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

Pridham, Michael

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

Held at:  Four Points Hotel – 60 Bryne Drive, Barrie
From: January 9
To: January 10, 2023
By: Dr. Geoffrey Bond, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Michael Pridham
Date and time of death:  December 21, 2018 at 1:25 p.m.
Place of death: Soldiers Memorial Hospital, Orillia
Cause of death: heavy blunt impact to the head
By what means: accident

(Original signed by: Foreperson)

The verdict was received on January 10, 2023
Coroner's name: Dr. Geoffrey Bond
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Michael Pridham

Jury recommendations

No recommendations.

Hassan, Abdurahman

Surname: Hassan
Given name(s): Abdurahman
Age: 39

Held at: virtual, Office of the Chief Coroner
From: January 16
To: February 10
By: Dr. David Eden, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Abdurahman Hassan
Date and time of death:  June 11, 2015 at 1:28 a.m.
Place of death: Peterborough Regional Health Centre
Cause of death: sudden death during struggle/restraint with a towel placed on the mouth, under the nose in the setting of schizophrenia and hypertensive heart disease
By what means: undetermined

(Original signed by: Foreperson)

The verdict was received on February 10, 2023
Coroner's name: Dr. David Eden
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Abdurahman Hassan

Jury recommendations
To Government of Canada
  1. Seek and allocate resources to develop and implement a plan to end the practice of housing immigration detainees in provincial correctional facilities in Ontario.
  2. Redefine the purposes of immigration detention to include rehabilitation and when appropriate to the detainee’s circumstances, reintegration into the community. This should include resources and facilities to:
    1. stabilize detainees with acute mental health symptoms
    2. develop care plans for detainees with mental illnesses
    3. assist with discharge planning
  3. Amend the agreement between Canada and Ontario to prohibit placing immigration detainees in conditions of segregation and to require immediate notification if this prohibition is violated.
  4. Establish an independent oversight body to:
    1. review and investigate conditions of detention for immigration detainees
    2. receive complaints about the conditions of detention
    3. investigate critical incidents and fatalities involving immigration detainees
  5. Collect data on conditions of detention and consider this data when determining whether to continue housing an immigration detainee in a provincial correctional facility, including:
    1. whether the detainee was in conditions of segregation
    2. whether the detainee was triple-bunked
    3. the number of days in lockdown and the impact of lockdown on access to health care
    4. whether a serious mental illness alert has been issued for the detainee
  6. Seek and allocate resources to expand access to alternatives to detention for individuals with a serious mental illness.
  7. Consult with the Province of Ontario about the possibility of funding beds at the St. Lawrence Valley Correctional and Treatment Centre for immigration detainees.
  8. Train Canada Border Services Agency (CBSA) employees operating in the detention continuum on the impacts of detention on mental health.
To Government of Ontario
  1. Consider withdrawing from the immigration detention agreement between Ontario and Canada.
  2. Review the existing ombudsman process to determine whether immigration detainees have reasonable access to put forth complaints that result in timely remedies to conditions of detention.
To Ontario Ministry of the Solicitor General

Segregation – interpretation and tracking

  1. Re-assess how the ministry interprets the term “highly restricted conditions” in Ontario Regulation 778. In particular, the ministry should adopt an interpretation designed to ensure that inmates are taken out of confined physical spaces for at least two hours per day.
  2. Develop and implement a plan to ensure that “meaningful social interaction” is clarified and operationalized in a manner that reflects the plain meaning of the phrase and that it allows for sustained social interaction with other individuals.
  3. Consider developing and implementing a new definition for “meaningful activities” that occurs when an inmate is alone and engaged in meaningful activities, to avoid confusion and facilitate public reporting.
  4. In the interim, when tracking and reporting “meaningful social interaction”, correctional staff should record solitary activities separately from social interaction involving other individuals.
  5. Update the ministry’s publicly released data on the use of segregation to clearly indicate that the reported number of inmates held in conditions of segregation is likely inaccurate because of how “meaningful social interaction” has been interpreted by correctional staff.
  6. The ministry’s future public reporting on the use of segregation should provide separate statistics for meaningful activities that occurs when an inmate is alone and meaningful social interaction that involves interaction with other individuals.
  7. Monitor how often racialized inmates with serious mental illnesses are held in conditions of segregation. Make this information available to correctional and health care staff and report disaggregated data publicly.

