health support for families of persons who die in a police encounter and ensure that those services are delivered in a timely and trauma-informed manner.

To the Ministry of the Solicitor General and Windsor Police Service

Provide enhanced police training in addressing mental health-related situations and crises, including awareness education in recognizing and identifying situations where mental illness may play a role.
1. provide mandatory standardized training bi-annually on de-escalation strategies and empathy for community mental health-related situations.

Review current procedures and processes in respect of police response to persons who have a mental illness.

To Windsor Police Service (Community Outreach and Support (COAST) Program)

Review the resources allocated with the COAST program to ensure and offer increased support based on the growing community mental health needs of the Windsor, Ontario region, to offer support 24 hours a day.

Directed towards Windsor Regional Hospital and the Ontario Ministry of Health

Continue ongoing quality assessments to drive continuous improvement of standard operating procedures and protocols, documentation, and best practices with mental health services:
1. to review and audit core services within Windsor Regional Hospital annually to ensure compliance to standards are met and keeping pace with community demands proactively.
Assess the feasibility and impact of establishing a mental health advocate role (or enhancing the abilities of social workers) to be the point person helping patients and families coordinate mental health services:
1. this advocate assists with scheduling follow-up sessions after appointments; check-ins, and visits; support after medication changes; recommends community services; collecting collateral information from relevant parties
2. based on demand and proper funding, this advocate will be required to manage multiple concurrent cases effectively within a framework of flagging and following up with the highest-risk outpatients
3. consistently offer a family meeting within 48-72 hours of hospital admission, regardless of the patient’s status in hospital, to collect collateral information
4. documented offer of a meeting with family members or support team occurs prior to discharge from hospital to ensure a patient with mental health issues has support
5. provide mental health services 24 hours a day to better assist communities by expanding self-help services to those in need through online, hybrid, or in-person supports

Ogundipe, Victor

Surname: Ogundipe
Given name(s): Victor
Age: 41

Held at: virtual inquest
From: September 26
To: October 7, 2022
By: Murray Segal, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Victor Ogundipe
Date and time of death: January 26, 2017, 10:14 p.m.
Place of death: 36 Queen Street East, Toronto
Cause of death: a) Hemoperitoneum, due to b) rupture of liver, due to c) blunt force injury to abdomen.
By what means: accident

(Original signed by: Foreperson)

The verdict was received on October 7, 2022
Presiding officer's name: Murray Segal
(Original signed by presiding officer)

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

Inquest into the death of: Victor Ogundipe

Jury recommendations

The Ministry of the Solicitor General (ministry) should review the Offender Tracking Information System OTIS to ensure that unit notification cards clearly identify OTIS alerts and other relevant information on the front of the card on a single page.
The ministry should ensure and enforce thorough training that:
1. All correctional staff read the unit notification cards of the inmates in their unit at the start of their work shift (immediately following shift change) and whenever an inmate returns to the unit from court or other external location.
2. All correctional staff and nurses have full access to OTIS regarding alerts and housing placement history during the admissions process.
3. All correctional staff and nurses perform a thorough review of OTIS during the admissions process.
The mnistry should ensure that the Toronto South Detention Centre, and any other detention centres organized in the same manner, have an additional copy of the unit notification card kept on the unit for review by correctional officers while an inmate is absent due to court or other external location.
The ministry should ensure that OTIS alerts are noted on unit notification cards, to facilitate quick and easy identification of the alerts by correctional officers and medical staff.
The ministry should ensure and enforce through training that all correctional staff ensure that any important information, including historical information, is entered into OTIS as an alert.
The ministry should conduct regular reviews to ensure its complement of nurses is sufficient to allow thorough assessments of each Inmate.
The ministry should explore safer alternatives to wooden pencils being provided to Inmates.
The ministry should upgrade key CCTV cameras to record audio in common areas, where permissible by privacy legislation.
The ministry should ensure that all correctional officers are trained regarding recognizing behaviour of Inmates that might pose a risk to the Inmate or others. This training should also include periodic or ongoing refresher training.
The ministry should ensure that all staff be trained regarding crisis and incident response and management. This training should also include periodic or ongoing refresher training.
The ministry should amend its policies and practices for admissions officer/OTIS booking officer and admission nursing staff to place a higher emphasis on the medical history and prior classification and housing history, in addition to the subjective presentation of an Inmate on the day of admissions and thereafter.
The ministry should require all forms related to the admissions of inmates to be completed in full, including review and signature by a sergeant (or their designate). The ministry should explore digital form tools that would ensure all required fields are completed.
The ministry should explore the use of a scoring metric to determine risk in areas such as mental health and violence, assessed first at Intake and re-evaluated on a continuous basis.
The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards.
The ministry should ensure that all correctional officers and nurses have full access to medical and mental health records, and previous incarcerations, where permitted by law.
The ministry should review OTIS to include features to allow certain alerts to be clearly highlighted for staff’s attention.
The ministry should review OTIS to include features, if not currently present, to allow for the recording of username and timestamps when new information is entered or amended (which is effectively a digital changelog)
The ministry should develop guidance to determine criteria by which OTIS alerts are expired. The ministry should maintain alerts on OTIS unless directed otherwise by a deputy superintendent, or where alert expiration is indicated by ministry guidance.
The ministry should ensure that pending the admissions process and related mental health assessments, Inmates are placed in a temporary housing unit without a cellmate.
The ministry should ensure mental health nurses are available on call 24 hours a day, seven days a week, to see any Inmates waiting for them as soon as possible to allow all assessments to be completed in a timely fashion regardless of whether any given Inmate has temporarily left the institution for court.
The ministry should explore the feasibility of creating and implementing a plan for mental health assessments to be completed by a qualified professional within six hours of the admission, and for all other admissions procedures to be completed within 24 hours of the inmate’s admission.
The ministry should ensure that correctional officers investigate cell change requests immediately, and grant same immediately, where merited. If it cannot be done immediately, the correctional officers should then bring the Inmate to admit and discharge pending re-assignment to a cell.
The Office of the Chief Coroner should consider conducting inquests within a timely manner, within 24 months from the incident date with the exception of extraordinary circumstances.

Freeman, Devon Russell James (Muska’abo)

Surname: Freeman
Given name(s): Devon Russell James (Muska’abo)
Age: 16

Held at: Hamilton
From: September 26
To: October 21, 2022
By: Jennifer Scott, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Devon Russell James Freeman (Muska’abo)
Date and time of death: April 12, 2018 (October 7, 2017 – April 12, 2018)
Place of death: 831 Collinson Rd, Flamborough
Cause of death: hanging by ligture
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on October 21, 2022
Presiding officer's name: Jennifer Scott
(Original signed by presiding officer)

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

Inquest into the death of: Devon Russell James Freeman (Muska’abo)

Jury recommendations

To the institutional parties (Chippewas of Georgina Island First Nation, the Children’s Aid Society of Hamilton (the society), Lynwood Charlton Centre (Lynwood) and Hamilton Police Services (HPS) and the Ministry of Children, Community and Social Services (MCCSS):

Led by the Chippewas of Georgina Island First Nation, support the development and delivery of a case study training module for children’s aid societies and residential service providers regarding the lessons arising from Devon Freeman’s life and death and incorporate information from the Narrative document (with the exclusion of personal identifiers or information that may identify individuals or otherwise assign blame). Any requests to obtain and use video or other recordings from the inquest shall be made to the Office of the Chief Coroner for their consideration.
Use or continue to utilize neutral, descriptive language to describe young people who leave their place of residence without permission.

To the Ministry of Children, Community and Social Services

Continue to work with bands and First Nation communities, including First Nations and urban Indigenous service providers, and Indigenous child well-being agencies to develop regulations as soon as possible that would support implementation and proclamation of amendments to the Child, Youth and Family Services Act, 2017 (the CYFSA) that received Royal Assent on March 3, 2022 through the Fewer Fees, Better Services Act, 2022 – Bill 84. This includes amendments that would provide a framework to distinguish customary care from residential care in specified circumstances and would not be subject to licensing requirements under Part IX of the CYFSA.
In accordance with subsection 1(2), paragraph 6, of the CYFSA, MCCSS should consider the need for a directive to children’s aid societies and licensed residential facilities to notify a child or youth’s bands and First Nation communities when a child or youth is absent from their residence without permission for more than 24 hours (and upon their return), is seriously injured, or dies in care and/or at the licensed facility.
Strongly recommend as part of the five-year review of the CYFSA that is currently underway, MCCSS is encouraged to engage with bands and First Nation communities and affiliated Indigenous stakeholders, and consider amendments that would require:
1. mandatory notification to a child or youth’s band or First Nation community when a child or youth is absent from their residence without permission for more than 24 hours (and upon their return)
2. mandatory notification to a child or youth’s band or First Nation community when a child who is a resident in a children’s residence dies, and in the event of any other serious occurrence, as listed at subsection 84(1) of the CYFSA.
To improve outcomes for First Nations children and youth, continue to work, through the Child Welfare Redesign Strategy, on potential further changes to the funding allocation and the child welfare service delivery model, including consideration of the following:
1. continue monitoring the effectiveness of annualized funding announced in July 2020 as part of the Child Welfare Redesign Strategy to provide access to prevention-focused customary care for bands and First Nation communities
2. support the implementation of models of service to enable children and youth to have meaningful, lifelong connections to their family, community and culture; a sense of belonging; a sense of identity and well-being and physical, cultural and emotional safety; and that plans of care are reflective of the child’s physical, mental, emotional, spiritual and cultural identities beginning from the time a case is opened by a society
3. continue to review the Ontario Eligibility Spectrum, the need for verification, and adopt a needs-based approach (instead of a caregiver deficits approach) to supporting and protecting the well-being of children and youth informed by Indigenous experts
4. consider the need for Navigators, in addition to resource persons, adult ally and circle of supportive persons to assist First Nations youth, as both a prevention and protection resource and for youth both on and off reserve, in navigating various systems such as child welfare and protection, mental health and criminal justice.
To ensure that First Nations children benefit from their legal entitlements under An Act respecting First Nations, Inuit and Métis children, youth and families, engage with its federal counterparts to discuss support to children’s aid societies to meet the enhanced requirements regarding prevention, service provision, and reassessment.

