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

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

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

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

You can also access verdicts and recommendations using Westlaw Canada.

January

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

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

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

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

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

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

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

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

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

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

(Original signed by: Foreperson)

The verdict was received on February 4, 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:
  1. Amend the Construction Regulations to include a mandatory requirement for training of Health and Safety Representatives who work on construction projects.
  2. Amend the notification requirements in section 7.1 of the Construction Regulations to include a signed and dated attestation that the work platforms will be installed, inspected, tested and maintained in accordance with the applicable regulations, including sections 139 and 139.1.
  3. Conduct scans of other jurisdictions’ use of emerging technologies and partnerships in the proactive reduction of workplace injuries and fatalities. Provide annual reports, accessible to the public, on ongoing research findings through the Chief Prevention Officer.
  4. Add a requirement under O. Reg. 213/91 for any supervisor of workers working at heights and/or using a supervisor to take the Working at Heights training under section 138.
  5. Chief Prevention Officer to track effectiveness of the Working at Heights training program through regular evaluations and public-facing reporting to demonstrate the relationship between the Working at Heights training program and falls from heights data generated through the Prevention Division. Make adjustments to program curriculum and delivery methods according to gaps and opportunities identified.
  6. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers).
  7. Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training.

February

MacDougall, Quinn Emerson

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

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

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

(Original signed by: Foreperson)

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

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

Inquest into the death of: Quinn Emerson MacDougall

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

April

Santos, Fernando

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

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

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

(Original signed by: Foreperson)

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

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

Inquest into the death of: Fernando Santos

Jury recommendations

No recommendations.

Saidi, Babak

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

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

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

(Original signed by: Foreperson)

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

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

Inquest into the death of: Babak Saidi

Jury recommendations
To the Ontario Provincial Police:

The Ontario Provincial Police (OPP) should:

  1. Develop, establish, and provide regular training to OPP officers on a policy addressing the planning and approach to arrests of individuals in potentially higher risk circumstances (the “policy”), which should include the following considerations:
    1. circumstances in which the policy is applicable, including when an individual would be considered potentially dangerous
    2. involving a supervising officer in the planning of the arrest, when possible
    3. completing an arrest decision tool, which may include a checklist of criteria
    4. how and when to contact the OPP Threat and Behavioural Analysis Team (TBAT) for information and assistance
    5. how to identify possible factors that could complicate an arrest, such as possible mental health issues, unpredictability, past incidents with police, and violent history
  2. In support of the planning process, develop and provide guidance and training on circumstances where it may be appropriate to contact a subject to ask them to attend a police detachment for the purpose of effecting an arrest. In the case of high risk and dangerous subjects, consider the application of Situation Mission Execution Administration Command & Communication (SMEAC) adapted for arrest planning.
  3. Where there is an existing threat assessment on file, provide contact information so that TBAT can discuss the assessment with the enquiring member.
  4. Deliver training to frontline officers on the purpose of the Crime Abatement Program, the information included in Crime Abatement Program records, and how to access such records.
  5. Research and, if appropriate, develop and integrate additional flags into the records management systems that accurately identify an active, serious threat to officers and the public, including behavioural and mental health flags, and a numerical measurement of risk.
  6. Implement regular reviews to ensure the accuracy and reliability of the information in the records management system available to officers.
  7. Ensure that any arrest planning course delivered by the OPP Academy includes training on how to assess and integrate the strengths and weaknesses of frontline officers at the planning, briefing, and execution stages of an arrest.
  8. Develop a mandatory training course for sergeants delivered by the OPP Academy pertaining to their role in leadership and mentorship, regarding planning, briefing, and execution stages of an arrest.
  9. Provide dedicated mandatory mental health training as part of the annual block training delivered to officers through the OPP Academy. Ensure that appropriate “people-first language” (type of linguistic prescription which puts a person before a diagnosis, describing what a person “has” rather than asserting what a person “is”) is embedded into the training.
  10. Ensure, where there are no legal impediments to doing so, that debriefs are held for involved officers after every major arrest, event, or unique policing scenario to gain insight on lessons learned, and that such lessons are shared with other OPP officers.
  11. Develop and deliver training for constables and sergeants on interpersonal skills, emotional intelligence, leadership, and team building. This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools.
  12. Consider the circumstances of all police-related inquests as training scenarios.
  13. Consider re-allocating more time to scenario-based de-escalation training during annual use of force certification at the OPP Academy.
  14. Post the verdict and recommendations of this inquest on the OPP Connections system, or otherwise distribute the verdict and recommendations to OPP officers. If possible, share with other Canadian police services.
To the Ministry of the Solicitor General