Central East Correctional Centre (CECC) segregation review

  1. Conduct a comprehensive review of compliance with segregation regulations at the CECC. The methodology for the review should include:
    1. an audit of a meaningful selection of segregation records
    2. interviews with correctional staff, management and affected inmates about how the terms “highly restrictive conditions” and “meaningful social interaction” are being interpreted and implemented
    3. an assessment of the infrastructure, staffing and operational resources required to comply with all segregation regulations, including the prohibition against placing inmates with serious mental illnesses in conditions of segregation
    4. share findings and best practices with other correctional centers
  2. The ministry should seek and allocate funds to complete and implement an action plan to address and support the results of the CECC segregation review. This should include a plan to upgrade the physical infrastructure at the CECC to ensure compliance with the prohibition against placing inmates with serious mental illnesses in conditions of segregation.
  3. The CECC segregation review and action plan should be made a high priority.

Hospitalization

  1. Develop clear policies about alerting family members when an inmate has been hospitalized.

Health care at CECC

  1. Prioritize implementation of the planned electronic medical records system at the CECC.
  2. Prioritize implementing the action plan that resulted from the CECC health care review.
  3. Seek and allocate resources to recruit and retain adequate health care staff to meet the needs of the inmate population at the CECC.
  4. Increase number of hours for primary care physicians and psychiatrists at the CECC.

Race-based data collection and reporting

  1. Collect and publicly report on the race and ethnicity of all people who are detained in provincial correctional facilities. Include characteristics such as reasons for detention, length of stay, age and sex distribution.

Policing

  1. The Ontario Police College should review current police training with respect to the use of the term “excited delirium” to ensure that it is consistent with the latest medical and scientific research concerning the risk of sudden death in cases of police restraint of persons experiencing extreme agitation. In particular, the term “excited delirium” should no longer be used to describe the risks associated with restraining an agitated individual.
  2. The Ontario Police College should review, and if appropriate, amend training policies and procedures respecting de-escalation tactics, crisis intervention, anti-racism, and mental health.
  3. All Ontario police services should seek and allocate resources to create and maintain advisory committees on mental health, addictions, and anti-racism, and that these committees include members of these communities, as well as organizations that advocate on behalf of these communities.
  4. Review the current Use of Force Model (2004) and related regulations and training.
  5. All Ontario Police services should consider requiring or encouraging officers to:
    1. communicate a concern when there is excessive use of force
    2. document all observed use of force and de-escalation strategies attempted.

To Ontario Provincial Police (OPP)

