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, 2023
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.

Beaver, Moses

Surname: Beaver
Given name(s): Moses
Age: 56

Held at:  189 Red River Road, Thunder Bay
From: April 17
To: May 12, 2023
By: Dr. Louise McNaughton-Filion, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Moses Beaver
Date and time of death:  February 13, 2017 at 10:01 p.m.
Place of death: Thunder Bay Regional Health Sciences Centre
Cause of death: hanging
By what means: undetermined

(Original signed by: Foreperson)

The verdict was received on May 12, 2023
Coroner's name: Dr. Louise McNaughton-Filion
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Moses Beaver

Jury recommendations
To the Governments of Canada and Ontario:
  1. In order to support Moses’ vision of preserving cultural knowledge through art, Canada and Ontario should provide annual funding. This funding will be directed to the Nibinamik Education Centre as well as one additional Nishnawbe Aski Nation (NAN) community, rotating annually, to support a program each school year for an artist to work with students to create art reflecting traditional knowledge.
  2. Ensure equitable funding, resources, and adequate policing services in Indigenous communities. Indigenous police services must be deemed an essential service under the Police Services Act (PSA). The PSA should be amended with Indigenous consultation to include an Indigenous specific section to address the unique cultural and geographical issues.
To the Ministry of the Solicitor General, the Ontario Ministry of Health, Indigenous Services Canada, Nishnawbe Aski Nation, Nishnawbe-Aski Police Service, Ontario Provincial Police, Sioux Lookout First Nations Health Authority, Ornge, and the Ministry of the Attorney General:
  1. In moving forward with any initiatives that respond to the following inquest recommendations, the recipients of these recommendations should be guided by the principle that funded supports and services are provided to meet the acute mental health needs in NAN communities on a substantively equal basis with non-Indigenous people.
  2. A regional review committee should be assembled to review cases on a regular basis where there is an adverse outcome of a treatment plan for a mental health emergency in a remote community. The committee should include representatives from local healthcare providers, non-healthcare providers as well as community members as appropriate. In each case reviewed, the committee should work to identify root causes of adverse events as well as lessons learned and opportunities for improvement. Committee findings, recommendations and/or actions should be shared amongst nursing stations in the interests of continuous quality improvement.
  3. All stakeholders working with members of remote First Nations should be required to fulfill informed trauma training inclusive of burnout awareness and prevention strategies.
To Indigenous Services Canada (ISC), Nishnawbe Aski Nation and the Ontario Ministry of Health (MOH):
  1. A mobile mental health and addictions clinic should be created in consultation with Nishnawbe Aski Nation, and funded by Indigenous Services Canada and the Ontario Ministry of Health with the following goals:
    1. to provide early intervention care in a culturally appropriate and safe manner
    2. to address mental health challenges before they become more significant and debilitating
    3. to offer a variety of services together under one roof close to home, including but not limited to case management of wrap-around services for the individual and to assist in sustained and continuous access to a therapeutic relationship
    4. to reduce the need for clients to travel to access healthcare services
    5. to ensure individuals receive the care and support they need when and where they need it
    6. if individual communities deem it appropriate, persons with lived experience should be integrated into the planning and implementation of service.
  2. NAN should be funded to develop an integrated, culturally safe mental health care plan for remote First Nations in Northwestern Ontario. This plan, through accessible, effective interventions, will reduce psychiatric emergencies, and provide aftercare services including patient education for the patient and their family to assist with healthy reintegration into the community upon discharge from a psychiatric facility.
To the MOH and NAN:
  1. A public health campaign should be created by Nishnawbe Aski Nation in consultation with, and funded by the Ontario Ministry of Health, to reduce stigma surrounding mental illness including bipolar disorder, and to enhance understanding of the role of psychiatric medication in the treatment of mental illness. The campaign should address mistrust of the colonial health care system amongst First Nations people.
To the Ministry of the Solicitor General and NAN:
  1. Representatives of NAN should create and annually present regional and community specific information to all frontline staff in the Thunder Bay district jail and the Thunder Bay Correctional facility. This will ensure all staff are trained in cultural awareness of Northern communities.
To ISC and NAN:
  1. ISC should work with NAN to fund the development and delivery of land-based and culture-based programs for persons with acute mental health crises in NAN territory.
To ISC:
  1. ISC should engage with First Nations communities on the construction of secure/safe rooms as well as similar options such as comfort rooms or safe houses. If a First Nation community wants a secure/safe room or similar option in the nursing station, ISC and the community should explore options to build physical space attached to or in proximity to the nursing station or elsewhere in the community. ISC and the community should explore options for funding, hiring and training attendants, developing appropriate protocols for the use of the secure/safe room and determining the specifications of the space. ISC nurses should not be expected to guard people in the secure/safe room or to otherwise operate the facility.
  2. ISC should provide funding to remote communities to support the employment of properly trained security guards. Training for security personnel should include, but not be limited to non-violent de-escalation, mental health and cultural safety training. Security personnel at nursing stations in remote communities will assist in maintaining safety and security for patients and healthcare staff in cases of psychiatric emergency, and police be available to assist in situations where guards aren’t present or need further support.
  3. Nurse practitioners should be authorized to assess and complete form 1 under the Mental Health Act.
To the MOH and Sioux Lookout First Nations Health Authority (SLFNHA):
  1. Nursing stations in First Nations communities, as well as their physicians, should have access to the “Connecting Ontario Clinical Viewer”, Meditech, SLFNHA’s emergency medical record (i.e. OSCAR), or any other relevant electronic medical records.
To the MOH:
  1. MOH should expand the mandate of Criticall to include acute mental health crisis calls and investigate the need for a dedicated mental health branch.
  2. MOH should designate Meno Ya Win Health Centre in Sioux Lookout as a Schedule 1 facility under the Mental Health Act.
  3. MOH should ensure that medical assessments of patients from a remote fly-in nursing station are effected at a Schedule 1 facility, as determined by the patient’s treatment team in consultation with the patient and his or her family. Patients who are to be transported to a Schedule 1 facility for definitive care should not be required to be medically assessed at a non-Schedule 1 facility, absent exigent circumstances.
  4. MOH should ensure that when a patient is in a psychiatric crisis, the wishes of the patient and family be considered first when searching for a schedule 1 facility, and if not feasible, then the closest geographical facility should be the receiving facility.
  5. A protocol/clinical pathway should be developed to guide decision-making and prioritize the delivery of health care services when an acute psychiatric emergency arises in remote First Nation communities.