The Ministry of the Solicitor General should:

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

May

Ekamba, Marc Diza

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

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

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

(Original signed by: Foreperson)

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

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

Inquest into the death of: Marc Diza Ekamba

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

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

    Peel Regional Police should seek and allocate funding and resources adequate to implement the above recommendations.
To the Ministry of the Solicitor General:
  1. The Ontario Use of Force model should be renamed to accurately capture the intent and purpose of the model, which is a guide to police engagement with the public rather than to suggest that force is inherent in police interactions.
  2. The Ontario Use of Force model shall be redesigned to highlight and emphasize the importance of de-escalation at all points during police interactions.
  3. The OPC shall ensure that persons with lived experience are engaged in the development and delivery of de-escalation training.
  4. The OPC shall ensure that affected communities and persons with lived experience be directly engaged in the development and delivery of anti-bias training. The OPC should ensure that community organizations who represent persons with lived experience are engaged in this work.
  5. Revise the use of force report form to require officers to document de-escalation techniques used.
To the Ministry of the Solicitor General and Peel Regional Police:
  1. There must be special recognition of the unique challenges Black people who also have serious mental health issues face when they come into contact with police. This unique intersection of Blackness and lived experience of mental health issues must be specifically addressed in any training on use of force, de-escalation, and police interaction with such persons.

    The Ministry of the Solicitor General and Peel Regional Police should seek and allocate funding and resources adequate to implement the above recommendations.
To the government of Ontario:
  1. Commission a study to examine the creation and implementation of a province-wide, civilian-led crisis intervention system to respond to persons in crisis, including mental health crisis. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience.
  2. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. Measures to improve public awareness should be developed in consultation with content experts and community organizations that represent persons with lived experience.
  3. Improve public awareness of both policing and non-policing community-based crisis responses to mental health crisis. Efforts to improve public awareness of these options should be developed in consultation with content experts and community organizations that represent persons with lived experience.
  4. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones.
  5. Improve public awareness and knowledge of community-based supports for persons experiencing mental health issues should target young people, and utilize channels of communication that are accessible and suitable for youth.
  6. Rename crisis hotline services and create awareness campaigns to educate the public about their existence to make the public aware that these services are available before a person reaches the point of crisis.

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

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

Veillette, Jean Hervé

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

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

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

(Original signed by: Foreperson)

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

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

Inquest into the death of: Jean Hervé Veillette

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

Rajendiran, Arun Kumar
Tavernier, Darrel
Kelly, Stephen

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

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

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

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

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

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

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

(Original signed by: Foreperson)

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

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

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

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

Central East Correctional Centre (CECC) Health Care Review

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

Health care staffing

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

Segregation

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

Suicide prevention

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

Investigation and communication

  1. Implement the corporate health care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. These reviews should analyze relevant health care files and assess quality of care. The reviewers should work with the local health care team to identify gaps and find solutions. These solutions should be communicated to relevant staff and stakeholders in a timely manner.
  2. Ensure that gaps or compliance issues identified during investigations into inmate deaths (including by Correctional Services Oversight and Investigations) are communicated and reinforced to relevant staff and healthcare providers.
  3. Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders.

Health care records

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

Security patrols

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

June

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

  1. Formally declare intimate partner violence as an epidemic.
  2. 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.
  3. 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.

  1. Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system.
  2. 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.
  3. 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

  1. 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.
  2. 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.
  3. Explore incorporating restorative justice and community-based approaches in dealing with appropriate IPV cases to ensure safety and best outcomes for survivors.
  4. Encourage that IPV be integrated into every municipality’s community safety and well-being plan.
  5. 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
  6. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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

  1. 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.
  2. 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.
  3. 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.
  4. Develop a plan for enhanced second-stage housing for IPV survivors.
  5. Fund for “safe rooms” to be installed in survivors’ homes in high-risk cases.