To the Ministry of Children, Community and Social Services and the Ministry of Health:

In the spirit of recommendations made in the past in other settings, including those in the Safe with Intervention report, and in recognition of the ongoing need for more residential children’s mental health placements; the need for programs that address complex needs of children; the need for land-based programs and programs that prioritize connections with family, culture and community, we strongly recommend that the ministries work with Indigenous providers and communities to ensure that Ontario’s Indigenous Healing and Wellness Strategy includes:
1. residential treatment resources for Indigenous communities
2. service coordination for children with complex trauma and complex needs to ensure safety, continuity of care, and the avoidance of long wait lists
3. support for the development of programs that are flexible and able to respond to a range of needs including chronic and acute needs in a range of health and well-being domains.
In partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, establish multisectoral, multidisciplinary roundtables at local, regional, and provincial levels accessible to community members and service providers to problem-solve regarding service to young people with complex needs. These roundtables should include representatives of relevant government ministries, including Children, Community and Social Services, Health, Education, and Indigenous Affairs, community-based service providers, societies, Indigenous child well-being agencies, mental health lead agencies, children’s rights experts, educators, youth justice workers, and police as necessary.

To the Hamilton Police Service:

Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a “pilot” project.
Work towards creating (including if necessary by making a request to the HPS Board for resources or funding) a new Missing Persons Unit (MPU) with the responsibility of coordinating and directing missing persons investigations. Any MPU that is created may still rely on officers from patrol or other divisions as appropriate in conducting missing persons investigations.
In developing an MPU, the HPS should consider and review the recommendations in Missing and Missed: The Report of the Independent Civilian Review into Missing Person Investigations and their application to the HPS. Specifically, they should consider:
1. developing a strategic plan; including review and potential amendments to missing persons investigations (MPI) policies
2. giving priority to MPIs and change in culture
3. consistent coordination of MPI
4. use of civilian support workers, civilians in duties not required for a sworn officer related to MPI, coordination and family support
5. use of FOCUS tables
6. continuity of investigations
7. maintenance and development of community partnerships and, in particular, the Indigenous community
8. timely media releases
9. partnerships with youth institutions and, in particular, child and youth mental health facilities
10. creation of an implementation strategy.
Provide training for officers in the MPU, and other officers who may work in conjunction with the MPU, on missing persons investigations. Such training may include programs or courses offered by other police forces and/or programming put on by HPS officers with particular experience and expertise in missing persons investigations. Such training should address issues such as identifying and dispelling stereotypes that arise in relation to missing persons, conducting risk assessments for missing persons, collecting information from the person/organization reporting a missing person, using investigative tools and techniques that assist in conducting missing person investigations.
Review and revise the risk assessment process and policies that govern whether a missing person is classified as “Level 1” or “Level 2”, as well as whether an urgent search is required. The revised risk assessment factors, as well as search urgency factors, should be evidenced-based and clearly defined. In determining whether an MPI is classified as a “Level 1”, the revised process should require gathering additional information about the missing person, including but not limited to:
1. any history of suicidal behaviours (ideations or attempts)
2. whether the person is in an out-of-home placement at a mental health facility for children and youth
3. whether the missing person is an Indigenous youth.
Once a risk assessment has been completed, ensure that all missing person cases are triaged to determine the appropriate response to a person’s disappearance, including whether that response should involve a combination of the police and/or other community organizations and/or a multi-disciplinary response. Consider an appropriate role for community members or organizations as part of the missing person investigation, or in a debrief with the missing person once the investigation is concluded.
Improve the HPS’s system for collecting and reviewing information relating to missing persons investigations, including considering the use of Powercase, alternatives to the Occurrence Enquiry Log system, and the ability to flag individual reports/occurrences where an individual demonstrates suicidal behaviours (ideations or attempts) (rather than just flagging the name of the individual).
In consultation with residential homes and child and youth mental health facilities like Lynwood, develop a common joint responsibility protocol governing the process, roles and responsibilities when it comes to searching for youth who have left congregate settings without permission. The protocol should address:
1. the circumstances in which a missing persons report should be filed
2. the information to be provided as part of that report
3. the residential home’s responsibilities prior, during, and after filing a report (including conducting a property search where appropriate)
4. the HPS’s responsibilities prior, during and after filing a report
5. Responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth.
In consultation with organizations like Hamilton Children’s Aid Society and other agencies servicing high-risk youth, develop a joint process whereby HPS and other community stakeholders come together to review any case of a missing youth from an out-of-home placement, on a timeline to be determined by the Missing Persons Coordinator based on the risk assessment for a particular youth.
Establish the role of an Indigenous Liaison within the HPS. This position would be filled by an Indigenous police officer whose responsibilities would include outreach and engagement with First Nation and Indigenous communities.
Review the process and criteria for issuing a media release to ensure that, where appropriate, timely media releases are issued in missing person investigations, and that due consideration to issuing a media release occurs within set time periods during an investigation.
Provide Indigenous-led cultural competency and cultural safety training to all officers.
Work in consultation with residential homes and child and youth mental health facilities like Lynwood to develop a living document for each youth in its care that can be readily shared with police if necessary, in the event that the youth is absent from the residence without permission and a missing person’s report is being filed, and in accordance with the requirements under Part X of the CYFSA.

To the Ministry of Health (MOH):

To support the cultural safety and well-being of First Nations children and young people and in keeping with the Truth and Reconciliation Commissions’ Calls to Action (2015), continue to support a range of Indigenous programs to include Youth Life Promotion initiatives which entail both school and land-based programs, Indigenous Mental Health and Addiction Workers in the Indigenous communities across the province, Mental Wellness Teams, Indigenous Professional Development and Tele-Mental Health.
1. Regularly consult with bands and First Nation communities and Indigenous stakeholders on program implementation and service delivery for new and existing initiatives; and report back within a reasonable period of time.
Consider the creation of a multidisciplinary mental health services team approach, (including a mental health case manager) for children and their families to support continuity of care throughout their childhood and to provide broad and supportive care.
To support and promote cultural safety for First Nations children and young people, the MOH will fund and support Lynwood and similar facilities to engage Indigenous experts to develop and assist in implementing culturally relevant mental health services and supports that reflect the unique needs and well-being of First Nations children and young people.
To address the mental health needs of children and young people, the MOH should fund mental health services to address funding shortfalls resulting from the multi- year freeze of Lynwood base-funding.
Fund a full range of Indigenous-led mental health services and facilities in the Hamilton region and other regions in Ontario to meet the need for culturally safe and restorative mental health and healing services for Indigenous children, youth and families.
Increase sustainable and equitable funding for community-based children’s mental health services, including residential placement options and family support, that are responsive to recruitment and retention needs of service providers to employ multidisciplinary staff and professionals and programs that are flexible, responsive, and facilitate the right services at the right time for children and young people with complex needs.

To the Children's Aid Society of Hamilton:

To support the well-being of children, continue to ensure that, as part of the intake process, staff acquire and review all relevant information and documents relating to a young person, including any plans of care developed by prior residential facilities and any information relating to suicidal behaviour or ideation. If there is any information relating to suicidal behaviour or ideation, it must be flagged so any other society workers are immediately aware of that aspect of a particular young person’s history.
To ensure the safety of children in care, train staff to ensure that, to the extent a youth’s file is transferred from one staff member to another, all information relating to a young person’s suicidal behaviour and ideation is clearly flagged in transfer discussions or communications between staff.
To ensure open and full communication, data collection, knowledge, and relationship-building regarding the children, youth, and families transferred to ongoing service, consider implementing a “one care team per family” system with consideration to the file loads of workers.
For young people in care, engage with any outside service provider at the intake stage to set clear lines of responsibility regarding communication of information regarding the young person to those in the youth’s circle of care, including communication of self-harm attempts and leaving the property without permission.
Continue to facilitate learning events related to the youth presenting with complex suicide needs and remain an active community participant in the Youth with Complex Suicide Needs (YCSN) protocol, a comprehensive and coordinated approach to care for children and youth who have been identified as being at high risk for suicide and have complex presentations.
Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care.
In partnership with the urban Indigenous community, continue active membership on the Indigenous Child Welfare Collaboration Committee established in January 2018 to strengthen relationships, develop pathways and strategies for a coordinated approach to services and wraparound support for First Nations Inuit and Métis children and families involved in child welfare services in Hamilton.
Enhance procedures for increasing communication and service coordination contained within the signed protocol between child welfare services and the services provided by urban Indigenous agencies, including but not limited to: De dwa da dehs nye s (Aboriginal Health Centre), Hamilton Regional Indian Center, Niwasa Kedaaswin Teg, the Native Women’s Centre and the Niagara Peninsula Aboriginal Area Management Board (NPAAMB).
Continue to prioritize the Child Welfare Sector Commitments to Reconciliation by transparently sharing data (without personal information and in accordance with Part X of the CYFSA) related to the following outcomes with Indigenous service partners: reducing the number of First Nations children and young people in care, reducing the number of legal files involving First Nations children and families, and increasing the number of formal customary care agreements.
Continue to be accountable to the child, the child’s family and the child’s First Nation community to ensure First Nations children in out-of-home placements maintain connection to family, community, and culture and that plans are reflective of the child’s physical, mental, emotional, and spiritual identities through the regular review of all First Nations children in care.
Enhance policies and procedures to support collaborative communication and planning with First Nations communities when providing services to an Indigenous family/child/youth by building upon the work of the specialized Indigenous service team, the Sharing Circles for Indigenous youth in care developed in partnership with Catholic Children’s Aid Society, the Hamilton Regional Indian Center and Niwasa Kedaaswin Teg, and the recommendations from the Society’s Child Death Update (Exhibit 24).
Recognize that the best practice is to consider Indigenous Dispute Resolution by connecting with the First Nation regarding any challenges faced by a First Nations young person and/or family.
Continue to ensure that all young people in care have reasonable access to cell phones or other technologies they may need to communicate with their family, their First Nation and others important to them.
Continue to prioritize the recruitment, hiring, and retention of workers with First Nations identity and from other equity-deserving groups, recognizing skills related to Indigenous knowledge and cultural identity alongside traditional mainstream credentials.
To support ongoing consultation, communication, and transparency between the Society and the bands and First Nations communities of the children and youth it serves, the Society shall reach out to those bands and First Nation communities and offer to develop a communication protocol and offer to initiate quarterly reviews regarding all children receiving services from the Society.

To Lynwood Charlton Centre:

To ensure the safety of the children in its care, Lynwood’s psychiatric nurse practitioner shall meet with staff upon admission of each new client regarding any diagnosis and/or mental health needs.
To ensure the safety and ongoing wellness of the children in its care, where a youth has disclosed suicidal behaviours or ideation, make best efforts to bring together all those involved in a youth’s circle of care to discuss and assess the youth’s situation and participate in safety planning for the youth (including the youth’s self-identified support, youth’s guardian, First Nation if applicable, medical team, supportive community members and family where appropriate).
To ensure proper coordination with the HPS, maintain a living document for each young person in its care that can be readily shared with police if necessary. Information shall include a recent photograph of the youth, any history of suicide ideation or attempts, known triggers including any incidents of bullying.
For a young person in its program, engage with the guardian at the intake stage to set clear lines of responsibility regarding communication of information regarding the youth to those in the youth’s circle of care, including communication of self-harm attempts and leaving the property without permission.
Develop further therapeutic activity programming for youth that reflects a wide variety of interests. Where possible and financially feasible, connect young people with external resources that could provide additional opportunities, including but not limited to sport, land-based learning, culture, art, and other pursuits that will assist in developing a forward pathway.
Ensure that all safety plans are written down and shared with Lynwood staff, the young person’s guardian, and other members of a young person’s circle of care where appropriate and consistent with privacy legislation and rights.
In consultation with the HPS, as well as residential homes and other child and youth mental health facilities, develop a common joint responsibility protocol governing the process, roles, and responsibilities when it comes to searching for youth who have left congregate settings without permission. The protocol should address:
1. the circumstances in which a missing persons report should be filed
2. the information to be provided as part of that report
3. the residential home’s responsibilities prior, during, and after filing a report (including conducting a property search where appropriate)
4. the HPS’s responsibilities prior, during, and after filing a report
5. responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth.
Continue to train staff to identify and address suicidal ideations and risk factors (acute and chronic) associated with suicide.

To the Children's Aid Society of Hamiton and Lynwood Charlton Centre:

Develop workable practices to improve contact and connection of individual young people with safe adults in their circle of care, to reduce circumstances where children are absent and their whereabouts are unknown.
Promote and utilize the participation of young people and youth-driven practices in services, tools and programs, such as: the Wise Practices resources and Life Promotions toolkit by Indigenous youth, that are about their own wellness and make space for the young people to put into practice tips and ideas from those services, tools and programs.
When non-Indigenous service providers are providing care, the First Nation Mental Wellness Continuum Framework should be considered when developing and delivering services to Indigenous children in care.
Foster and support the co-development of life promotion programs such as Promote Life Together between Indigenous and non-Indigenous stakeholders to establish and develop meaningful programs and services, with an emphasis on the inclusion and engagement of Indigenous stakeholders from inception.
As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights.

To the Office of the Chief Coroner of Ontario:

In recognition of the important roles of family and Indigenous communities, offer to involve the family and the Indigenous community of a deceased Indigenous young person in the Pediatric Death Committee Review process where appropriate, having due regard to confidentiality concerns.
Review, in consultation with stakeholders, the discretionary nature of inquests into the deaths of children in care and consider advocating for legislative change requiring said deaths to be the subject of mandatory inquests.

To all Institutional parties:

That the MCCSS and all institutional parties to this inquest work together in a collaborative manner towards ensuring that First Nations children have a right to return to their home communities when receiving services under the CYFSA. This should be adopted and developed as “Devon’s Principle”.

To the Ministry of Children, Community and Social Services and the Ministry of Health and the Government of Canada:

Provide direct, sustainable, equitable, and adequate joint funding from the named Ministries and Government of Canada to First Nations, off-reserve Indigenous service providers, and non-Indigenous service providers serving off-reserve First Nations children, youth and families to increase the capacity for collaboration in the provision of child welfare and mental health services.
Implement the Spirit Bear Plan through collaboration with MCCSS, MOH and government of Canada

To the Ministry of Children, Community and Social Services:

In partnership and in consultation with First Nations, provide direct, sustainable, equitable, and adequate funding to First Nations for prevention services, cultural services, and Band Representative Services to service and support both on- and off-reserve First Nations children, youth and families involved in child welfare and in support of children and youth in need of mental health supports pursuant to a needs-based approach that meets substantive equality.
In partnership and in consultation with bands and First Nation communities, and affiliated Indigenous stakeholders, provide direct, sustainable, equitable, and adequate funding accessible to children’s aid societies and residential service providers to access Indigenous-led cultural services, culturally restorative practices, cultural competency, and educational supports and other cultural supports within the child welfare system.
To improve outcomes for First Nations children and youth, empower and seek to fund bands and First Nation communities and affiliated stakeholders (such as the Association of Native Child and Family Services Agencies of Ontario) to collect data and analyze data to determine whether, and to what extent, child welfare interventions and services are improving outcomes for children and youth.
Once the data is gathered and analyzed, in partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, seek authority and any necessary funding to implement and act upon the data recommendations to support better outcomes for children and youth, including seeking the necessary authority to make any legislative and regulatory changes to support changes for better outcomes.
Provide support for training and capacity building for children’s aid societies and licensed residential facilities to meet the consultation requirements with bands and First Nation communities under sections 72 and 73 of the CYFSA, including the ability for Indigenous children to return to their home communities to support cultural safety.
Provide adequate and sustainable funding and resources to ensure that a range of placement options and transition services, including independent and semi-independent living arrangements, are available for children and young people receiving services from children’s aid societies and Indigenous well-being agencies.
In consultation with civil society child rights experts and Indigenous rights experts, undertake a Child Rights Impact Assessment with respect to all proposed regulations made under and amendments to the CYFSA.
To improve outcomes for First Nations children and youth, continue to work through the Child Welfare Redesign Strategy on potential further changes to the funding allocation and the funding model and approach to the child welfare service delivery model, including consideration of developing a prevention and reunification process that focuses on family preservation, family reunification, kinship preservation, family contact, assessment of child, youth and parent strengths and needs, parenting skills, home management and routine, infant care, and exploring and developing support networks.
In order to support fulsome assessment, information sharing within the child welfare system and ensuring a holistic approach to caring for children and young people, develop future amendments to O. Reg. 156/18 that would improve service coordination, service integration and oversight as part of implementation of the Quality Standards Framework, including:
1. development of an integrated Plan of Care focused on the social determinants of health for the family and child that follows them through community services when they are in the community and also when they are in the care of a children’s aid society and incorporate the cultural and spiritual needs of the child; and,
2. Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission.

To the Ministry of Health and to the Ministry of Children, Community and Social Services:

Work with Indigenous communities to support the creation of residential treatment options that are Indigenous-run and Indigenous-informed with Indigenous-specific programming. These would keep Indigenous youth within their local community and connected to family, culture, and local supports.
In partnership with children’s mental health residential service providers, develop and effectively fund programs that are responsive to the needs of hard-to-serve young people presenting with high-risk behaviors such as aggression or suicidal ideation and other complex needs. These programs must also consider service coordination when a young person transitions to a new community to avoid the young person being placed on a waiting list to receive assistance.