    1. This protocol/clinical pathway should be developed in consultation with First Nation communities and all relevant stakeholders, and should be made available publicly as well as available to a member of the public upon request.
    2. This clinical pathway should have a checklist which considers:
      1. whether a safe or secure room would be required for a violent/aggressive patient. This would include consideration of the patient’s experience with residential schools, the criminal justice system and other factors which might impact the choice of restraint
      2. an emergency assessment by a physician arranged in a timely manner by videoconference to assess the patient regarding Section 15 of the Mental Health Act
      3. the security needs for the patient
      4. contact to Criticall under the proposed “Life or Limb” policy for mental health crises
      5. the need for police escort and escalation of this request for police escort if air ambulance transfer in a dedicated mental health aircraft is not possible
      6. the compilation of medical information and a transfer note to accompany the patient whether at a hospital or correctional facility.
  6. MOH should develop culturally specific public health education related to bipolar disorder and its many presentations.
  7. The MOH should amend the provincial “Life or Limb” policy to include acute mental health crises in geographically remote areas as emergent risks to life or limb.
  8. The MOH should fund Ornge to continue and expand its Mental Health Transport Team Program. Expansion should include, at minimum, two dedicated Standing Agreement aircraft to support no less than two dedicated teams comprised of one mental health nurse, one primary care paramedic and one security officer. Expansion should result in at least two full shifts of the Mental Health Transport Team capable of providing 24/7 emergency transportation and care for mental health patients in remote communities in Ontario. Evaluation of need should occur on an annual basis and be adjusted according to the relevant statistics.
  9. The MOH in consultation with the Ministry of the Solicitor General should consider amendments to Sections 18 and 33 of the Mental Health Act, to make clear where an examination by a physician under section 16 or 17 should occur, and the duties of a police officer once a person is brought to a nursing station or non-Schedule 1 facility.
To Nishnawbe-Aski Police Service (NAPS), Ontario Provincial Police (OPP) and the Ministry of the Solicitor General:
  1. Restorative justice should remain at the forefront of all planning and implementation of decisions made regarding corrections including but not limited to accountability, restitution and reconciliation, authentic communication, and community engagement.
To NAPS and the OPP:
  1. NAPS and the OPP should consider pre-charge diversion of those with recognized or declared mental health issues for persons in First Nations communities.
  2. NAPS and OPP should each create written procedures in consultation with ORNGE, ISC, and SLFNHA for external circulation to healthcare partners and stakeholders setting out the circumstances in which OPP or NAPS may assist ORNGE in transportation security of an individual suffering a mental health crisis in a remote community by providing an escort officer. Such escort officers shall only be made available upon special request and in exigent circumstances. The procedures shall expressly consider, among other things, the following issues:
    1. a contact path within each of OPP and NAPS for requests to be made
    2. a direction or specification from each of OPP and NAPS explaining what medical assessments external providers must first complete before making requests under the procedure
    3. a protocol for repatriation of any police officer escorts authorized under the procedure
To NAPS:
  1. NAPS should continue to review and operationalize training to recognize acute mental health crises, and have their officers approach an apprehension under the Mental Health Act as a first alternative to arrest with criminal charges in the case of a person in crisis in a remote First Nations community.
  2. When NAPS officers are removing a member of the community through arrest or apprehension, they should ask the person being transported for consent to contact the nursing station regarding medications, medical records or health conditions, and follow up where consent is given with the nursing station as required.
  3. NAPS should develop the equivalent of Police Order 2.20 of the Ontario Provincial Police Service, respecting their structure and available resources. This should include the completion by police officers of the Brief Mental Health Screener, or equivalent, for all occurrences involving a person in crisis where mental health-related issues are known or suspected, regardless of whether an apprehension is made under the Mental Health Act. The police officer should then provide a copy of this document to health facility staff during police-hospital transition, and to any correctional facility where deemed necessary.
To the Ministry of the Solicitor General (the ministry) and the Ministry of Health:
  1. The ministry and the Ministry of Health should both have representatives sit on the Community Reintegration Table to help inform policy and practice and encourage a close liaison with the provincial healthcare system.
To the Ministry of the Solicitor General:
  1. The ministry should establish a patient-centred model of care that promotes consistent, integrated, and team-based care, and that enhances continuity of care and successful transitions to and from the community.
  2. A provincial agency under the Ministry of Health and in liaison with the Ministry of the Solicitor General, should directly deliver and oversee healthcare services in correctional facilities, including responsibility for quality improvement, capacity-building, and system planning.
  3. The ministry should conduct training to reinforce understanding of the policy requiring a nurse completing a health assessment upon admission to ask the individual about prior engagement with healthcare providers concerning the individual’s mental health. The training should include direction with respect to obtaining written consents from the individual to obtain records from those providers when, in their clinical judgement, such records would assist in meeting the health care needs of the individual.
  4. When a family member or outside medical professional contacts a correctional facility with medical information regarding an individual, this information should be shared with a healthcare professional, documented and flagged to the most responsible practitioner.
  5. When a care plan is formulated for an individual with a mental illness at a correctional facility, all inter professional team supports and community participants in care plan formulation should be identified and contacted directly, with the request and their response regarding input into the care plan recorded in the individual’s file. This would include the patient’s participation and input.
  6. The ministry should ensure that inmates who are at elevated risk of suicide are placed in cells where the risks associated with tie-off points are mitigated.
  7. An individual’s medical record at a correctional facility should have up to date information related to next of kin and the primary healthcare providers in the community.
  8. The next of kin and primary healthcare provider should be advised of the individual's discharge into the community, with the consent of the individual being collected upon admission. Where consent is given, relevant medical information should be transmitted to the healthcare provider to allow for timely and appropriate follow up.
  9. The ministry should develop key performance indicators in provincial correctional facilities, related to:
    1. success in integrating individuals back into their community, evaluated with the care plan goals as a guideline
    2. tracking the number of individuals with mental health alerts returning to a correctional environment
    3. worker and patient experience survey within correctional institutions.