  1. The OPP should implement a policy in the Ontario Provincial Police Orders with respect to the use of “additional means of restraint” that applies to OPP officers using such restraints at a facility that is not an OPP lockup, courthouse, or lockup of another police service.
  2. The policy with respect to “additional means of restraint” should apply to OPP officers on both regular and paid duties.
  3. The policy with respect to “additional means of restraint” should apply to both restraints that are authorized by the OPP and to improvised restraints.
  4. The policy with respect to “additional means of restraint” should require that prior authorization be obtained from a supervisor for the use of additional means of restraint. Where exigent circumstances do not permit prior authorization, the policy should require that the use of additional means of restraint be reported to a supervisor as soon as practicable.
  5. The OPP should amend the current Ontario Provincial Police orders relating to spit hoods to clarify that it applies to any item that is improvised to be used as a spit hood.
  6. The OPP should immediately notify all frontline officers that the use of any restraints in a manner that obstructs or partially obstructs an airway imposes a significant risk of sudden death. Information concerning the risk of sudden death from the obstruction or partial obstruction of a person’s airway should be incorporated into Use of Force training.
  7. The OPP should alert other police services in Ontario to the potential need to clarify policies concerning the use of improvised restraints.
To OPP, Peterborough Police Service (PPS), CECC and Peterborough Regional Health Centre (PRHC)
  1. PRHC, the OPP, PPS, and CECC should collaborate on developing a protocol to clarify the roles, responsibilities and interactions of hospital personnel, police, correctional officers, and special constables in situations where they are assigned to guard patients in custody.
  2. The protocol should require that hospital personnel and resources, including multi-disciplinary staff, be considered before police officers or correctional officers are requested to restrain a patient in custody for the provision of healthcare.
  3. The OPP, PPS, CECC and PRHC should develop and implement the necessary policies and training to support the protocol.
  4. PRHC and the CECC health unit should collaborate on developing a protocol that provides for the sharing of relevant patient information (subject to applicable law) necessary to provide trauma-informed care to patients and to improve safety. PRHC should support input from relevant community organizations and people with lived experiences in the development of the protocol.
  5. Where feasible, the CECC should ensure that patients in CECC custody are accompanied at all times by correctional officers.
  6. The OPP, PPS, and CECC should collaborate on developing a protocol for the sharing of information necessary for the safety of the patient, the public, hospital personnel and police or correctional officers assigned to guard the patient.
To Peterborough Regional Health Centre
  1. PRHC should update their procedures/policies to state that hospital personnel should not apply or assist anyone in applying a non-hospital approved restraint. After the update, ensure that the policy is circulated to relevant hospital personnel.
  2. PRHC should update their procedures/policies to state that no form of restraint should be applied in a manner that may obstruct or partially obstruct a patient’s airway. After the update, ensure that the policy is circulated to relevant hospital personnel.
  3. PRHC should review their workplace violence prevention program and consider training updates with a focus on restraints and supports for de-escalation, using a trauma-informed, intersectional lens.
  4. The PRHC Health, Equity, Diversity and Inclusion Committee should include in its mandate the development and deployment of training in the areas of trauma informed care, anti-racism, equity, and implicit bias in clinical settings. People with lived experience should be involved in the development, deployment and review of such training.
  5. The PRHC Health, Equity, Diversity and Inclusion Committee should review what steps may be taken to facilitate and promote data collection practices to obtain meaningful information, including the collection of disaggregated socio-demographic data from all areas of the hospital, to inform the development and deployment of ongoing training.
  6. The PRHC should implement a process to provide adequate access to counseling and confidential debriefs when traumatic events occur.
To the Office of the Chief Coroner / Ontario Forensic Pathology Service
  1. Consider conducting inquests in a timelier manner from the date of the incident.
To the Special Investigations Unit (SIU)
  1. Provide direct notification in a timely manner to individuals involved in an SIU investigation that the investigation has concluded and confidentiality is no longer necessary.
  2. Inform civilians involved in an SIU investigation of their rights and responsibilities and allow them access to confidential counseling services for the duration of the investigation.

February

Nicholas, Brennan

Surname: Nicholas
Given name(s): Brennan
Age: 24

Held at:  virtual, Toronto
From: February 27
To: March 10, 2023
By: Dr. Bob Reddoch, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Brennan Nicholas
Date and time of death:  June 15, 2018 at 7:25 p.m.
Place of death: Millhaven Institution – Regional Treatment Centre, Bath
Cause of death: incised wound of the neck
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on March 10, 2023
Coroner's name: Dr. Bob Reddoch
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Brennan Nicholas

Jury recommendations
To Correctional Services of Canada (CSC):

Facility

  1. CSC shall ensure that there is sufficient space at the Millhaven Institution – Regional Treatment Centre to provide Indigenous ceremonies, cultural practices and correctional programs including dedicated sacred grounds.
  2. CSC should prioritize and expedite establishing a permanent and more purpose-built therapeutic psychiatric facility for patients at the Millhaven Institution – Regional Treatment Centre. As an interim measure but not to replace the establishment of a permanent purpose-built therapeutic psychiatric facility, they should prioritize and expedite making modifications to create a more therapeutic psychiatric facility.

Indigenous services

  1. CSC should ensure that Indigenous patients have sufficient and timely access to Indigenous-specific services while in federal custody by ensuring there are resources and funding available to support Indigenous elders and Indigenous liaison officers in providing services to Indigenous people in federal custody.
  2. CSC shall ensure that appropriate healthcare staff members promptly review patients’ provincial health care records as soon as they are admitted to the Millhaven Institution – Regional Treatment Centre.
  3. CSC shall ensure to flag an individual’s past suicide attempts in the Electronic Medical Record – Open Source Clinical Application Resource.