To the Ontario Association of Chiefs of Police:

Consider extending the recommendations 10-22 to include all municipal police forces across Ontario.

To the Ministry of Children, Community and Social Services:

Develop an expert panel including Indigenous leaders, researchers, as well as leaders from other provincial child welfare ministries, such as British Columbia’s Ministry of Children and Family Development who can provide expertise on best practices to revise the child welfare funding formula to address the needs of Indigenous youth. In addition, the panel will identify priorities for funding from existing resources to support Indigenous welfare programs and First Nation communities.
The same expert panel as noted above should provide recommendations to define outcome measures which clearly describe the successful progression of Indigenous youth through the welfare system to independence and adulthood. These outcome measures should be supported by key performance indicators (KPI) that are measured and updated on a quarterly basis in collaboration with provincial child welfare agencies. These KPIs will be used to assess performance and efficiencies within the agencies and support ongoing quality improvement initiatives.

October

Mamakwa, Donald
McKay, Marlon Roland

Names of the deceased: Mamakwa, Donald; McKay, Marlon Roland
Held at: Thunder Bay
From: October 11
To: November 4, 2022
By: Dr. David Cameron, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Mamakwa
Given name(s): Donald
Age: 44

Date and time of death: August 3, 2014 at 12:03 a.m.
Place of death: Thunder Bay Police Service
Cause of death: ketoacidosis, complicating diabetes mellitus, chronic alcoholism, and septicemia
By what means: undetermined

Surname: McKay
Given name(s): Marlon Roland
Age: 50

Date and time of death: July 20, 2017 at 1:34 a.m.
Place of death: Thunder Bay Regional Health Centre
Cause of death: hypertensive heart disease
By what means: natural

(Original signed by: Foreperson)

The verdict was received on November 4, 2022
Coroner's name: Dr. David Cameron
(Original signed by coroner)

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

Inquest into the deaths of: Donald Mamakwa and Marlon Roland McKay

Jury recommendations

Statement of Principle

The following recommendations are made in recognition and acknowledgement of the following principles:

It is essential that services provided by all institutions listed below be reflective of Indigenous cultural needs. Inclusion of and consultation with Indigenous communities/agencies is essential. This will require consultation with and inclusion of a diverse group of Indigenous communities/agencies, in recognition of the fact that Indigenous cultures/traditions/ways of being are not monolithic and that Thunder Bay is home to Indigenous peoples from across the North who possess a spectrum of cultural values/languages/ways of being.
That care and services must be provided using a trauma informed approach to ensure that individuals who have suffered complex traumas are not excluded from the services that may assist them. This should incorporate recognition of the historical and ongoing traumas faced by Indigenous communities and adequate cultural competency to provide care/services in a manner that recognizes these traumas.

Recommendations

To the Thunder Bay Regional Health Sciences Centre, Ministry of Children, Community and Social Services, and the Ministry of Health of Ontario:

That a Task Force be developed with a mandate to establish a sobering centre in Thunder Bay. The task force would involve representatives from, and meaningful input from:
1. Members of the Thunder Bay community including individuals with lived/living experience
2. St Joseph’s Care Group
3. Dilico Anishinabek Family Care
4. Anishnawbe Mushkiki
5. members of the Thunder Bay District Mental Health & Addictions Network
6. members of the Thunder Bay Drug Strategy
7. Thunder Bay Police Service
8. City of Thunder Bay
9. Superior North Emergency Medical Services
10. Shelter House and Grace Place
11. Fort William First Nation
12. Nishnawbe Aski Nation and Anishinabek Nation
13. other Indigenous and community partners who wish to participate
14. Urban Abbey
15. Salvation Army
That an accessible sobering centre with a locally developed model of care appropriate to meet the needs of Thunder Bay and surrounding communities be established.
That the sobering center meet the criteria for the designation of an alternate level of care by the Ministry of Health to permit paramedics to transport patients to the sobering center rather than an emergency room.
In recognition of the shortage of beds in detox/treatment (rehabilitation) facilities in the City of Thunder Bay, the number of beds in such programs should be increased to adequately meet the needs of the community. This increase shall:
1. Not come as an alternative to the creation of a sobering centre, in recognition of the fact that these institutions would provide different services.
2. Follow a study to determine the scale and volume of increase that is necessary to address the shortage of beds in Thunder Bay for all communities that access Thunder Bay for services.
3. Include the development of strategic partnerships between the sobering centre, managed alcohol programming, medical providers, all subsidized housing providers and community care teams to provide and facilitate appropriate discharge planning for individuals who are to be released from the centre.
In recognition of the fact that law enforcement agencies in the City of Thunder Bay lack the appropriate training, cultural competency, and resources to provide appropriate services to individuals suffering from alcohol/substance use disorder and/or chronic housing insecurity, work to ensure that community-based programs which provide outreach and services to such individuals are maintained and continued, including and not limited to:
1. the Street Outreach Service (SOS) program operated by Shelter House
2. the Care Bus, operated by NorWest Community Health Centre
3. the WiiChiiHehWayWin street outreach initiative, operated by Matawa First Nations Management
In recognition of the seriousness of alcohol/substance use disorder as a medical condition which may mask the appearance of other serious medical conditions, a program should be established in the City of Thunder Bay to provide medical alert bracelets to individuals at high risk for adverse medical outcomes. Such a program should:
1. operate only upon the consent of each individual participant
2. be managed in partnership between a sobering centre, managed alcohol facility and community care teams
3. include a system by which first responders can contact case managers/care team members to: inform them that an individual in their care has been in contact with first responders (emergency medical services (EMS), police, fire); inform them if an individual has been taken into custody/to hospital/to detox/to a sobering centre; and inquire about any medical concerns that such institutions shall be aware of
In recognition of the seriousness of alcohol/substance use disorder (A/SUD) as a medical condition which puts individuals at a high risk for other precarious positions including chronic housing insecurity and poor medical care, the availability and scope of managed alcohol programming (MAP) in the City of Thunder Bay should be increased. Aspects of this increase shall include but not be limited to:
1. The provision of medical care including the appropriate dispensing of medications to participants in the program, in recognition that participants may face barriers in accessing medical care and carrying out treatment plans independently.
2. The provision of therapeutic care. This shall include adequate training and resources for all care providers and all staff within MAPs so that individuals with a likelihood of violent behaviour as a result of trauma are still able to receive care and services from the MAP.
3. The provision of MAP that is available to individuals who are released from correctional facilities/hospitals or other residential institutions, in recognition of the increased risk of death following such release.

To the Thunder Bay Police Service and Superior North Emergency Medical Services:

That joint training be scheduled on an on-going basis, allowing first responders to learn more about the roles and responsibilities of other agencies.
That the services collaborate to discuss the practice of “wave offs,” and develop policies and training for first responders, on how a “wave off” should not occur. Communication between first responders at the scene must be documented.
That all police officers be trained that paramedics cannot ‘medically clear’ any person, and that an assessment by a paramedic does not mean that a patient does not require medical treatment.
That mandatory training for all first responders and all staff of both services be provided on an ongoing basis that addresses issues around impacts of systemic and structural racism. The foundation of training should include, but not be limited to, the history of colonization and the impact on Indigenous peoples; residential schools; trauma informed approaches; anti-Indigenous racism; unconscious bias; and Indigenous cultural safety training. The training should address:
1. managing implicit bias
2. understanding how emotional prejudice impacts decision making
3. tactics/solutions for mitigating the harmful impact of stereotyping on health and criminal justice outcomes
That both services consult with Indigenous Nations, Provincial Territorial Organizations (PTOs) and community agencies to create a process to audit the effectiveness of the training listed above.

To the Thunder Bay Police Service

Conduct a review and consider the role of jailers, the level of supervision given to individuals in custody, and training given to staff in that role, and in particular:
1. Review the level of staffing, and consider a policy that links the number of staff to the number of prisoners, similar to the Ontario Provincial Police’s standard of using one ‘guard’ for seven individuals in custody.
2. Review whether the policy for the care and handling of individuals in custody needs to be clarified, particularly in relation to which individuals in custody should be considered “high risk”.
3. Review whether one on one supervision needs to be provided to individuals in custody who pose particularly high risk, such as individuals who expressed suicidal ideation.
4. Report to the Thunder Bay Police Services Board on the above.
That the Thunder Bay Police Service (TBPS) provide access to counsel as required by s. 10(b) of the Canadian Charter of Rights and Freedoms to all individuals, including those charged with minor or public intoxication offences.
The arresting officers and jailers must clearly indicate/communicate verbally and with diverse signage the procedures and rights of people in custody. Visual signage should be placed in the booking area and cell blocks.
That where an individual dies in cells, all officers involved in the arrest or monitoring of the deceased be provided information about the cause of death, and training on symptoms that may be related to this cause of death, as soon as reasonably possible following the death.
Institute a policy to mandate regular debriefs with officers involved with incidents that engage the Special Investigations Unit to ensure that supports are in place and the incident to be used as a learning tool so that future incidents can be prevented.
That bystander training be provided to police officers so that officers feel more comfortable addressing inappropriate behavior by colleagues.
That the use of ‘medically fragile’ flags be considered for the TBPS records management system.
That the use of paper “green sheets” be discontinued, that the booking process and prisoner management systems be digitized, and that documentation used for charges in court be separated from the documentation used to manage and care for individuals in custody.
That officers and jailers continue to be trained on an ongoing basis to seek out and record answers from the arrested person about their medical condition.
That the Community Inclusion Coordinator be part of the process for reviewing relevant TBPS policies, to review these policies with a cultural lens to ensure they are culturally appropriate and reflective of Indigenous cultural needs. The police service will ensure that the Community Inclusion Coordinator is provided with the capacity and support needed to complete such a review.
That the Thunder Bay Police Service review its jailer academic programming and, if not already included, incorporate an educational component on the Human Rights Code and training on cultural sensitivity.
That the Thunder Bay Police Service ensure that the Reconciliation training currently being undertaken by the service is not a one-time training course, but rather provided as continuous training over the course of an officer’s career and that the police service consult with Indigenous Nations, PTOs and community agencies to create a process for the community to audit the effectiveness of the police services Reconciliation training.