Key performance indicators should be available to correctional workers, individuals housed in the jail and the public and should be evaluated on an annual basis, to guide further decision making in provincial corrections.

  1. The ministry should ensure that all health professionals employed or contracted by the ministry have access to Connecting Ontario.
  2. The ministry should continue to implement its own province-wide electronic medical records system.
  3. The ministry should explore whether the Intake Unit, which is now being used for COVID/infectious disease observation before direct admission to a correctional facility, should also be used as a tool for obtaining medical information and identifying mental health behaviours which may require psychiatric intervention. As part of this process, consideration should be given to:
    1. obtaining pertinent past medical records for an individual
    2. observing for signs of acute mental illness, and thereafter recording and reporting such observations, particularly when the individual is on a form of enhanced watch
    3. employing Correctional officers with enhanced mental health training and professional interest in mental health issues, subject to collective bargaining requirements
    4. conducting daily debriefing sessions to ensure quick access to mental health professional assistance
    5. determining the housing required and the initial treatment plan (if required) for an arriving individual.
  1. A mental health unit should be created in the new Thunder Bay correctional institution, where residents experiencing mental health symptoms, or those being assessed for a mental illness diagnosis, can be housed, assessed and treated. Consideration should be given to:
    1. Correctional officers, health care staff, Native Inmate Liaison Officer (NILO) and other service providers sharing information regarding individuals in this unit, sharing any observations made and needs for the day, according to their care plan
    2. Correctional officers, health care staff, NILO and other service providers working together on this unit to provide a therapeutic environment
    3. ensuring that there is a focus on mental health treatment, assessment, and activities promoting optimal mental health both inside the institution and at the time of discharge into the community.
  1. The new correctional facility being built in Thunder Bay should ensure that there be a dedicated outdoor cultural space available and the construction and use will be in consultation with Indigenous representation.
  2. All front-line staff working within a correctional institution should have ongoing mental health and suicide prevention education and learning opportunities. Recognition of acute behavioural changes related to mental illness, non-violent de-escalation techniques, the risk and recognition of psychosis and lessons learned from critical events which may occur in the institution (for example suicides or near suicides) should be part of this ongoing learning.
  3. Investigate how incentive pay be made available for correctional officers who choose to work in the special handling unit (SHU) and fulfill extra mental health training.
  4. The ministry should conduct an information and outreach campaign to individuals housed within the correctional facility to educate them as to the signs and risk of mental health crisis to facilitate prompt reporting of such crises to health care staff.
  5. Correctional facilities should work with Indigenous communities and the NILO, to ensure there are Elders and/or Indigenous service providers able to serve the needs of those in custody. There should be an approach to correctional healthcare for Indigenous people in custody that is Indigenous designed, developed and delivered, in keeping with self-determination and self-government.
  6. The ministry should expedite Indigenous cultural safety training for all frontline correctional staff, including healthcare staff.
  7. The ministry should establish an Indigenous Advisory Committee comprised of regional Indigenous representation from across the province to provide advice on the provision of health services and correctional services to Indigenous individuals housed in correctional facilities.
  8. When critical incidents occur in a correctional facility, such as a death or an attempted suicide, a quality of care review should be conducted within a week, with all involved staff participating. The quality of care review should account for any privacy and/or legal privileges.
  9. The ministry should implement the following changes with regard to the reports produced by the Correctional Services Oversight and Investigations office (CSOI) following a death in custody:
    1. The investigation be conducted independent from the ministry
    2. The investigator should have access to the review of the health record conducted by Corporate Health and Corporate Health should be provided with a copy of the report to provide comment before it is finalized
    3. The report should be provided to the relevant health care manager, superintendent, regional director, and assistant deputy minister
    4. The family of the deceased should be advised that they may request a copy of the report
    5. The report should be made available to the public with special attention to the following:
      1. any non-pertinent medical information should be redacted to allow for privacy
      2. all names should be redacted
  10. The ministry should pursue health accreditation with Accreditation Canada, or other comparable body. The ministry should support the development of standards focused on ensuring culturally safe care for Indigenous individuals housed in correctional facilities.
  11. The ministry should conduct a workforce assessment to determine the appropriate staffing levels for health professionals (e.g. psychologists, psychiatrists, mental health nurses) and program staff for the Thunder Bay District Jail and its population. The number of individuals housed in the facility will be reflective of this assessment and accommodated in appropriate and humane living conditions.
  12. The ministry should ensure that all staff with direct clinical care responsibilities report to the correctional institution’s healthcare manager.
  13. The ministry should ensure all physicians or psychiatrists working within the correctional system in Ontario update their knowledge of bipolar disorders as part of their annual required continuing professional development.
  14. The ministry should supply laptops or equivalent technology for correctional officer posts to ease in the documentation process and the sharing of information.
  15. The ministry should install cameras that can monitor each individual cell in the special handling unit.
  16. Individuals housed at a correctional facility who are being transported to a courthouse should have a 2-3 days supply worth of any current medication as well as their personal belongings in case of discharge. The ‘red bag’ initiative could be of reference. Upon discharge, individuals should also receive a city bus ticket.
  17. The ministry should provide a minimum of five hours daily of stimulating activity for individuals housed in the correctional facility. This should include a mix of programming, education, rigorous physical activity, and no less than one hour of outdoor time being offered.
To the Crown Attorneys and criminal defense lawyers in Thunder Bay:
  1. Best efforts should be made to provide as much relevant information as possible regarding the circumstances that led to an arrest to the forensic court support nurse at the Thunder Bay court when seeking a Criminal Code mental health assessment. This may include information from family members or health care providers who were engaged with the individual prior to their arrest.
To the Ministry of the Attorney General (MAG):
  1. MAG should consider implementing a mental health court in Thunder Bay.
To the Office of the Chief Coroner for Ontario:
  1. The Office of the Chief Coroner should conduct an annual review of recommendations from past Ontario inquests dealing with mental illness and addiction issues experienced by First Nations persons. This examination should take place to determine whether such recommendations have been implemented, and to identify any patterns in the implementation of recommendations and common obstacles in the non-implementation of recommendations. The results should be reviewed with political territorial organizations, such as NAN, to evaluate the ongoing need.

May

Sargent, Shannon Nichole

Surname: Sargent
Given name(s): Shannon Nichole
Age: 34

Held at:  virtual, Office of the Chief Coroner, Toronto
From: May 29
To: June 14, 2023
By: Dr. Robert Reddoch, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Shannon Nichole Sargent
Date and time of death:  July 20, 2016 at 1:20 a.m.
Place of death: Ottawa-Carleton Detention Centre
Cause of death: cardiac complications of chronic intravenous drug abuse in a woman with recent cocaine use
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on June 14, 2023
Coroner's name: Dr. Robert Reddoch
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Shannon Nichole Sargent

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

Medical escorts

  1. The ministry shall ensure that all correctional staff involved in medical escorts are provided initial training and annual refresher training that covers the following topics:
    1. health care staff’s authority to determine whether or not a person in custody requires care at a hospital
    2. a procedure for assigning staff to a medical escort
    3. the roles and responsibilities of staff assigned to a medical escort
    4. the roles and responsibilities of staff overseeing a medical escort
    5. the roles and responsibilities of staff upon returning to the correctional facility with the person in custody
    6. a procedure for addressing issues relating to a medical escort

Policy analysis and compliance

  1. The ministry should consider revising its Correctional Services Code of Conduct and Professionalism to expressly state: the vital role of correctional officers in preserving life.
  2. The ministry shall ensure that all correctional and health care staff at the Ottawa Carleton Detention Centre (OCDC) are formally directed to review new policies, procedures, and standing orders.
  3. The ministry should secure and retain all available security footage immediately following an incident that occurs at a correctional facility.

Ethics and professionalism

  1. The ministry shall direct correctional staff at the OCDC to report any suspected breaches of the Statement of Ethical Principles and/or the Ontario Correctional Services Code of Conduct and Professionalism to their appropriate supervisor.

Staff collaboration

  1. The ministry shall consider implementing additional initiatives to improve correctional and health care staff communication and collaboration at the OCDC.

Correctional health care

  1. The ministry shall ensure that persons in custody are assessed for any health issues promptly after being admitted into the OCDC.
  2. The ministry shall review all operational policies and procedures to advance the principle of equivalency (entitling people in detention to have access to a standard of health care equivalent to that available outside prison and conforming to professionally accepted standards).
  3. The ministry should establish a patient-centred model of care that promotes consistent, integrated, and team-based care and that enhances the continuity of care and successful transitions to and from the community.
  4. The ministry shall explore ways to increase addictions-specific supports for persons in custody at the OCDC.
  5. The ministry shall ensure that a person in custody’s medical record at a correctional facility has up-to- date information on the person in custody’s primary health care providers.
  6. The ministry should provide health services relating to the provision of methadone or suboxone to persons in custody at the same time every day so that persons in custody receiving opioid agonist therapy receive it at consistent and regularly scheduled times.
  7. The ministry shall pursue health accreditation with Accreditation Canada, or another comparable body. The ministry should support the development of standards focused on ensuring culturally safe care for Indigenous individuals housed at correctional facilities.
  8. The ministry should conduct a comprehensive and ongoing process of engagement with persons in custody at the OCDC in the development of health care strategy, policy, and delivery.
  9. The ministry should consider providing an independent advocate to protect the interests of inmates.

Admissions

  1. The ministry should implement an enhanced admission screening form for persons in custody who disclose the use of street drugs during the admission process. This form should require an admissions nurse to identify: type(s) of drugs used, frequency of use, dosage, means of administration, number of consecutive days used prior to incarceration, and any other relevant information.

Training

  1. The ministry shall ensure that all correctional staff receive additional training related to unconscious bias that includes the stigmatization of persons who have substance use disorders.
  2. The ministry should invite representatives from Indigenous and Inuit organizations in the Ottawa Carleton region to create and annually present regional and community specific information to all frontline staff in the OCDC. This will ensure all staff are trained in cultural awareness.
  3. The ministry shall provide correctional officers who work on ranges designated for women with specialized training in gender, mental health, and Indigenous realities.

Indigenous supports

  1. The ministry should establish a formal process to engage Indigenous advisors to provide advice on the provision of health services to Indigenous persons in custody.
  2. 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 correctional 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 2SLGBYQQIA 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.