Indigenous staffing and engagement

  1. CSC should explore a change of title for the role of the Indigenous liaison officer and seek guidance from current Indigenous liaison officers and elders on what the title should be.
  2. CSC frontline staff should endeavour to better understand the role of elders and Indigenous liaison officers.
  3. CSC should revise Commissioner’s Directive 702: Indigenous Offenders to recognize the role of elders and Indigenous liaison officers as central to the delivery of Indigenous spiritual and cultural access for healthcare and wellness.
  4. CSC should continue ensure that Indigenous liaison officer and elder services are adequately resourced to meet the needs of Indigenous people. Indigenous people should be able to access their spiritual rights as well as programs with regularity and without unreasonable delay. Specifically:
    1. CSC should strive to ensure that all Indigenous liaison officer and elder positions are adequately funded and so that they can recruit, retain and keep Indigenous liaison officer, elder and elder helper staff in full time, permanent positions.
    2. CSC should consider increasing Indigenous liaison officer staff at its correctional institutions to meet the needs and services of the Indigenous persons in the custody population, so that services for Indigenous persons are representative of the needs or recognizes the number of Indigenous persons at each institution.
  5. CSC should consider targeted recruitment efforts to attract and retain qualified Indigenous healthcare professionals. 
  6. CSC shall endeavour to ensure that Indigenous elders and Indigenous liaison officers at the Millhaven Institution and the Regional Treatment Centre are sufficiently resourced to complete elder reviews and elder review updates in a timely manner at the institutions.
  7. CSC staff in both healthcare and operations/security should receive in-person training, facilitated by an Indigenous person(s) on Indigenous social history/factors so that they are educated and aware of how various Indigenous specific circumstances may impact considerations of options, solutions or decisions about an Indigenous person in custody.

Clinical framework

  1. CSC shall ensure that any improvements or evaluations to CSC’s Clinical Framework for Identification, Management and Intervention for Individuals with Suicide and Self-Injury Vulnerabilities include Indigenous community and Indigenous medical professional input about how the framework applies to Indigenous persons in custody.

Transfer of healthcare records

  1. CSC shall continue to ensure that appropriate staff members at Millhaven Institution – Regional Treatment Centre review incoming individuals’ health care transfer packages as part of their referral and admissions process. CSC shall also make individuals’ health care transfer packages easily accessible for healthcare staff review at the Millhaven Institution – Regional Treatment Centre.
  2. CSC shall review its processes to better ensure that a patient’s provincial health care transfer record is promptly uploaded onto the Electronic Medical Record – Open Source Clinical Application Resource upon their admission to the Millhaven Institution – Regional Treatment Centre.
  3. CSC shall ensure that once an individual arrives at Millhaven Institution – Regional Treatment Centre, the interdisciplinary healthcare team will meet to discuss the individual’s relevant healthcare information and previous healthcare management.

Razor protocol

  1. At the Millhaven Institution – Regional Treatment Centre, CSC shall continue to ensure that only CSC staff members distribute, account for and collect electric razors and disposable heads from patients.
  2. The Millhaven Institution – Regional Treatment Centre shall continue to ensure that patients are not in possession of more than one electric razor at one time.
  3. CSC shall make electric shavers available at a reasonable cost to persons in custody at all of its correctional institutions.

Correctional healthcare

  1. CSC shall explore how to offer Indigenous mental health coping strategies to patients at the Millhaven Institution – Regional Treatment Centre.
  2. CSC should create a process where non-medical professionals within individuals’ interdisciplinary healthcare teams can easily alert the individuals’ medical prescribers about any of their concerns when the individuals change psychotropic medications.
  3. CSC should develop further initiatives to support existing employees and service providers and increase the recruitment of nurses, psychiatrists, and psychologists, such as:
    1. explore the use of open-posting platforms (i.e. “Indeed”) for positions at CSC
    2. advertise for psychiatry positions at psychiatric professional conferences
    3. advertise for psychiatry positions in Canadian medical journals
    4. explore opportunities for psychological student placements through practicums and other supervised-based roles
  4. CSC should ensure, as reasonably possible, that individuals at the Millhaven Institution – Regional Treatment Centre are treated by the same psychologist and /or psychiatrist while residing in a particular unit.
  5. An individual’s primary care psychiatrists at the Millhaven Institution – Regional Treatment Centre should attend the individual’s Interdisciplinary Mental Health Team meetings as reasonably possible.
  6. CSC should consider a review of the objectives, functions, members and leadership of the interdisciplinary team and consider including appropriate input from custodial staff and as appropriate.