To the Thunder Bay Police Services Board

That the Thunder Bay Police Service Board consider creating a position of Deputy Chief, Indigenous Relations.
That the Thunder Bay Police Service Board retain an expert consultant for the purposes of providing an independent assessment of the level of staffing required of the Thunder Bay Police Service.
That the Board create a process for regular review of board policy to determine which policies need to be updated or created.
The Board will consider yearly public reports setting out the initiatives taken by the Board, the progress of those initiatives and an expected timeline for completion of the initiatives.
In compliance with its by-laws, the Board will create terms of reference for its governance committee and make the terms of reference public.
The Board’s Governance Committee will consider creating an implementation plan that includes but is not limited to: a timeline for implementation of all recommendations received through various reports, inquests and inquiries; a plan for how the recommendation will be implemented; and how consultation and follow-up with Indigenous community will take place. The implementation plan should be made public in order to ensure accountability.

To the Ministry of Health

That the Ministry of Health immediately address patient flow at the Thunder Bay Regional Health Sciences Center emergency department to address police and ambulance off-load delays and code black events.
The funding formula should reflect the population of Thunder Bay and surrounding areas that uses Thunder Bay as a “Hub” for medical services.

To the Ministry of Health and Superior North EMS

That access to electronic health records be provided to all paramedics in Ontario, and if such access is available, that Superior North EMS consider the introduction of the necessary technology to access this system and provide access to paramedics.

To the Ministry of Colleges and Universities

To the extent that this training is not already provided, that educational institutions such as colleges and universities provide training for first responders on the history of colonization; residential schools; trauma informed approaches; anti-Indigenous racism; cultural safety, and unconscious bias.

To the Solicitor General and Thunder Bay Police Service:

That training be delivered to police officers and jailers relating to medical issues that may mimic intoxication, or that may be concurrent with intoxication, and that this be provided both at the Ontario Police College and to serving officers.

Bruneau, Olivier

Surname: Bruneau
Given name(s): Olivier
Age: 24

Held at: Ottawa (virtual)
From: October 11
To: November 10, 2022
By: Dr. Geoffrey Bond, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Olivier Bruneau
Date and time of death: March 23, 2016 at 8:08 a.m.
Place of death: Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, Ontario
Cause of death: blunt force chest injury
By what means: accident

(Original signed by: Foreperson)

The verdict was received on November 10, 2022
Presiding officer's name: Dr. Geoffrey Bond
(Original signed by presiding officer)

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

Inquest into the death of: Olivier Bruneau

Jury recommendations

To Ministry of Labour, Immigration, Training and Skills Development (MLITSD)

Amend section 232(1) of the Construction Regulations to:
1. Clarify that the walls of an excavation shall be stripped of “ice” that may slide, roll or fall upon a worker.
2. Provide additional guidance on how to assess the risk of ice on excavation walls.
Clarify the definition of “accident” in sections 52 and 53 of the Occupational Health and Safety Act.
Consider amending the Occupational Health and Safety Act to require constructors and/or employers to notify the ministry when material has fallen at a construction project in a manner that could have resulted in a critical injury.
Consider studying the effectiveness of Alberta’s Occupational Health and Safety Act, as it relates to “Potentially Serious Incidents” on construction sites.
Consider how the concept of “Safety by Design” has been implemented in other jurisdictions and assess whether these concepts can be incorporated into Ontario’s health and safety regulations. “Safety by Design” refers to the concept of incorporating worker safety into the design and planning of large construction projects.
Strike a sub-committee of industry partners to review hazards presented by the formation of ice on excavation walls and develop best practices for eliminating or mitigating those risks. Include in those best practices training requirements or other criteria for achieving competency regarding the assessment of ice on excavation walls as a hazard. Share those best practices with construction sector employers and constructors
Consider conducting an ice management campaign for large construction projects in Eastern Ontario.
Consider including a case study focused on falling ice in excavations in future inspector training material.
Work with the Infrastructure Health and Safety Association to develop guidance material for employers and constructors on how to address the hazard of falling ice.
In addition to posting hazard alerts on the ministry’s website, develop and implement a system of communication to distribute hazard alerts so that they are sent directly to constructors and employers. This may be done through by creating a mailing list of employers, constructors and trade unions, in the construction sector or in consultation with the Infrastructure Health and Safety Association, or such other partners as may assist with the development and implementation of the system.
Identify all ongoing construction projects involving Claridge Homes group of companies in Ontario and conduct proactive inspections of those sites. The inspections should focus on assessing whether projects are organized in a manner that ensures safety of all workers.

To Claridge Homes Group of Companies

Conduct a comprehensive, third-party audit of its health and safety system. The audit should be independent and should result in an action plan that must be submitted to the MLITSD for their review, to ensure:
- All site supervisors are competent and aware of their duties and responsibilities. This includes:
  - knowledge, training and experience
  - familiarity with the act and the regulations that apply to the work
  - knowledge of the workplace hazards
  - ability to identify and address workplace hazards
- All health and safety representatives are competent and aware of their duties and responsibilities.
- Workplace incidents are properly investigated and addressed, and the results of those investigations are communicated to the relevant workplace parties.
- Health and safety representatives are selected in a manner that ensures independence.

Dhindsa, Vikram

Surname: Dhindsa
Given name(s): Vikram
Age: 34

Held at: Town of Midland
From: October 17
To: October 20, 2022
By: Dr. Mary Beth Bourne, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Vikram Dhindsa
Date and time of death: January 18, 2017 at 5:12 a.m.
Place of death: Unit 3 A Wing, Cell #16 Central North Correctional Centre 1501 Fuller Avenue, Penetanguishene
Cause of death: hanging
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on October 21, 2022
Presiding officer's name: Dr. Mary Beth Bourne
(Original signed by presiding officer)

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

Inquest into the death of: Vikram Dhindsa

Jury recommendations

To Central North Correctional Centre superintendent:

To Workplace Safety and Insurance Board:

All site supervisors are competent and aware of their duties and responsibilities. This includes:
- knowledge, training and experience
- familiarity with the act and the regulations that apply to the work
- knowledge of the workplace hazards
- ability to identify and address workplace hazards
All health and safety representatives are competent and aware of their duties and responsibilities.
Workplace incidents are properly investigated and addressed, and the results of those investigations are communicated to the relevant workplace parties.
Health and safety representatives are selected in a manner that ensures independence
1. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20.
2. Inform staff of the LivingWorks Start online training on suicide prevention and provide them with information to register.
3. Inform staff and affected personnel that resources are available to support them with respect to work related stress.
4. Expedite the processing, and provision of support (if warranted), to front-life provincial corrections staff claims when they are involved in inmate suicides. We recommend that, absent exceptional circumstances, claims should be processed within 30 days of receipt of the documentation from the correctional facility.

November

Frenette, Steven
Foreman, Daniel
Bullen, David
McConnell, Jonathan
Borja, Susan

Names of the deceased: Frenette, Steven; Foreman, Daniel; Bullen, David; McConnell, Jonathan; Borja, Susan
Held at: virtual, Office of the Chief Coroner
From: November 14
To: December 1, 2022
By: Dr. Robert Reddoch, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Frenette
Given name(s): Steven
Age: 35

Date and time of death: September 20, 2018 at 7:38 p.m.
Place of death: Ross Memorial Hospital, Lindsay
Cause of death: central nervous system depression due to (or as a consequence of) combined fentanyl toxicity and diazepam
By what means: accident

Surname: Foreman
Given name(s): Daniel
Age: 39

Date and time of death: October 3, 2018 at 9:10 p.m.
Place of death: Central East Correctional Centre, Lindsay
Cause of death: fentanyl intoxication
By what means: accident

Surname: Bullen
Given name(s): David
Age: 50

Date and time of death: December 29, 2018 at 7:52 a.m.
Place of death: Central East Correctional Centre, Lindsay
Cause of death: acute fentanyl toxicity
By what means: accident

Surname: McConnell
Given name(s): Jonathan
Age: 36

Date and time of death: April 28, 2019 at 8:40 a.m.
Place of death: Central East Correctional Centre, Lindsay
Cause of death: carfentanil toxicity
By what means: accident