Care review

  1. The ministry shall conduct a quality-of-care review when critical incidents occur at a correctional facility, such as a death, with all involved staff participating. The quality-of-care review should account for any privacy or legal privileges.

Staffing and recruitment

  1. The ministry should conduct a workforce assessment to determine the appropriate staffing levels for health professionals and program staff for the OCDC and its population.
  2. The ministry should develop wellness initiatives to support existing correctional and health care employees.

Contact lists

  1. The ministry shall ensure that a person in custody’s institutional record at a correctional facility has up-to- date information on the person in custody’s next of kin.
  2. When admitting a person that has previously been in the custody of the OCDC and information from any prior admittance is relied on to complete admission forms, care should be taken to proactively update or confirm their contact list.

Death notification

  1. The ministry shall implement a process requiring the inclusion of a letter describing what is contained in the return of property of an individual that has died in custody.
To The Ottawa Hospital (TOH)

Health care

  1. TOH will continue to revise its interdepartmental consultation and referral guideline as needed to ensure that it reflects clinical scenarios for patients presenting to the emergency department within a specific timeframe following a procedure or surgery.
  2. TOH will continue to leverage EPIC’s existing functionalities with respect to the ability to flag a patient’s Plan of Care and continue to provide education to staff on this feature.

Training

  1. TOH will provide training to physicians, nurses, and allied health practitioners on providing safe care to Indigenous patients.
To the ministry and TOH

Medical escorts

  1. The ministry and TOH shall collaborate to establish a joint protocol to govern medical escorts from the OCDC to TOH. The parties should consult with all appropriate stakeholders and partners in establishing the protocol.
  2. The ministry shall ensure that all staff involved in medical escorts are informed of the details of the protocol once it is established. TOH shall ensure that all staff in the emergency department who may interact with medical escorts are informed of the details of the protocol once it is established.
  3. The ministry and TOH should streamline delivery of Health Care Consultation Forms between the Hospital and OCDC by way of electronic transmission.
To the Ottawa Police Service (OPS)

Transportation

  1. The OPS shall ensure that officers comply with the Prisoner Transportation Policy 6.09 and the Transporting Prisoners to Hospital Procedures 6.09-1.
  2. The OPS should provide additional training to relevant staff on the Prisoner Transportation Policy 6.09 and the Transporting Prisoners to Hospital Procedures 6.09-1.

Death notification

  1. The OPS shall explore how to improve procedure to determine how to efficiently locate a person in custody’s next of kin when their next of kin is unknown.
To the Ministry of Health (MOH)

Public education

  1. A public health campaign should be created by Indigenous and Inuit urban organizations, in consultation with, and funded by the MOH, to reduce stigma surrounding mental illness and substance use disorder, and to enhance understanding people living with opioid use disorders, especially those who receive opioid agonist or substitution treatment (e.g., methadone). The campaign should address mistrust of the colonial health care system amongst Indigenous people.

June

Baragar, James
Howes, Jeffrey
Jansen, Darcy
Shorrock, Kyle

Names of the deceased: Baragar, James; Howes, Jeffrey; Jansen, Darcy; Shorrock, Kyle
Held at: virtual, 25 Morton Shulman Avenue
From: June 5
To: June 14, 2023
By: Dr. David Eden, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Barager
Given name(s): James
Age: 39

Date and time of death:  December 14, 2017
Place of death: 1221 Upper Flinton Road, Northeast of Tweed
Cause of death: blunt impact injuries of head and chest due to helicopter crash
By what means: accident

Surname: Howes
Given name(s): Jeffrey
Age: 26

Date and time of death:  December 14, 2017
Place of death: 1221 Upper Flinton Road, Northeast of Tweed
Cause of death: multiple blunt force injuries due to helicopter crash
By what means: accident

Surname: Jansen
Given name(s): Darcy
Age: 26

Date and time of death:  December 14, 2017
Place of death: 1221 Upper Flinton Road, Northeast of Tweed
Cause of death: multiple injuries due to helicopter crash
By what means: accident

Surname: Shorrock
Given name(s): Kyle
Age: 27

Date and time of death:  December 14, 2017
Place of death: 1221 Upper Flinton Road, Northeast of Tweed
Cause of death: multiple blunt force injuries due to helicopter crash
By what means: accident

(Original signed by: Foreperson)

The verdict was received on June 14, 2023
Coroner's name: Dr. David Eden
(Original signed by coroner)

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

Inquest into the deaths of: James Barager, Jeffrey Howes, Darcy Jansen and Kyle Shorrock

Jury recommendations
We the jury recommend to Transport Canada:
  1. Amend the Canadian Aviation Regulations (CARs) to explicitly stipulate that an air operator must obtain Transport Canada approval before attaching equipment, bags or other material to the outside of a helicopter. The amendment and any associated guidance documents should set out the approval criteria and the approval process.
  2. Review the sections of the CARs that apply to the practice of a person performing work at or in the vicinity of transmission towers and wires from a helicopter while it is in flight (including in a hover position) and develop a clear position on:
    1. whether this practice meets the definition of a Class A external load or a Class D external load
    2. what type of helicopter may be used for this practice, with particular reference to safety precautions in the event of an engine failure
    3. whether this practice requires approval from Transport Canada
    4. the approval criteria
    5. the approval process
  3. Provide the position referred to in Recommendation #2 to all aircraft operators with approval and authorization to carry out helicopter operations. If the position is revised in the future, provide any updates to that position with all aircraft operators with approval and authorization to carry out helicopter operations.
  4. Conduct a comprehensive review of sections 702 and 703 of the CARs to identify any provisions related to helicopter modifications and approvals that require clarification. The review should include consultation with relevant stakeholders, including air operators and Design Approval Representatives who have delegated authority to make approvals under these sections.
  5. Develop internal guidance material and educational programs to inform Transport Canada safety inspectors, engineers and managers about the types of equipment modifications and aviation activities that require Transport Canada approval.
  6. Develop public guidance material to inform air operators and Design Approval Representatives about the types of equipment, equipment modifications and aviation activities that require Transport Canada approval.
  7. Amend the CARs to include a definition of the term “attachment device” in section 702.45.
  8. Review the practice of allowing Design Approval Representatives to approve their own helicopter designs and modifications. The review should include considering enhanced audits, a mandatory oversight or peer review process for each design approval.
  9. Formalize the process for providing advice to air operators and Design Approval Representatives about the interpretation of the CARs. In particular, all advice that Transport Canada safety inspectors, engineers or managers provide to air operators and Design Approval Representatives about the interpretation of the CARs should be documented in writing and confirmed with the operator in writing and Transport Canada should maintain records of this advice in accordance with Government of Canada record-keeping and retention requirements.
  10. Introduce an enhanced safety inspection regime to increase Transport Canada’s awareness about the types of aviation activities that air operators are engaged in and to identify design modifications, operational activities or operational risks that might require Transport Canada approval. The enhanced regime should assist Transport Canada in fulfilling its mandate to ensure the safety of all persons travelling in aircrafts and should include:
    1. increased frequency of onsite inspections
    2. routine proactive, unannounced safety inspections
    3. audits and reviews of all standard operating procedures
    4. attending aviation training sessions put on or provided by air operators
    5. observing air operator activities
    6. inspection of equipment or operational activities not previously inspected or approved by Transport Canada
  11. To facilitate the new enhanced safety inspection regime, develop regulations, policies or guidelines to require air operators to provide notice to Transport Canada when an air operator:
    1. has amended its standard operating procedures
    2. has scheduled aviation training sessions
    3. has scheduled new or novel aviation operational activities not previously inspected or approved by Transport Canada
    4. has acquired equipment not previously inspected or approved by Transport Canada
  12. Amend the CARs to require Standard Operating Procedures for all flight operations where an approval has been issued to carry an external load pursuant to section 702.45.
  13. Review all of Hydro One’s current helicopter operations and any new operations not previously undertaken, inspected or approved, for which an approval is required pursuant to the CARs and is not in place, to determine if such operations might require Transport Canada approval.
We the jury recommend to Hydro One:
  1. If Hydro One introduces the practice of aerial transfers or mid-span work using helicopters:
    1. Continue the prohibition against attaching tools, materials or equipment to the outside of helicopters.
    2. Ensure placard is displayed on the helicopter to confirm the prohibition referred to in (a).
    3. Ensure that adequate safety precautions are in place in the event of an engine failure.
    4. Consider consulting a third-party expert on human factors to provide additional support in updating work activities and policies to ensure the safety of all workers involved in and performing this type of work.
    5. Consider including in the new work method, work instructions that address the transportation of PLTs to the base of a transmission tower while work platforms of any type are installed on a helicopter. In developing this procedure, consider whether the helicopter should be used to transport crew while a work platform of any type is installed.
    6. Consider developing policies or updating any existing policies, including training, to ensure that any new or novel use of equipment, bags or other material by power line technicians while being transported on or working from a helicopter be reviewed and approved by Helicopter Services before deployment.
  2. Ensure that the 30-minute Helicopter Services Safety video is made mandatory (and reviewed every year; and/or inactivity of being in the helicopter for an extended period of time example 3 months) for any employee flying on Hydro One helicopters.
  3. Periodically reassess policy and procedures (Hydro One Document System HODS) with fresh eyes and/or Third party. Not to assume it is safe because it has been in use for a number of years.