Education and training

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. Review existing training for justice system personnel who are within the purview of the provincial government or police services.
  7. 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.
  8. Provide specialized and enhanced training of police officers with a goal of developing an IPV specialist in each police detachment.
  9. Track whether mandated IPV-related professional education and training is completed by all justice system personnel.

Measures addressing perpetrators of IPV

  1. Establish a province-wide 24/7 hotline for men who need support to prevent them from engaging in IPV.
  2. 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.
  3. 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.
  4. 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.
  5. Improve the coordination of services addressing substance use, mental health, child protection, and IPV perpetration, and encourage cross-agency service provision and case management.
  6. 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.
  7. 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.
  8. 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

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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

  1. 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.
  2. Set up IPV Registry for repeat IPV offenders similar to the Sex Offender Information Registry Act registry.
  3. 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.
  4. 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).
  5. In referrals made by the OPP to Victim Services, ensure adequate information is provided, including relevant history, safety concerns and known risk factors.
  6. Ensure that OPP conduct a study on improving tactical response timelines as it applies to rural environments generally and in IPV cases in particular.
  7. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services.
  8. 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).
  9. 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.
  10. 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.
  11. Crowns should actively oppose variation requests to have firearms returned for any purpose, such as hunting.
  12. Strengthen annual education for Crowns regarding applications for Dangerous and Long-term Offender designations in high-risk IPV cases.
  13. 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.
  14. Conduct study of judges’ decisions in IPV cases and track in longitudinal studies for recividism, violence escalation, and future victims.
  15. 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
  16. 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.
  17. 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.
  18. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented.
  19. 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.
  20. Review the mandate of Probation Services to prioritize:
    1. condition compliance
    2. victim safety
    3. offender rehabilitation
  21. 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.
  22. 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.
  23. 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:

  1. 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.
  2. 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.
  3. Require that a PAL is automatically reviewed when someone is charged with an IPV-related offence.
  4. 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.
  5. 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:

  1. Ensure that the DVDRC reviews its mandate with a view to enhancing its impact on IPV and provide the DVDRC with improved supports.
  2. Ensure DVDRC annual reports are published online in a timely manner.
  3. Ensure that DVDRC reports and responses to recommendations are publicly available and will continue to be available without charge.
  4. 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:

  1. 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:

  1. Explore adding the term “Femicide” and its definition to the Criminal Code to be used where appropriate in the context of relevant crimes.
  2. 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.
  3. 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.
  4. Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing.
  5. Implement the National Action Plan on Gender-based Violence in a timely manner.
  6. 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.
  7.  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:

  1. 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
  1. It is recommended that the Ministry of Labour, Training & Skills Development take steps to amend the Occupational Health and Safety ActR.S.O. 1990,c. O.1, Regulation 213/91 “Construction Projects”, section 102 to include a dump-truck with its dump box and other implements raised.
  2. It is recommended that construction associations, including without limitation those listed at subparagraph 2.1, incorporate and promote a “best practice” for dump truck operators exiting haulage trucks to adhere to the following steps:  
    1. lower the dump box
    2. engage the brakes
    3. position wheel chocks in appropriate locations
    4. refrain from placing yourself between tires and/or axles
    • 2.1 Infrastructure Health and Safety Association
      Public Service Health and Safety Association
      Provincial Labour Management Health and Safety Committee
      Construction Safety Association of Ontario
      Ontario General Contractors Association
      Ontario Good Roads
      Ontario Trucking Association
      Ontario Dump Truck Association
      Ontario Road Builders Association
  3. It is recommended that the chief coroner take steps to expedite the hearing of coroner’s inquests, if feasible that they be held within three years.
  4. It is recommended that the Ministry of Labour, Training and Skills Development take steps to amend the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, Regulation 213/91 “Construction Projects”, to add that a requirement that employers shall conduct a risk assessment of the workplace for the purpose of identifying, assessing and managing hazards, and potential hazards, that may expose a worker to injury or illness.
    • 4.1 It is recommended that employers, constructors, supervisors ensure that any hazard identified in risk assessments be relayed to workers together with the associated level of risk.
  5. That the Occupational Health and Safety Act, R.S.O. 1990, c. O.1, be amended to promote first aid training for all workers on mining property.