Surname: Borja
Given name(s): Susan
Age: 50

Date and time of death: August 10, 2019 at 6:26 a.m.
Place of death: Central East Correctional Centre, Lindsay
Cause of death: toxic effects of oxycodone, methadone, quetiapine and pregabalin
By what means: accident

(Original signed by: Foreperson)

The verdict was received on December 1, 2022
Coroner's name: Dr. Robert Reddoch
(Original signed by presiding officer)

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

Inquest into the deaths of: Steven Frenette, Daniel Foreman, David Bullen, Jonathan McConnell and Susan Borja

Jury recommendations

To the Ministry of the Solicitor General (SOLGEN)

Ensure that the Central East Correctional Centre (CECC) Corporate Health Care Review Action Plan includes a comprehensive plan for the CECC Health Care Unit to comply with all requirements of the Opioid Agonist Treatment Policy and Management of Opioid Withdrawal (OAT Policy) and all other health care policies.
Implement recommendation #5 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Specifically: prioritize the Health Care Performance and Planning Unit’s analysis of recruitment challenges for correctional health care staff.
Implement recommendation #6 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Specifically: ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the CECC.
Conduct a comprehensive post audit to determine the correctional staffing levels needed at the CECC. The post audit should include consultation with the CECC Health Care Unit and the SOLGEN Corporate Health Care Unit.
Analyze the causes of correctional staff absenteeism at the CECC and take appropriate action.
Complete an action plan based on the results of the post audit and staff absenteeism analysis. The action plan should be completed in consultation with the CECC Health Care Unit and the SOLGEN Corporate Health Care Unit and should include a plan to maintain adequate correctional staffing levels.
Prioritize continued efforts regarding bed shortages for female inmates.
Prioritize developing and implementing a long-term plan to establish adequate housing for male/female inmates. The plan should include adequate staffing and infrastructure to avoid triple bunking and to accommodate intermittent inmates and inmates in need of specialized care or stabilization.
Ensure that the “file reviewer” position that has been implemented at the CECC becomes a formalized, permanent position that is available seven days per week.
Increase the number of hours for physicians at CECC.
Explore options to increase the physical space available at the CECC for inmate programming.
Ensure that health care transfer summaries are completed in compliance with provincial policies when inmates are transferred between institutions.
Reinforce the policy requirement for a Part C health care summary to be completed in every patient’s health care record. The summary should be placed at the front of each health care record and should list all serious medical diagnoses, including opioid use disorder.
The planned Electronic Medical Record (EMR) system should include an easily accessible patient profile that includes the type of information contained in the Part C health care summary.
Begin implementing the EMR system at the CECC in 2023.
Implement recommendation #20 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Specifically: 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.
Consider giving access to OTIS and LSI-OR reports (Level Service Inventory – Ontario Revised) to all physicians working at provincial correctional institutions in the province of Ontario.

To the Central East Correctional Centre

A health care manager and/or physician should be notified when an inmate brings a suspected opioid or prescription medication into the institution or when an inmate appears to be intoxicated while in custody.
When a community prescription for an opioid medication is discontinued or amended by a CECC physician, the patient should be notified of this decision and provided with options for managing the potential consequences, including a referral to health care staff and/or addictions counseling and/or community resources. A clinical opioid withdrawal scale form should also be initiated to monitor for opioid withdrawal symptoms when appropriate according to policy.
Physicians should be encouraged to communicate with a patient’s community health care providers when discontinuing or amending a prescription for an opioid medication, when consent is provided by the patient.
A physician and/or nurse practitioner should be available to provide in-person health care services on weekends at the CECC.
Addictions counselors, discharge planners and social workers should be available to provide in-person services on weekends at the CECC.
Develop strategies on prescribing and dispensing medications in a manner that would assist with protecting patients from being coerced into diverting the medication to other inmates.
Ensure that all nurses at the CECC are trained and registered to use Connecting Ontario Clinical Viewer.
Encourage all fixed term Nurse Practitioners at the CECC to receive certification to prescribe OAT.

To the Government of Ontario

Reinstate funding for an embedded Kawartha Lakes Police Service detachment inside the Central East Correctional Centre. This should include funding for more dedicated officers who can conduct drug investigations and share information with appropriate CECC staff with the aim of protecting the health of the inmate population.
Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary.
Implement recommendation #35 from the Inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Specifically: increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities.
Develop and implement a plan to cap the length of time for fixed term employment status, and roll over into full time status (for correctional officers and nursing staff).
Seek and allocate adequate funding and resources to implement these recommendations.

To the Office of the Chief Coroner

Inquests should be completed within 24 months from the incident date unless the circumstances warrant additional time.

Couvrette, Gordon Dale

Surname: Couvrette
Given name(s): Gordon Dale
Age: 43

Held at: North Bay
From: November 21
To: November 24, 2022
By: Dr. S.C. Bodley
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Gordon Dale Couvrette
Date and time of death: February 22^nd 2018 06:21
Place of death: North Bay Regional Health Centre, 50 College Dr, North Bay, Ontario, P1B54A
Cause of death: Sudden death with no anatomical cause associated with acute-on-chronic cocaine and amphetamine abuse/intoxication, forcible struggle and possible Autonomic Hyperactivity Syndrome
By what means: accident

(Original signed by: Foreperson)

The verdict was received on November 24, 2022
Presiding officer's name: Dr. S.C. Bodley
(Original signed by presiding officer)

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

Inquest into the death of Gordon Dale Couvrette

Jury recommendations

It is recommended that the North Bay Police Service and the North Bay Police Services Board consider policy and training amendments that require officers to notify Emergency Medical Services (EMS) that a Conducted Energy Weapon (CEW) was deployed in cases of a medical emergency where EMS is called to the scene.
It is recommended that the North Bay Police Service and the North Bay Police Services Board consider steps that are required to ensure that EMS policies are shared with them so as to make any required changes to operating procedures and/or training requirements.
It is recommended that the North Bay Police Service, the North Bay Police Services Board and the Special Investigations Unit, review the process for data extraction from a Conducted Energy Weapon (CEW) to ensure the Pulse Log Graph is reviewed in combination with the Enhanced Data Log to validate the effect of the CEW and share the data with all relevant parties.

Blackett, Craig

Surname: Blackett,
Given name(s): Craig
Age: 41

Held at: Toronto
From: November 21
To: November 24, 2022
By: Dr. Jennifer Tang
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Craig Blackett
Date and time of death: 17:08 - May 27, 2016
Place of death: 3058 Lakeshore Blvd West, Toronto, Ontario
Cause of death: Multiple blunt force injuries
By what means: accident

(Original signed by: Foreperson)

The verdict was received on November 24, 2022
Coroner's name: Dr. Jennifer Tang
(Original signed by coroner)

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

Inquest into the death of: Craig Blackett

Jury recommendations

To the Ministry of Labour, Immigration, Training and Skills Development and the Infrastructure Health and Safety Association (IHSA):

Assess the feasibility of requiring a constructor’s supervisor (as required by section 14 of O Reg 213/91) to clearly delegate their authority over an entire project to another supervisor or competent person. Means to do so could include the following:
1. Post in a conspicuous place the name of the current constructor’s supervisor
2. Require a written delegation of supervisory authority
Review the supervisor awareness training required by section 2 of O Reg 297/13 to determine whether it sufficiently makes supervisors aware of the roles of constructor supervisors and employer supervisors. Such a review should discuss delegation of responsibility and include the following components:
1. Clear communication of the transfer of supervision;
2. Clear communication of the scope of supervision; and
3. Acknowledgement of i) and ii) by the competent assistant.

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

Consider adding the following recommendation to O Reg 213/91 of the OHSA:
1. With respect to elevating work platforms not in use: implementing the requirement of actively storing any operational access (i.e., key) in a secured location whereby only authorized competent individuals have access.

Davis, Murray James

Surname: Davis
Given name(s): Murray James
Age: 24

Held at: London
From: November 21
To: November 30, 2022
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Murray James Davis
Date and time of death: August 17, 2017 8:00 a.m.
Place of death: Elgin Middlesex Detention Centre, 711 Exeter Road, London, ON
Cause of death: Acute combined fentanyl and hydromorphone toxicity
By what means: accident

(Original signed by: Foreperson)

The verdict was received on November 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: Murray James Davis

Jury recommendations

Facility

The Ministry of the Solicitor General (the ministry) shall replace Elgin Middlesex Detention Centre (EMDC) with a new, modern facility designed to adequately accommodate, with dignity, people in custody and to provide an environment with suitable space in which people in custody can achieve rehabilitation and reintegration through training, treatment and services designed to afford them opportunities for successful personal and social adjustment in the community.
The ministry shall immediately assess the number of people in custody at EMDC, recognizing that the overcrowding of people in custody worsens their mental and physical health.