July

Oruitemeka, Emmanuel

Surname: Oruitemeka
Given name(s): Emmanuel
Age: 25

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: July 4
To: July 14, 2023
By: Dr. Robert Reddoch, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Emmanuel Oruitemeka
Date and time of death:  February 16, 2014 at 3:42 p.m.
Place of death: Thunder Bay Regional Health Science Centre, 980 Oliver Road, Thunder Bay
Cause of death: a. anoxic ischemic brain injury, due to or as the consequence of  b. cardiovascular collapse, due to or as the consequence of  c. cocaine ingestion
By what means: undetermined

(Original signed by: Foreperson)

The verdict was received on July 14, 2023
Coroner's name: Dr. Robert Reddoch
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Emmanuel Oruitemeka

Jury recommendations
To the Thunder Bay Police Service:
To the Government of Ontario:
  1. 1. Schedule joint training on an annual basis, allowing first responders to learn more about the roles and responsibilities of other agencies, in consultation with the Thunder Bay Fire Department and Superior North Emergency Medical Services (SNEMS).
  2. Review and develop a plan to incorporate mandatory anti-Black racism training into future anti-racism programs and initiatives. The content of this training should include, but not be limited to, the history of Black people in Canada and the justice system, anti-Black racism, and unconscious bias. The training must address:
    1. identifying and managing implicit bias
    2. internal reluctance to acknowledge the existence of systemic racism
    3. identifying, understanding, and eliminating systemic racism
    4. understanding the impact and perception of police conduct during interactions with Black people
    5. understanding the meaning and connotation of certain words and actions in relation to Black people
  3. The training described at paragraph 2 should comply with the following principles:
    1. The content of the training should be developed in consultation with community organizations and content experts with lived experiences.
    2. The training is updated on an ongoing basis with different simulations and examples of interactions with Black people.
    3. There is a mechanism to test, and a record is maintained of, all police members that have completed the training.
  4. Ensure that all police members are aware of internal policies by providing in-person training on all policy updates and critical policies during annual block training and during a member’s regularly scheduled shifts. The training should include interactive scenario-based exercises that are relevant to the duties of Thunder Bay Police Service police members.
  5. Consider the implementation of an electronic learning (“e-learning”) platform to facilitate the delivery of policy training that may occur outside of the annual block training.
  6. Where an individual dies in police custody, ensure that all police members involved in the detention, arrest, or monitoring of the deceased are provided information about the cause of death, and provided training on symptoms that may be related to the cause of death, as soon as reasonably possible following the death.
  7. Institute a policy to mandate regular educational and mental health debriefs with all police members involved with incidents that engage the Special Investigations Unit to ensure that supports are in place, and ensure that the incident is used as a learning tool so that future incidents can be prevented.
  8. Implement and train all police members on a policy that requires all police members to communicate clearly and directly, and apply the “closed-loop” communication method (i.e., the person receiving instruction or information repeats it back to make sure the message is understood correctly, and the sender confirms).
  9. Train and require all police members to ascertain any medical information and salient factors about persons in their care or custody who are unresponsive or experiencing medical distress, to clearly record this information in the police member’s notebook, and to ensure to communicate this information with other police members actively involved in the care of the person. This should include medical personnel being made aware of this information.
  10. Deliver training to all police members related to the recognition of medical distress. The training should include interactive scenario-based exercises that are relevant to the duties of Thunder Bay Police Service police members. Include the facts and circumstances of Mr. Emmanuel Oruitemeka’s death as the basis of a scenario-based policy training exercise. Consider creating a re-enactment video of Mr. Emmanuel Oruitemeka’s death to portray the actions of the officers that were not conducive to life saving actions in relation to excited delirium. This should include all information from the time of entering the cruiser on the scene forward to SNEMS intervention.
  11. Redraft the prisoner care and control policy to clearly delineate elements of care (e.g., mandatory health checks, safety assessments) and elements of handling (e.g., seizure of property, detention), and further train all police members to understand the differences and balance between the care of persons and the handling of persons in their custody.
  12. Revise the “jailer responsibilities” section of the jailer training guide to include a mandatory requirement to assess the safety and well-being of a person who may be placed in a cell.
  13. Require both the Jailer and Watch Commanders to have Emergency First Responder First Aid certification (i.e., a level above standard first aid).
To the Government of Ontario
  1. Provide funding to permit the Thunder Bay Police Service to implement the e-learning program.

Legarde, Daniel Christopher

Surname: Legarde
Given name(s): Daniel Christopher
Age: 45

Held at:  Nipigon
From: July 31
To: August 11, 2023
By: Etienne Esquega, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Daniel Christopher Legarde
Date and time of death:  November 26, 2016 at 8:04 p.m.
Place of death: Nipigon District Memorial Hospital, 125 Hogan Road, Nipigon
Cause of death: gunshot wound to abdomen
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on August 11, 2023
Coroner's name: Etienne Esquega
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Daniel Christopher Legarde

Jury recommendations
To the Ontario Provincial Police (OPP):

Indigenous-specific training for OPP officers and relationship building with local Indigenous communities

  1. Consider ways to implement refresher training that is developed in conjunction with local Indigenous communities for past participants of the OPP’s Indigenous Awareness Training Course (IATC).
  2. Engage with Indigenous communities to develop and distribute information packages for OPP officers to help develop relationships with local Indigenous communities as it relates to OPP detachments located near First Nations communities.
  3. Provide increased resources to the Indigenous Awareness Training Unit to increase the number of Indigenous Awareness Training Courses offered annually including increased opportunities for officers.
  4. Provide increased resources to support the attendance of participants of the IATC in order to address capacity at detachments to support police operations.