Training

  1. CSC shall provide increased in-person suicide awareness and suicide prevention training for frontline staff at the Millhaven Institution – Regional Treatment Centre.
  2. CSC shall provide increased in-person Indigenous-specific training for frontline staff at the Millhaven Institution – Regional Treatment Centre. The training should try to achieve culturally appropriate and trauma-informed models of care specifically for Indigenous people in custody. The training should include information about colonialism, the impacts of trauma and intergenerational trauma. It should also include the use of Indigenous celebration, ceremonies and cultural events to promote awareness of Indigenous communities, strengths and resilience.
  3. CSC shall provide in-person training on how to support persons related to mental health, self-harm and suicide prevention for correctional officers who work or may work at the Millhaven Institution – Regional Treatment Centre.

Rehabilitation supports

  1. CSC should ensure, when family connection and communication for a patient at the Millhaven Institution – Regional Treatment Centre is a protective factor for the patient, to build in communication opportunities as part of the patient’s mental health treatment plan.

Implementation

  1. CSC should seek funding to implement these recommendations.
To the Ministry of the Solicitor General:
  1. The Ministry of the Solicitor General should review the health care transfer summary to enhance information-sharing when an individual is being transferred from provincial custody to federal custody based on evidence heard in the inquest into the death of Brennan Nicholas or with input from the Correctional Services of Canada. In particular, the review of the health care transfer summary should focus on including additional information in relation to previous self-injurious behavior and/or suicide attempts including but not limited to:
    1. the number of attempts
    2. the date of attempts
    3. the means involved
    4. the level of severity and treatment required (i.e. hospitalization)
    5. known triggers
    6. any preventative measures that may have been in place while in custody (i.e. restrictions or bans)
    7. specifically identify if the patient is being followed by a psychologist and / or psychiatrist
  2. The Ministry of the Solicitor General should consider incorporating the results of the review into the electronic medical record system once it is implemented.

Implementation

  1. The Ministry of the Solicitor General should seek funding to implement these recommendations.

March

Penner, Frederick

Surname: Penner
Given name(s): Frederick
Age: 56

Held at: St. Catharines
From: March 20
To: March 30, 2023
By: Dr. Geoffrey Bond, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Frederick Penner
Date and time of death:  January 1, 2020 at 12:27 p.m.
Place of death: Hamilton General Hospital
Cause of death: multiple gunshot wounds
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on March 30, 2023
Coroner's name: Dr. Geoffrey Bond
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Frederick Penner

Jury recommendations
To: Niagara Health
  1. Conduct a comprehensive quality of care review into Frederick Penner’s hospitalization between December 23 and 27, 2019, in accordance with the Quality of Care Information Protection Act, including a review of:
    1. Mr. Penner’s medical file
    2. compliance with the principles for documenting patient encounters
    3. communication between psychiatrists and other health care providers
    4. discharge planning.
    The review should address any opportunities for improvement that are identified.
  1. Conduct an audit into compliance with respect to record keeping as outlined in the College of Physicians and Surgeons (CPSO) policy and guidelines. The audit should be sufficiently comprehensive to ensure compliance with CPSO policies.
  2. Remind physicians and other health care providers that when discharging a patient who has been diagnosed with a substance use disorder, they should discuss all relevant options for addictions treatment, counseling and therapy and that these discussions should be documented in the patient’s health care file.
  3. Consider conducting an automatic quality of care review upon the occurrence of the death of any person admitted under section 17/Form 1 of the Mental Health Act who has subsequently/recently been discharged from hospital.
To: Niagara Health and the Canadian Mental Health Association
  1. Consider creating and providing an information package regarding mental health and addiction program resources, to patients during assessment and at time of discharge.
To: Niagara Regional Police Service and the Canadian Mental Health Association
  1. Continue to review and revise policies and procedures for Mobile Crisis Rapid Response Teams (MCRRT) and Crisis Outreach and Support Teams (COAST).
To: Niagara Health, Niagara Regional Police Service and the Canadian Mental Health Association
  1. Explore options for additional information-sharing and referral processes about psychiatric patients who have been apprehended under section 17 of the Mental Health Act and/or have been discharged from hospital after an involuntary admission.
To: Ontario Ministry of the Solicitor General
  1. Consider introducing training scenarios involving MCRRT at Ontario Police College.
To: Government of Ontario
  1. Increase funding and resources for community based mental health and addictions services in the Niagara Region, including to:
    1. expand the services offered by MCRRT and COAST
    2. assign liaison workers to assist with consent discussions, discharge planning and referrals for psychiatric patients.
To: Niagara Regional Police Service and Ontario Ministry of the Solicitor General (Police College)
  1. Consider exploring/researching the effectiveness of additional non-lethal options not significantly impacted by outside conditions. (i.e. rubber projectiles, bean bag projectiles, flash grenades etc.)