Harm Reduction

Implement more rigorous and thorough assessment of potential and current employees.
1. within hiring practices to ensure personality and culture fit, situational judgement, role-specific skills
2. incorporate in regular performance evaluations to ensure that the individual’s values remain consistent with expectations

EMDC will ensure constant supervision when volunteers from the persons in custody population are used for the service of meals, or any other similar activities.
The ministry should abandon its zero-tolerance policy with respect to both the use of street drugs and the diversion of prescribed drugs, recognizing that this policy stigmatizes and punishes people for behaviours that stem from underlying medical issues.
The ministry should embrace an evidence-based approach to harm reduction in a manner that protects the mental and physical health of persons in custody.
The ministry should adopt “Good Samaritan” principles in operational policies and practices to encourage persons in custody to call for help or try to help another person suspected of being in medical distress or come forward with information about drugs within the institution, without being subjected to any institutional misconduct proceedings for possession or use of contraband.
The ministry should provide educational opportunities to persons in custody and operational staff at correctional facilities about the “Good Samaritan” principles that it adopts in its operational policies and practices.
The ministry should explore implementation of harm reduction strategies similar to those used at supervised consumption sites.
The ministry should take steps to actively promote awareness of information, services and programs available to persons in custody regarding opioid/other substance use.
The ministry should provide education opportunities to persons in custody on the following topics:
1. signs of drug overdose
2. illicit opioid/other drugs available/in circulation
3. mental and physical health risks of using illicit opioid/other drugs
4. safe drug-use practices, including never to inject, smoke or ingest drugs alone
5. the risks of mixing illicit opioid/other drugs with prescription drugs
The educational opportunities should be provided upon intake and at least once a month in a group setting, and the contact information for healthcare workers should be provided to persons in custody if they would like to get more information.
The ministry should create and implement a policy that requires the use of specific language by correctional officers and healthcare workers at each correctional facility which prioritizes humanizing people in custody by addressing them as patients, persons in custody and/or persons who use drugs.
In conjunction with recommendation number12, the ministry should abandon the use of the title, “Native Inmate Liaison Officer,” and move toward the exclusive use of the title, “Indigenous Liaison Officer.”
The ministry should deliver alerts to persons in custody on an urgent basis regarding new and emerging threats from novel street drugs.
The ministry should undertake a study to identify the effects of overcrowding, and other living conditions on inmate populations especially those with addictions and/or pre-existing mental illness and to take any appropriate corrective measures.
The ministry should collaborate with the London Middlesex Medical Officer of Health in developing its harm reduction strategies.
The ministry should implement dedicated and centralized real time monitoring of cameras at EMDC to facilitate identifying problems as they arise and that sufficient staff be hired if necessary to maintain monitoring in real time.

Access to Naloxone for People in Custody

The ministry should provide direct access to Naloxone spray for people in custody, including within locked cells.
The ministry should ensure that people in custody receive training concerning the use of Naloxone within a custodial setting, including the need to engage an emergency medical response following its use.
The ministry should ensure that Naloxone spray devices deployed in areas accessible to people in custody are positioned in a manner that correctional staff on security rounds may determine that a device has been used or removed.

Responses to Medical Emergencies

The ministry should ensure that people in custody have access to a reliable means of initiating an emergency medical response.
The ministry should retrofit all units within EMDC to facilitate the implementation of the direct observation model, as a means of ensuring that people in custody are able to initiate a prompt response to a medical emergency. Direct observation should include the ability to monitor sound on the unit.
The ministry should position equipment necessary for an emergency medical response close to living units.
The ministry should install monitoring equipment of good quality at EMDC to ensure that all areas of the living units may be viewed with an image clear and large enough to detect any unusual occurrences or problems.

Provision of Healthcare for Substance Use Disorder

The ministry should ensure that EMDC has sufficient space to permit private interactions between persons in custody and nurses, including addiction and mental health nurses, social workers and counsellors. This should include sufficient correctional staff to permit safe movement of people in custody who are accessing these services.
The Ministry should ensure that Opioid Agonist Treatment (OAT) is available to persons in custody within 48 hours of the person’s initial assessment during the admission process. The ministry should ensure that there are sufficient physician clinics and staffing of qualified addiction nurses to meet this standard.
Corporate health care with the ministry should continuously monitor wait times for the availability of OAT initiation to ensure that the 48 hour standard for offering OAT is met.
Programs and other initiatives to address drug addiction and abuse should be encouraged, prioritized and promoted in prominent places throughout the facility where they are likely to come to the attention of persons in custody. Consideration of streaming short video clips or other helpful information via the television screens on each living unit should also be given.
That sufficient staff be hired and maintained to allow for constant visual monitoring of the living units and to adequately and immediately intervene in any circumstances of drugs or other contraband being found.

Culturally Appropriate Healthcare for Indigenous People

The ministry should conduct an Indigenous led study that consults with Indigenous community organizations and Indigenous healthcare providers to obtain information regarding Indigenous cultural and spiritual healing practices and use of Indigenous traditions known to assist in prevention of substance use, wellness and a means to address addictions in a culturally sound way.
The ministry should use the Indigenous led study to create and implement a policy on using Indigenous cultural practices as solutions to combating the opioid crisis at EMDC.
The ministry should ensure that any of the Indigenous Liaison Officers and Indigenous elders are engaged in the provision of health care information and treatment when requested by patients.
The ministry should engage with Indigenous communities, organizations and health care providers in the development of corporate strategies, such as the Correctional Health Care Strategy and the Mental Health and Addictions Strategy for Corrections.

Necessary Rehabilitation Supports

The ministry should take immediate steps to improve opportunities for persons in custody to access recreation and exercise facilities and programs. This should include the provision of adequate space within EMDC, and correctional staff to permit safe movement of people in custody who are accessing these opportunities.
In order to ensure the EMDC is operated in a safe and respectful way, the ministry should explore resurrecting the community advisory board program to access, tour and inspect EMDC and to present reports of their findings to the Solicitor General at least annually. These reports should be posted publicly.
In order to ensure the EMDC is operated in a safe and respectful way, the ministry should employ outside agencies and experts to access, tour and inspect EMDC and to present reports of their findings to the Solicitor General at least annually. These reports should be posted publicly.

Ontario Health Insurance Plan cards and Identification

The ministry should conduct a review of the barriers to accessing OHIP cards and identification to identify solutions to the lack of access by people in custody to necessary documentation.
EMDC should designate a staff person responsible for ensuring that persons admitted to EMDC have the necessary identification to facilitate discharge planning. The designated staff person should consult with health care units in other correctional facilities to identify best practices in obtaining this documentation, pending a ministry-wide solution.

Correctional Health Care

The ministry should conduct a needs assessment to determine whether patients at EMDC receive health care services equivalent to the services received by people who are not in custody. Where gaps and disparities are identified, the ministry should take immediate steps to ensure that the quality of healthcare delivered at EMDC is equivalent to that in the broader community.
The ministry should conduct a comprehensive and ongoing process of engagement with patients in its custody in the development of healthcare strategy, policy and delivery.
The ministry should consider changing the reporting structure for healthcare to ensure that the health care manager at the institutional level reports directly to Corporate Health Care.
The ministry should prioritize the completion of its project to implement electronic health records for patients living in correctional facilities.
The ministry should advocate for total compensation offered to nurses and healthcare staff be competitive with that in non-correctional settings.
The ministry should consult with and receive expert advice on remedies to improve living conditions and healthcare delivery and implement any potential life saving strategies on an urgent basis.

Supports for People in Custody Who Witness a Traumatic Event

The ministry should engage with people with lived experience to develop enhanced supports for people in custody who witness a traumatic event. These supports should account for the social barriers to accessing such supports within a custodial environment.

Training

The ministry should ensure that healthcare and correctional staff at correctional facilities receive additional training about building rapport and resolving challenging encounters with persons in custody.
The ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive awareness training regarding the causes and nature of substance use disorder to address stigma surrounding addiction.
The ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive additional Indigenous cultural safety training. This training should be designed and delivered by Indigenous people. Refresher training should be delivered annually.
The ministry should develop training for correctional officers on strategies to work constructively with Indigenous men in custody, similar to the “Biidaaban Kwewok and Biidaaban Niniwok Beginnings for Indigenous Women and Men” training.