Resources for detachments

  1. Increase for OPP Nipigon Detachment and similar detachments:
    • the number of officers both assigned to the detachment and dedicated to each shift
    • specialized training
    • resources and necessary supports for the above

Police training

  1. Consider refresher training during block training on responding to intimate partner violence calls including scenarios where both parties are separated and confirming that separating and keeping separate intimate partners is a critical de-escalation strategy.
  2. Amend Police Order 2.14 Domestic Violence/Intimate Partner Occurrence to make it clear and unambiguous that:
    1. This policy applies to all intimate partner incidents including verbal disputes where there has been no criminal offence.
    2. That intimate partners should be separated and kept separate, and not only when being interviewed.
To the Ontario Police College (OPC) and the OPP:
  1. Integrate a scenario into annual police training that draws from the circumstances of this inquest including a call for assistance to address an unwanted person, which in flight turns into a non-violent intimate partner occurrence, and where the officers are confronted with a weapon immediately upon arrival, while being mindful not to re-traumatize the officers involved in this inquest.

    Teaching points would be:

    • proper communication from dispatch
    • proper application of the Trespass to Property Act
    • proper application of the Intimate Partner Occurrence
    • mental/emotional preparedness of the responding officers
    • de-escalation techniques
    • Ontario Public – Police Interaction Training Aid
  2. Develop additional training regarding the proper application and interpretation of the Trespass to Property Act.
  3. Ensure that training at the OPC and OPP yearly re-certification training emphasizes in class and scenarios, that when police officers are dealing with a person armed with a weapon, whenever reasonable and safe to do so, that creating time and distance is a priority.
  4. Increase training of officers when dealing with persons in crisis, including but not limited to mental health and trauma.
  5. Increase emphasis of verbal and non-verbal de-escalation training for police officers as part of Basic Constable Training and annual block training.
To the Ministry of Children, Community and Social Services:
  1. Develop an approach to engage with Indigenous communities and organizations about Family Responsibility Office’s policies and programs.
  2. Improve communications with recipients and support payors with respect to their responsibilities with receiving and making support payments.
  3. Initially communicate with the payor verbally that an order has been issued for collection of support arrears and ensure that the payor understands the options available for repayment. This verbal communication should be followed by written communication with what was discussed.
To The Office of the Chief Coroner (OCC):
  1. The OCC should set targets for the completion of inquests and implement a strategy to reduce wait times to meet the targets.
  2. The OCC should make public on their web site response and actions to all coroner’s jury recommendations.
To the Ministry of the Solicitor General:
  1. Should implement a process that the Ontario Public - Police Interaction Training Aid is reviewed as to its effectiveness every five years and amended as required to keep it a living document.

August

Brubacher-Horst, Lawrence
Bouwman, Talbot
Chmielarz, Adam
 

Names of the deceased: Brubacher-Horst, Lawrence; Bouwman, Talbot; Chmielarz, Adam
Held at: virtual, Toronto
From: August 8
To: August 11, 2023
By: Jennifer Scott, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Brubacher-Horst
Given name(s): Lawrence
Age: 24

Date and time of death:  13 March 2018 at 8:17 a.m.
Place of death: 3854 Boomer Line, St. Clements, Ontario
Cause of death: Blunt force injuries of the head and neck
By what means: accident

Surname: Bouwman
Given name(s): Talbot
Age: 55

Date and time of death:  18 October 2018 at 9:17 a.m.
Place of death: 54 Main Street, Milton, Ontario
Cause of death: Multiple blunt force injuries
By what means: accident

Surname: Chmielarz
Given name(s): Adam
Age: 31

Date and time of death:  17 December 2020 at 4:32 p.m.
Place of death: St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario
Cause of death: Blunt force head trauma in a pedestrian due to motor vehicular trauma
By what means: accident

(Original signed by: Foreperson)

The verdict was received on August 11, 2023
Coroner's name: Jennifer Scott
(Original signed by coroner)

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

Inquest into the deaths of: Lawrence Brubacher-Horst, Talbot Bouwman and Adam Chmielarz

Jury recommendations
To the Ministry of Labour, Immigration, Training and Skills Development (MLITSD):
  1. It is recommended that the MLITSD consult with the Ministry of Transportation (MTO) and other interested parties on amending Ontario Regulation 213/91, “Construction Projects”, made under the Occupational Health and Safety Act, R.S.O. 1990, c.O.1 (OHSA), to require compliance with applicable guidelines and layouts contained in MTO’s Ontario Traffic Manual Book 7, “Temporary Conditions”.
  2. It is recommended that the MLITSD work with the Infrastructure Health and Safety Association and other Health and Safety Association partners to develop a joint working group dedicated to implementing strategies for communicating health and safety requirements and guidelines for construction projects, including traffic protection requirements and guidelines, to small businesses.

To the MLITSD and the Provincial Labour Management Health and Safety Committee:

  1. It is recommended that the MLITSD and the Provincial Labour Management Health and Safety Committee as appointed under section 21 of the OHSA design a feasible implementation plan to introduce a mandatory and standardized training program relating to traffic control on construction projects, similar to the “Working at Heights Training” requirements. A training program should include information and instruction regarding the traffic protection requirements under Ontario Regulation 213/91, “Construction Projects”, and applicable guidelines and layouts contained in MTO’s Ontario Traffic Manual Book 7, “Temporary Conditions”.

    1. It is further recommended that the training program as set out in recommendation number 3 shall be required for any relevant constructor, employer, supervisor and/or worker as defined in section 1(1) of the OHSA that could be reasonably seen to be responsible for traffic control at a construction project on a public way and/ or highway and/or freeway.
    2. It is further recommended that in the event of an accident or fatality related to traffic control on a construction project, all workplace parties involved in the traffic control and/ or traffic control planning must be retrained under the training program as set out in recommendation number 3.

Bailon, Miguel

Surname: Bailon
Given name(s): Miguel
Age: 50

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: August 15
To: August 17, 2023
By: Dr. John Carlisle, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Miguel Bailon
Date and time of death:  August 24, 2013 at 7:17 p.m.
Place of death: Sunnybrook Health Sciences Centre
Cause of death: blunt head trauma
By what means: accident

(Original signed by: Foreperson)

The verdict was received on August 17, 2023
Coroner's name: Dr. John Carlisle
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Miguel Bailon

Jury recommendations
To the Ministry of Labour, Immigration, Training and Skills Development
  1. Work with the Provincial Labour Management Health and Safety Committee as appointed under section 21 of the Occupational Health and Safety Act, the Infrastructure Health and Safety Association and any other relevant stakeholders to develop a joint working group dedicated to exploring and implementing approaches to ensuring "lockout and tagout" is required for machines and devices that may endanger the safety of a worker on construction projects.

Brown, Samuel Patrick

Surname: Brown
Given name(s): Samuel Patrick
Age: 18

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: August 28
To: September 7, 2023
By: Dr. David Cameron, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Samuel Patrick Brown
Date and time of death:  February 9, 2018 at 7:06 a.m.
Place of death: Brantford General Hospital
Cause of death: acute bronchopneumonia
By what means: natural causes

(Original signed by: Foreperson)

The verdict was received on August 17, 2023
Coroner's name: Dr. David Cameron
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Samuel Patrick Brown