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”

  1. 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.
  2. 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.
  3. The ministry should revise both health and NILO/ILO policy to recognize cultural and spiritual support as a fundamental health care right to all.
  4. 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.
  5. The ministry should investigate how security is assessed concerning spiritual elders, knowledge keepers, and traditional teachers.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. The SWDC/ministry shall ensure that all correctional officers are trained on the importance of inmate care plans.
  11. 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.
  12. The SWDC shall make best efforts to ensure the Managed Clinical Care Unit (formerly known as the Female Mental Health Unit) is directly supervised.
  13. 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.
  14. 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.
  15. 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.
  16. 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.
  17. The ministry shall update policy so that phone calls by persons in custody are not referred to as a privilege.
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. The SWDC/ministry should incorporate substantive feedback from persons in custody in determining health care services.
  23. 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.
  24. 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).
  25. 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.
  26. 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.
  27. 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.
  28. The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody.
  29. The SWDC/ministry shall include automated external defibrillators in nurses’ equipment for emergency response (e.g. emergency bag/crash cart).
  30. 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.
  31. 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.
  32. 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.
  33. 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.
  34. 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.
  35. 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.
  36. 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”.
  37. 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:
  1. 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):
  1. 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.
  2. 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.
  3. Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors.
  4. 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:
  1. Utilizing the resources publicly provided by the MLTSD, WSIB and IHSA, draft a hot weather plan/heat response plan.
  2. Designate an employee to manage this plan, monitor the weather, ensure compliance with the plan and maintain records.
  3. 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.
  4. 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.
  5. 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:
  1. 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.
  2. Utilizing the resources publicly provided by the MLTSD, WSIB and IHSA, draft a hot weather plan/heat response plan.
  3. Designate an employee to manage this plan, monitor the weather, ensure compliance with the plan and maintain records.
  4. 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.
  5. 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.
  6. 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:
  1. 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.
  2. Mandatory skid steer operation certification and re-certification process.

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

  1. 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.
  2. 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
  1. 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.
  2. 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.
  3. 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
  1. 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
  1. 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
  1. 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.
  2. 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.
  3. The Toronto Police Service should consider the use of dedicated negotiators.
  4. 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.
  5. 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.
  6. The Toronto Police Service should continue to build a diverse ETF that represents the communities they serve.
  7. 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
  1. 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.
  2. The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model.
  3. 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
  1. 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)
  1. 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)
  1. 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
  1. 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.
  2. 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.
  3. 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
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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
  1. 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)
  1. 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.
  2. 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.
  3. 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
  1. 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 24th, 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
  1. 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.
  2. 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.
  3. 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)
  1. 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.
  2. 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
  1. 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
  1. 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.
  2. 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.
  1. 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.
  2. 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
  1. 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
  2. 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.

  1. 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
  1. 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

  1. 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.
  1. 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)
  1. 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
  1. 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.
  2. 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

 

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. The ministry should conduct regular reviews to ensure its complement of nurses is sufficient to allow thorough assessments of each Inmate.
  7. The ministry should explore safer alternatives to wooden pencils being provided to Inmates.
  8. The ministry should upgrade key CCTV cameras to record audio in common areas, where permissible by privacy legislation.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards.
  15. 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.
  16. The ministry should review OTIS to include features to allow certain alerts to be clearly highlighted for staff’s attention.
  17. 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)
  18. 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.
  19. 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.
  20. 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.
  21. 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.
  22. 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.
  23. 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):
  1. 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.
  2. 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
  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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:
  1. 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.
  2. 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:
  1. Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a “pilot” project.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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).
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. Provide Indigenous-led cultural competency and cultural safety training to all officers.
  13. 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):
  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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:
  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care.
  7. 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.
  8. 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).
  9. 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.
  10. 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.
  11. 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).
  12. 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.
  13. 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.
  14. 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.
  15. 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:
  1. 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.
  2. 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).
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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:
  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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:
  1. 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.
  2. 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:
  1. 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:
  1. 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.
  2. Implement the Spirit Bear Plan through collaboration with MCCSS, MOH and government of Canada
To the Ministry of Children, Community and Social Services:
  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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:
  1. 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.
  2. 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:
  1. Consider extending the recommendations 10-22 to include all municipal police forces across Ontario.
To the Ministry of Children, Community and Social Services:
  1. 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.
  2. 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

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:
  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.
To Workplace Safety and Insurance Board:
  1. 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.