Baker, Beau Aaron

Surname: Baker
Given name(s): Beau Aaron
Age: 20

Held at: virtually from Toronto
From: March 20
To: March 31, 2023
By: Dr. David Eden, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Beau Aaron Baker
Date and time of death:  April 2, 2015 at 10:10 p.m.
Place of death: St. Mary's General Hospital, Kitchener
Cause of death: gunshot wound of the torso
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on March 31, 2023
Coroner's name: Dr. David Eden
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Beau Aaron Baker

Jury recommendations
We the jury recommend to the Regional Municipality of Waterloo:
  1. Coordinate and lead all necessary local stakeholders in submitting an application with an evidence-based business plan to the Province of Ontario for the funding of one or more youth wellness hubs to be established in Waterloo region.
We the jury recommend to the Province of Ontario:
  1. Provide base funding for, and facilitate the creation of, youth wellness hubs across the province as introduced under the Ontario’s 2020 Road to Wellness Strategy, using the following eight guidelines:
    1. operate with extended hours and in transit-friendly locations, appropriate for transition-aged youth (aged 16-24)
    2. be housed in youth-friendly, non-clinical settings to support trust and comfort amongst youth
    3. be connected to a 24-hour crisis line with sufficient funding and staffing to ensure callers encounter no wait times
    4. provide developmentally appropriate primary care, peer supports, mental health and addiction services
    5. ensure that the voice of transition-aged youth is included in the design and delivery of the design of the sites and the delivery of services
    6. conduct outreach through methods appropriate for transition-aged youth to ensure that youth are aware of the services provided
    7. be subject to continuous research and evaluation to ensure that they operate in a manner that is evidenced-based
    8. promote/communicate awareness of the program within the community.
  2. Provide full funding to Children’s Aid Societies for youth aged 18 to 23 in the care of a Children’s Aid Society through the Ready Set Go Program. To achieve the government’s stated goals of the Ready Set Go initiative, full funding needs to be permanent and guaranteed for the duration of the program.
  3. Adequately fund community mental health and addiction services (evidenced by no wait lists) for assessment, treatment and relapse prevention services.  The Province of Ontario should increase system capacity to provide adequate levels of in-home and live-in intensive treatment services across the province.
  4. Adopt a commitment to move away from licensing traditional group home settings and toward licensing and fully funding smaller, family model care settings, with access to multi-disciplinary care teams that wrap around a youth and respond to their individual needs effectively, to improve outcomes and support youth health and wellness.
  5. Identify and implement critical linkages between its Child Welfare Redesign strategy (Ministry of Children, Community and Social Services) and its Roadmap to Wellness strategy (Ministry of Health) to streamline access and facilitate early intervention and wraparound services for children and families. The Province of Ontario should adequately fund and implement community-based prevention services to avoid intrusive child welfare involvement. This should include addiction and mental health services for parents.
  6. Provide sufficient and sustained funding for programs like IMPACT (i.e., mobile crisis intervention teams (MCIT)) and crisis call diversion programs and specifically, those initiatives in the Waterloo region for the Canadian Mental Health Association Waterloo Wellington.
  7. Support and implement Waterloo Regional Police Service’s submitted 2021 Ontario Association of Chiefs of Police resolution, as endorsed and passed, as it relates to response to mental health (non-public safety) calls and authorities under the Mental Health Act.
  8. Ensure that community-based non-police crisis response teams are available 24/7 across the province and are sufficiently funded to provide effective response times.
  9. Create or amend legislation, and provide supporting funding, that would allow for “situation tables” or “connectivity tables” within all communities to be mandated. Consideration should be given to authorizing the sharing of information to allow for the efficient identification of persons in crisis for referrals and support. The mandate of such Tables should be the identification and support of those that may be receiving treatment while in crisis but not accessing or offered support in between those crises.
  10. Use the model adopted by the Gerstein Crisis Centre to roll out similar programs across Ontario and continue support of the existing centre in the City of Toronto.
We the jury recommend to the Province of Ontario and municipal governments:
  1. Adopt a Housing First commitment for youth 16 and over in the care of a Children’s Aid Society and receiving extended support from a society under the Ready Set Go program, by ensuring there is adequate funding and supply for affordable, supportive transitional housing up to and including young adults aged 23.
We the jury recommend to all police agencies, Children’s Aid Societies, and healthcare clinics or healthcare professionals who are supporting a transition-aged (16-24) young person with complex needs:
  1. Be empowered to initiate case conferencing and case management if such a process would be helpful in coordinating supports for the young person.  Any case conference process should be strengths-based and place the young person and his or her family at the centre.
We the jury recommend to Children’s Aid Societies:
  1. Ensure youth are being connected with a worker in the community in which they reside in order to maximize knowledge of, and referrals to, local resources and supports. In the case of interjurisdictional case management, information about available local services should flow regularly and freely between the collaborating agencies.
We the jury recommend to police services that employ MCITs:
  1. Ensure that such teams are promptly advised of any calls involving persons in crisis for which they are not part of the initial response by police, subject to applicable privacy laws and other statutory restrictions. This will ensure that the MCIT is available to engage in any follow-up with the person after the immediate crisis is resolved.
We the jury recommend to the Ministry of the Solicitor General:
  1. Support initiatives (including amendments to any adequacy standards or legislation) that would allow for the transfer of first response to mental health calls not involving safety concerns (such as a threat of violence to others or the person in crisis) to other, community-based non-police agencies.
  2. Consult with mental health experts, people with lived experience, and the police, to create, maintain and mandate integrated use of force, mental health and de-escalation training for all police officers (after recruitment training). This training should also be made available to crisis response workers who work with police to respond to persons in crisis.
We the jury recommend to the Waterloo Regional Police Service (WRPS):
  1. Until such time as there is provincially mandated curriculum as set out in recommendation 17 above, undertake to have their in-service training with respect to use of force and de-escalation reviewed by peer-run advocacy groups and other community-based crisis and mental health service providers prior to the training being delivered. The Ministry of the Solicitor General should provide sufficient and consistent funding to allow the WRPS to engage in this type of training review and to allow for members from the same peer-run advocacy groups and other community-based crisis and mental health service providers to assist with the delivery of de-escalation training.
  2. Ensure that any officer involved in a situation in which they are required to draw their firearm as a result of threat of serious bodily harm or death shall receive a documented debrief with a supervisor prior to their next shift.
We the jury recommend to the Province of Ontario and medical schools in Ontario:
  1. Take necessary measures to ensure that patients have timely access to child and adolescent psychiatrists, including but not limited to funding for additional residency positions dedicated to child and adolescent psychiatry.
  2. Take necessary measures (i.e. raising caps) to allow for training of additional primary care physicians and child and adolescent psychiatrists.
We the jury recommend to the College of Physicians and Surgeons of Ontario:
  1. Encourage physicians to remain up-to-date with evidence-based treatment plans and drugs related to mental health cases.
We the jury recommend to the Ontario Ministry of Education:
  1. Provide information on mental health supports available in the community through schools and incorporate age-appropriate curriculum regarding mental health.
We the jury recommend to ALL recipients:
  1. Secure adequate funding and resources to implement these recommendations.

April

Miskie, David

Surname: Miskie
Given name(s): David
Age: 56

Held at:  Toronto
From: April 11
To: April 11, 2023
By: Dr. R. McLean, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: David Miskie
Date and time of death:  December 5, 2017 at 4:26 p.m.
Place of death: Pine Avenue North, Mississauga
Cause of death: blunt trauma/head and neck injury
By what means: accident

(Original signed by: Foreperson)

The verdict was received on April 11, 2023
Coroner's name: Dr. Richard McLean
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: David Miskie

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 forklift work and the risks of operating a forklift with the load raised and / or extended away from the mast of the forklift.
  2. Ministry of Labour should institute regular inspections to ensure Ron Little Trucking complies with recommendations set out below.