Jury recommendations
To the Ministry of Education, Provincial and Demonstration Schools Branch
  1. That the Provincial and Demonstration Schools Branch (PDSB) of the Ministry of Education (MOE) review the availability of overnight medical resources provided to provincial and demonstration schools with overnight lodgings to ensure that schools are able to provide timely access to medical practitioners for students.
  2. For the purpose of enhancing the safety of students who reside in on-campus lodging overnight at provincial schools, that the MOE draft and implement policies and procedures to enhance/ensure the 24 hour on-call availability of medical staff for students staying in lodging.
  3. That the PDSB provide mandatory training on ableism, with particular emphasis on the dangers that medical ableism in general and diagnostic overshadowing in particular pose for people with disabilities to all staff who work in schools or classrooms with students with intellectual and developmental disabilities (IDD). Such training should be developed in collaboration with ableism experts and include instruments for identifying and assessing personal and/or internalized ableism. Each staff member will be required to take this training at least once a year.
  4. That the PDSB provide mandatory medical training on how to identify potential early symptoms of aspiration pneumonia and other potentially serious illnesses known to be common among people with IDD to all medical, classroom, and residential student support staff who work in schools with students with IDD. Each staff member will be required to take this training at least once a year.
  5. That the PDSB mandate that all schools develop and support protocols for ongoing monitoring, documenting, and interdisciplinary consultation among staff regarding noticed changes in students’ behaviour and/or medical symptoms. Such protocols should include a particular emphasis on identifying and flagging early signs and symptoms of potentially serious illness.
  6. All phone locations be equipped with signage identifying the address, including building number and phone extension, to direct emergency personal to the proper location.
  7. Ensure wheelchair accessibility at all entrances and ensure they are maintained to always allow for safe access for emergency personnel.
  8. Send annual invitations to paramedics and fire departments to attend and tour of the school to allow familiarity of the layout.
  9. Ensure the nurse supervisor is also a nurse for the purpose of medical oversight.
  10. Develop and implement a system to verify that overnight bed checks are being completed, example cameras or bar code scanning in rooms.
To the W. Ross Macdonald School (WRMS)
  1. Review and enhance Student Health Services (SHS) policies to require medical staff to give written instructions to classroom or residence staff, clearly detailing the medical surveillance required and with clear times and direction on when to return for further instruction, and how to access further medical advice.
  2. Mandate that where SHS staff (or team lead in the absence of SHS staff) take a student’s vital signs, in addition to pulse, blood pressure and respiratory rate, the oxygen saturation be measured with a portable oximeter and that all vital signs be properly documented on the medical notes.
  3. Mandate that any particular risks of injury and/or illness that a student may have (falls, choking, aspiration, recurrent infections) be noted on the student’s records, including Plan of Care. The existence and location of a Plan of Care for a specific student will be communicated in the student’s bedroom. Any action plan initiated or changed must be signed off on by all staff.
  4. Require parents or guardians to provide a yearly swallowing assessment by a speech language pathologist of any student with dysphagia and/or risk of aspiration, with the results of the assessment readily available on the student health record.
  5. WRMS to review its current practice with respect to signage regarding any special requirements to be observed for students at risk for aspiration and PDSB to review its policy.
  6. WRMS will facilitate a speech language pathologist (SLP), as provided by the parents or guardians, to observe, at a schedule established by the SLP, any student with a risk of aspiration who needs assistance of staff with eating, so they can provide advice to staff.
  7. Provide annual training or orientation to all staff about how to access medical resources provided via the school on a 24-hour basis.
  8. Draft and implement staffing policy and procedures that pair staff teams with specific groups of students in order to optimize effective communication, particularly where students are non-verbal. The staffing shall be organized to ensure that at least one of a student’s regular staff is scheduled to cover all shifts.
To the Office of the Chief Coroner.
  1. That the formulation of cause of death statements involving persons with IDD be reviewed to avoid ableist conclusions and to ensure illness or injury, where appropriate, is listed as the primary cause of death.
To the College of Physicians and Surgeons of Ontario.
  1. Working in collaboration with ableism experts, develop and offer training to doctors on ableism and medical ableism, with particular emphasis on the dangers that medical ableism, in general, and diagnostic overshadowing in particular, pose for people with disabilities. Such training should include instruments for identifying and assessing personal and/or internalized ableism.
To the College of Nurses of Ontario
  1. Working in collaboration with ableism experts, develop and offer training to nurses on ableism and medical ableism, with particular emphasis on the dangers that medical ableism, in general, and diagnostic overshadowing in particular, pose for people with disabilities. Such training should include instruments for identifying and assessing personal and/or internalized ableism.

September

Shea, William "Billy"

Surname: Shea
Given name(s): William "Billy"
Age: 27

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: September 5
To: September 8, 2023
By: Haniya Sheikh, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: William "Billy" Shea
Date and time of death:  July 23, 2019 at 10:30 p.m.
Place of death: Peterborough Regional Health Centre, 1 Hospital Drive, Peterborough
Cause of death: gunshot wound to the torso
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on September 8, 2023
Coroner's name: Haniya Sheikh
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: William "Billy" Shea

Jury recommendations
To the Ontario Police College
  1. Continue to provide specialized crisis negotiation training and education for officers in Ontario.
  2. Expand the curriculum of the Ontario Police College (OPC) crisis negotiation training program in Ontario to include further hands-on scenario training, with scenarios based on cases such as this one.
  3. Continue to provide instruction with respect to resilience and the maintenance of an officer’s own mental health when he or she is engaging in crisis negotiation.
  4. Participants in the OPC crisis negotiation training program in Ontario should be made aware of the need and opportunities for mental health care support services after an engagement.
  5. Continue to review the training for crisis negotiation, including training with respect to resilience and mental health, and reassess the curriculum on an annual basis.
  6. Develop and offer a refresher or re-training program for crisis negotiation training for officers in Ontario.
  7. Make the Canadian Police College aware of the above recommendations.
To the Government of Ontario
  1. Continue to provide adequate funding to the Ontario Police College to permit the continuation and expansion of its crisis negotiation training program and the development of refresher or re-training programs.
  2. Increase awareness of the importance of mental health support for police officers in Ontario.
To the Peterborough Police Service
  1. In consultation with current Peterborough Police Service Crisis Negotiators, regularly review and update accordingly the:
    • Peterborough Police Service Crisis Negotiation Manual
    • the Crisis Negotiation General Order ER-005
    • policy and procedure for follow-up for the mental health support of staff following any traumatic incidents
  2. Continue to provide all Peterborough Police Service crisis negotiators with crisis negotiation training by way of the Canadian Police College or the Ontario Police College.
  3. Continue to provide all Peterborough Police Service crisis negotiators with refresher training.
  4. Improve Peterborough Police Service mental health care policies and the scope of the mental health care support services that are available to assist officers in addressing the mental health challenges that arise as a result of exposure to or engagement in traumatic events during the course of their employment.
  5. Develop a confidential debriefing program for Peterborough Police Service officers involved in traumatic incidents during their employment to occur upon the conclusion of any internal, external or SIU investigation.
  6. This confidential debriefing program should aim to provide mental health support for the officers involved and ascertain ways of improving police procedures for engaging in future high-risk situations.
  7. Ensure that patrol units are aware of any high-risk "be on the lookout" (BOLO) notifications.
  8. Equip uniformed officers with recording devices to record interactions between officers and the public, where permissible under existing legislation.