Supports for Indigenous People

The ministry should ensure that each institution: develops Indigenous specific programming which reflect the local Indigenous communities and agencies surrounding the institution; provides Indigenous persons in custody with access to Indigenous healing practices including Knowledge Keepers and Elders.
The ministry should ensure that Indigenous Liaison Officer (ILO) services are adequately resourced and funded to meet the needs of Indigenous people. Indigenous people should be able to access spiritual rights as well as programs with regularity and without unreasonable delay. Specifically:
1. The ministry should ensure that all ILO positions are adequately funded and strive to achieve more equitable compensation so that they can recruit, retain and keep ILO staff in full time, permanent positions;
2. The ministry should create policy and direction that recognizes the role and function of ILO staff as central to the delivery of Indigenous spiritual, cultural access and for health and wellness;
3. The ministry should consider increasing ILO staff at each Institution to meet the needs and services of the Indigenous persons in custody population, so that programing for Indigenous persons is, at minimum representative of the needs or recognizes the number of Indigenous persons in each institute;
4. Spiritual Elders, knowledge keepers and helpers should be provided honoraria or some form of financial compensation for the important work they are conducting as part facilitating their access to their spiritual rights or as part of culturally relevant programing, and that the Ministry should revise both health and ILO policy to recognize cultural and spiritual support as a fundamental healthcare right to all;
5. The ministry should engage in community consultation on the development of Indigenous core programing with Indigenous leadership including First Nation, Metis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres.
The ministry should analyze the data they collect to determine where there are gaps in service delivery of programs at particular institutions. Where gaps exist, the ministry should explore and research means to increase actual programing at Detention and Correctional Centres:
1. Analysis of data collection or research of Indigenous core or other programing should include identification of gaps, steps taken to resolve gaps, improvements and best practices;
2. This analysis and research should be reported, maintained and disseminated to Ontario`s correctional Institutions, service providers and for use with consultation with First Nation, Metis and Inuit community;
3. The ministry should consider evaluating and modifying their policies on allowing volunteers into the facility that have a criminal record. Specifically, they should consider the length or passage of time since a volunteer had any criminal convictions and the nature of the criminal conviction to determine criteria that would increase Indigenous volunteers’ participation in Indigenous programing and to provide peer resources in an effective way.
EMDC should report to the ministry on any steps or progress being taken at EMDC in relation to traditional Indigenous medicine. The ministry should research and report on, with a mind to exploring the development of programs and facilities with Indigenous community consultation, the health and wellness benefits of similar Indigenous practice and resources.
The ministry should ensure cooperation between ILO and addiction and mental health nurses with respect to discharge and community reintegration. The ILO team should be seen as crucial members for integrated assessment, treatment, care and reintegration plans for any self- identifying Indigenous person.
EMDC should encourage staff participation in Indigenous ceremony and celebrations to promote better understanding of the strengths of Indigenous cultural practices.
The ministry should seek funding to implement these recommendations.

December

Amaral, Jose

Surname: Amaral
Given name(s): Jose
Age: 49

Held at: Toronto (virtual)
From: December 6
To: December 9, 2022
By: Mr. Etienne Esquega, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jose Amaral
Date and time of death: November 25, 2015 at 2:40 a.m.
Place of death: Musselwhite Mine
Cause of death: blunt force trauma to head and neck
By what means: accident

(Original signed by: Foreperson)

The verdict was received on December 9, 2022
Presiding officer's name: Mr. Etienne Esquega
(Original signed by presiding officer)

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

Inquest into the death of Jose Amaral

Jury recommendations

The Ministry of Labour shall review and consider whether to impose a renewal requirement on Common Core Underground Certification.
The Ministry of Labour shall review and consider whether to amend R.R.O. 1990, Reg. 854: MINES AND MINING PLANTS under the Occupational Health and Safety Act, R.S.O. 1990, c. O.1 to impose controls to prevent an occupied scoop from crossing the “no person” threshold in an underground mine while production mucking in an unsupported stope from a muck stand.
The Ministry of Labour shall review and consider whether to amend R.R.O. 1990, Reg. 854: MINES AND MINING PLANTS under the Occupational Health and Safety Act, R.S.O. 1990, c. O.1 to require a supervisor to visit a production miner mucking from a muck stand in an underground mine once per shift.

Millette, Denis Joseph Stanley

Surname: Millette
Given name(s): Denis Joseph Stanley
Age: 52

Held at: Timmins
From: December 12
To: December 20, 2022
By: Dr. David Eden, Presiding Officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Denis Joseph Stanley Millette
Date and time of death: June 3, 2015
Place of death: Detour Lake Mine
Cause of death: acute cyanide intoxication
By what means: accident

(Original signed by: Foreperson)

The verdict was received on December 9, 2022
Presiding officer's name: Dr. David Eden
(Original signed by presiding officer)

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

Inquest into the death of Denis Joseph Stanley Millette

Jury recommendations

To: Agnico Eagle Detour Mine

Ensure that the employer continues to properly identify and review Potential Chemical Hazards of cyanide at the mine site and modify the training, procedures and medical response as required.
Continue to follow the international Cyanide Management Code.
Task analysis safety card form to be reviewed and signed off by supervisor prior to the work commencing, to ensure it has been properly and thoroughly completed.

To: Mining Industry - Ontario

Ensure that the employer properly identifies and reviews all potential chemical hazards at the mine site including, but not limited to, the dangers of cyanide.
Take all reasonable measures to ensure workers are educated, understand and avoid the hazard. This would include training, equipment or work processes and the continued availability of safety data sheets.
Prepare an emergency response plan to use if a worker does come into contact with a hazard. This includes education of workers, availability and maintenance of rescue equipment (e.g. antidote and oxygen), and rapid access to emergency response, as well as fast and efficient egress from the area to an appropriate hospital.
When a worker experiences a medical issue in the workplace, the possibility that the medical event is due to a workplace hazard should always be considered. Possibilities should include, but not be limited to factors such as toxic exposure through skin or inhalation.
Ensure that the emergency medical care providers for the mine site have a thorough orientation of the mine site they are assigned to and are aware of the hazards and the measures adopted at the workplace. It is recommended that all mine and metallurgical sites where cyanide is present conduct periodic simulation exercises of cyanide exposure events as a means to promote preparedness by testing policies and plans, standard operating procedures, and personnel training. This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities.
Encourage review and participation in all best practices regarding cyanide safety put forth in the international Cyanide Management Code.
Checklists and plan for ensuring all safety and medical equipment is readily available and in working order.
Recommend training programs be reviewed on an ongoing basis to maximize employees’ comprehension of content.
Joint health and safety committee to include a refresher of WHMIS in crew safety meetings including, but not limited to, any changes and locations of MSDS binder locations.
It is recommended that all Ontario mines actively using metallurgical cyanide establish clearly demarcated cyanide zones wherever cyanide is used or may be reasonably found at harmful concentrations. This would both provide a warning and a specific ongoing reminder to any person entering such areas. It would also provide a primary point of communication for emergency response and medical personnel. (Note: this is included in both mining industry and Ministry of Labour section).

To: Remote Emergency Medical Services (REMSI) (North)

All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. The orientation should include hazards, work processes and medical issues, that may be unique to that work site.
All physician assistants and doctors are trained on all medical equipment available at the worksite.
All physician assistants and doctors ensure that workplace hazards are incorporated into the assessment of any medical emergency.
At every employer site at least two physician assistants / medical professionals should be available to perform medical assistance.
Regular meetings between mine emergency response team and REMSI staff be held including post-incident de-briefing.
When first addressing an employee in medical distress, a full body assessment (‘head to toe’) must be completed.

To: Workplace Safety North

Distribute current contact information for ORNGE, air ambulance to all remote workplaces including but not limited to the mining, forestry, and construction industries.

To: Ministry of Labour, Immigration, Training and Skills Development (MLITSD)

Refer to the mining legislative review committee the consideration of amendments to Ontario Regulation 854, Mines and Mining Plants (the Regulation) that would:
1. Require the following precautions be taken should a worker perform maintenance work in an area in which the work may reasonably be expected to expose the worker to a material containing cyanide at concentrations that may endanger the worker. The Regulation would require that, in such circumstances:
  1. impermeable personal protective equipment to be used and there be a process for verifying or confirming the use of the required personal protective equipment before work is performed in the area
  2. procedures for:
    1. the flushing of cyanide-containing material from lines
    2. housekeeping of such areas
    3. titrations to ensure cyanide content in any debris or materials in the area is below a set threshold (e.g. 50 ppm) before any work can be performed within the area
    4. personal protective equipment
    5. lock out and tag out procedures are to be developed and implemented
  3. workers required or assigned to work in the area have received cyanide awareness training and proper removal of PPE once work has been completed to avoid further contamination
  4. Require employers to develop and implement cyanide awareness training that meets requirements set out in the Regulation for the content of such training and frequency of refresher training. The content of such training to include:
    1. what cyanide is used for within the workplace and where it can be found
    2. the method for identifying cyanide within the workplace
    3. personal protective equipment and limitations associated with such equipment
    4. the signs of cyanide leakage
    5. the signs and symptoms of cyanide exposure
    6. first aid / treatment procedures for people potentially exposed to cyanide
  5. Require cyanide distribution lines be painted purple for identification and dye be added to cyanide solutions during mixing to make it red/purple in colour.
  6. Establish the frequency of review, for currency, accuracy, and protectiveness, of cyanide-related procedures.
  7. Require emergency response personnel in plants using cyanide to be provided with basic first aid/CPR training and training on oxygen administration.
  8. Prepare and distribute a hazard alert about the hazards of cyanide in the workplace. The hazard alert should identify cyanide, in all of its forms, as a potential workplace hazards.
  9. Hazard alerts should be distributed in a timely manner after a health and safety concern is made evident.
1. It is recommended that all Ontario mines actively using metallurgical cyanide establish clearly demarcated cyanide zones wherever cyanide is used or may be reasonably found at harmful concentrations. This would both provide a warning and a specific ongoing reminder to any person entering such areas. It would also provide a primary point of communication for emergency response and medical personnel.
2. It is recommended to the MLITSD that Regulation 854 be amended to require mining plants in Ontario to have a hazardous substance communication program. This program should be reviewed with all workers annually and be updated as required.

Updated: March 21, 2024

Published: March 14, 2022

2022 coroner’s inquests’ verdicts and recommendations

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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

Jury recommendations

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

Rajendiran, Arun Kumar
Tavernier, Darrel
Kelly, Stephen

Culleton, Carol
Kuzyk, Anastasia
Warmerdam, Nathalie

Mamakwa, Donald
McKay, Marlon Roland