To Ron Little Trucking:

  1. Develop and implement a comprehensive forklift safety plan and process. Said plan should be reduced to writing and reviewed annually with all employees and include (but not be limited to):
    1. A mandatory mechanical safety review that must be completed each day, prior to commencing work with a forklift. Said plan should include ensuring that the seatbelt on the forklift is operational and that a copy of the forklift manual is available on the forklift.
    2. A bi-weekly inspection of all safety features on forklifts by a Supervisor or Management to ensure that they have not been tampered with or disengaged.
    3. Mandatory record keeping related to the safety reviews and bi-weekly inspections that identifies when they occurred, who conducted them and that there were no issues or, if there were issues, how those issues were corrected.
    4. Mandating the use of seatbelts for all workers when they are operating a forklift on behalf of Ron Little Trucking.
    5. Ensure that a health and safety rep is selected and that the identity of the representative is communicated to all employees.
  2. Educate any worker who is to utilize a forklift for or on behalf of Ron Little Trucking, at the commencement of their employment or contract and thereafter every three years regarding:
    1. The appropriate way to properly and safely operate a forklift.
    2. The risks and dangers associated with working with forklifts, including the import of not operating a forklift with the load raised or extended away from the mast.
    3. The availability of safety features on a forklift and the importance of utilizing those safety features at all times during operation, including the seatbelt.
    4. The company’s health and safety program and policy statement.
  3. Implement and enforce existing workplace health and safety policies and procedures.
  4. Institute mandatory record keeping of all employee safety training.
  5. Require employees to sign off on training records.

Allard, Ethan

Surname: Allard
Given name(s): Ethan
Age: 24

Held at:  City of Toronto
From: April 17
To: April 20, 2023
By: Dr. Geoffrey Bond, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ethan Allard
Date and time of death:  January 16, 2017 at 4:28 p.m.
Place of death: 200 Woodbine Avenue, City of Toronto
Cause of death: crushing injury to the chest
By what means: accident

(Original signed by: Foreperson)

The verdict was received on April 20, 2023
Coroner's name: Dr. Geoffrey Bond
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Ethan Allard

Jury recommendations
To the Ministry of Labour, Immigration, Training and Skills Development:
  1. Work with industry partners to review current education efforts for construction companies and their employees regarding legal rules and requirements as they relate to:
    • The operation of equipment in accordance with manufacturer’s manuals and all other requirements in Sections 93-95 of Ontario Regulation 213/91 made under the Occupational Health and Safety Act, 1990 (the Act).
    • The duty of employers and supervisors to ensure that workers work in accordance with the Act and its regulations and other requirements on employers under section 25 of the Act and supervisors under Section 27 of the Act.
    • The use of fencing when equipment must be located on a public roadway as required under Section 65 of Ontario Regulation 213/91 made under the Act.
  2. Increase random inspections of job sites with particular focus on equipment safety.
  3. Undertake an inspection of the Employer (Torrent Shotcrete Canada Limited) regarding their compliance with sections 25 and 27 of the Act and sections 93-95 Ontario Regulation 213/91 under the Act.
  4. Appoint an advisory committee under section 21 of the Act to inquire into the feasibility of amending the Construction Regulations (subsections 94 (1) and (2) of Ontario Regulation 213/91) to require third party inspection of mechanically-powered vehicles, machines, tools and equipment rated at greater than 10 horsepower on an annual basis.
To the employer and all construction companies in Ontario:
  1. Consider replacing air-powered chisels/chippers (which require an air hose) with battery powered tools that eliminate the need for both air hoses and electrical lines which may become entangled in augers and other moving parts of machinery.
To manufacturers of concrete pumps and similar equipment:
  1. Consider installing an engine kill switch at the point of the hopper, such that it is readily accessible to anyone at any point of immediate proximity to the hopper.
  2. Consider reinforcing safety sensors, bushings and camshafts in order to ensure proper functionality, durability and longevity.
  3. Consider incorporating added resistance and/or other safety features in or around the transmission lever controlling the forward-spin, backward-spin, and neutral gears, of the auger, in order that the lever is less prone to switching gears by accident or by physical contact with passerby, air lines, water hoses, or other inadvertent interference.