Vander Wal, Wade

Surname: Vander Wal
Given name(s): Wade
Age: 44

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: September 18
To: September 27, 2023
By: Dr. John Carlisle, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Wade Vander Wal
Date and time of death:  December 3, 2019 at 7:21 p.m.
Place of death: South Huron Hospital, 24 Huron Street West, Exeter
Cause of death: gunshot wounds to the torso
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on September 27, 2023
Coroner's name: Dr. John Carlisle
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Wade Vander Wal

Jury recommendations
To the Government of Ontario:
  1. Create a recruitment and retention incentive program to recruit social workers and psychiatrists to rural Ontario communities.
  2. Investigate the development of a fourth-tier system for 911 calls, which would offer mental health as an option for a caller when asked whether fire, emergency medical services, or police are required.
  3. Investigate funding mental health supports for witnesses and families involved in a death that requires an inquest and ensure that these services are delivered using a trauma informed manner in a timely manner.
  4. Increase awareness of the mental health crisis hotline services (988). Increase public awareness of its existence.
To the Office of the Chief Coroner for Ontario:
  1. Develop a plan to ensure that inquests are carried out in a timelier manner.
  2. Make the responses and actions to all coroner-jury recommendations public on the Office of the Chief Coroner's website.
To the Ontario Ministry of Health and Long-Term Care:
  1. Increase funding to Ontario Health Teams for mental health initiatives.
  2. Conduct a review of current funding allocation and create a process that provides Ontario Health Teams with greater input on how best to allocate funding within their specific regions, given their unique needs.
  3. Review the feasibility of standing but revocable consent policies for treating physicians to communicate with other healthcare providers, a patient’s family, or designated person.
To the Ministry of Health and Long-Term Care and Ontario Provincial Police (OPP):
  1. Explore the feasibility of standing but revokable consent policies for the OPP to communicate with healthcare providers, a patient’s family, or designated person about persons involved with the OPP.
To the Huron Perth and area Ontario Health Team and the Ontario Ministry of Health and Long-Term Care:
  1. Increase funding for long-term assigned case workers for both routine and assertive case management for people diagnosed with serious mental illnesses.
  2. Collaboratively, conduct a needs-based analysis for Mobile Crisis Rapid Response Teams (MCRRT) and review current funding to ensure service demands are met across Huron County.
To the Ministry of the Solicitor General:
  1. Review approved non-lethal use of force options to determine whether any items should be added or subtracted from existing equipment.
To the Ministry of the Solicitor General and the Ontario Provincial Police:
  1. Consult with the Special Investigations Unit to clearly identify the parameters of when an officer can speak about an incident when a Special Investigations Unit investigation is ongoing (e.g., with a psychologist/psychiatrist/family member) with the goal of permitting an officer to receive the necessary health and/or mental health supports.
To the Ontario Provincial Police, Huron County, South Huron Fire Department, and Municipality of South Huron:
  1. Establish a process for regular communication between South Huron Fire Department, Ontario Provincial Police, and Emergency Medical Services, including joint training opportunities.
  2. Establish a process for consultation, debriefs, and meetings after South Huron Fire Department, Ontario Provincial Police, and Emergency Medical Services are involved in a joint call for service.
  3. Investigate and develop a process to ensure communication between the Ontario Provincial Police, Emergency Medical Services, and local Fire Departments, which may include an incident specific line protocol or shared communication equipment.
To the Ontario Provincial Police:
  1. Conduct a yearly review of “Persons Experiencing a Mental Health Crisis Checklist.” Revise and update to ensure appropriate questions are being asked and increase training to ensure adequate use.
  2. Establish a process to incorporate the circumstances surrounding inquests into annual call taker and dispatcher training, where relevant.
  3. Establish a process to ensure OPP officers provide feedback to call takers and dispatchers where there is an identified lack of full and/or timely information. Explore a policy that requires all police officers to communicate clearly and directly and apply the closed-loop communication method.
  4. Ensure completion of the Mobile Crisis Rapid Response Team Critical Policy, as to when a call taker and/or dispatcher is to dispatch an MCRRT.
  5. Provide training to call takers and dispatchers on the MCRRT Critical Policy, once implemented.
  6. Integrate a scenario into Basic Constable Training at Ontario Police College (OPC) and annual OPP block training across Ontario that draws from the circumstances of this inquest.
  7. Develop a process to integrate the circumstances of all law enforcement related inquests into training scenarios at Basic Constable Training at the OPC and annual OPP block training.
  8. Increase emphasis of mental health, de-escalation and other verbal training for police officers as part of Basic Constable Training at OPC and annual OPP block training.
  9. Explore methods to encourage the use of earpieces by OPP officers as part of their mandatory uniform.
  10. Provide additional training for officers on how to make an effective arrest following a conducted energy weapon deployment.
  11. Review the adequacy of the existing support services and implement changes where required to improve support to officers that arise because of engaging in a traumatic event. This review should include officers with lived experience.
  12. Once the Ontario Public Police Interactions Training Aid is implemented, develop a policy to collect and analyze data gathered through Use of Force Reports about the effectiveness of the Ontario Public Police Interactions Training Aid (2023). Publish a public report annually, including trends in the use of force, use of force options involved and the efficacy of the Ontario Public Police Interactions Training Aid (2023) in decreasing the number of police related fatalities.
  13. Ensure that up to date training on the use of force occurs following the implementation of the Ontario Public Police Interactions Training Aid (2023).
To the South Huron Fire Department and the Ontario Provincial Police:
  1. Collaboratively develop a process for determining communication and incident command at a scene.
To the South Huron Fire Department:
  1. Provide training to firefighters on how to respond to calls involving a person who is experiencing a mental health crisis.
To all parties mentioned above:
  1. Secure adequate funding and resources to implement these recommendations.

Ryan, Gladys Helen
Ryan, William Thomas

Names of the deceased: Ryan, Gladys Helen; Ryan, William Thomas
Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: September 18
To: October 3, 2023
By: Murray Segal, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Ryan
Given name(s): Gladys Helen
Age: 77

Date and time of death:  October 27, 2017, 11:08 p.m.
Place of death: Northumberland Hills Hospital, Cobourg
Cause of death: gunshot wound of the head
By what means: homicide

Surname: Ryan
Given name(s): William Thomas
Age: 70

Date and time of death:  October 27, 2017, 11:10 p.m.
Place of death: Northumberland Hills Hospital, Cobourg
Cause of death: multiple gunshot wounds
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on October 3, 2023
Coroner's name: Murray Segal
(Original signed by presiding officer for Ontario)

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

Inquest into the deaths of: Gladys Helen Ryan and William Thomas Ryan

Jury recommendations
  1. Ministry of Health (Emergency Health Services Branch) : To review the Ambulance Documentation Standard and the Ambulance Call Report (ACR)completion manual for paramedic services across Ontario with a view to improving how information about intimate partner violence (IPV) risk factors is flagged for hospital staff in an ACR, for example, including relevant check boxes and a comment area to note source who communicated risk factors and/or details.
  2. Ministry of Health, Ontario Hospital Association and Hospitals: Develop an appropriate mechanism on electronic triage patient records to ensure that where staff input data on abuse, that the fact it has been completed is prominently visible to the user. Incorporate safety considerations when developing the mechanisms.
  3. Ministry of Health: Develop and implement information sharing policies and protocols to enhance coordination of assessments and intervention by LHINs/HCCSS organizations and their contracted service provider organizations (including personal support workers), paramedics, police and nursing, particularly around attendance at hospital emergency departments.
  4. LHINs/HCCSS organizations and their contracted service provider organizations (including personal support workers): Review current policies and procedures to ensure they include the following:
    1. direction on how to identify IPV risk factors
    2. IPV risk assessment and risk management strategies
    3. clear guidance on when and how information regarding IPV may be shared with other health care providers, paramedics or police
  5. LHINs/HCCSS organizations and their contracted service provider organizations (including personal support workers): Review current policies to ensure they include procedures on how information about client safety, including intimate partner violence risks, is shared between service provider organizations and the LHINs/HCCSS to ensure reciprocal notification.
  6. LHINs/HCCSS organizations: Develop and implement policy guidance for staff who receive information from a service provider organization indicating a request for police assistance or for staff who are asked directly by the client for police assistance. The guidance should address the need to treat the client as a credible source of information and include a requirement to document the information and report it to a supervisor.
  7. Paramedics services across Ontario and central ambulance communication centres: Review internal information sharing protocols and work to ensure that paramedics teams have the necessary guidance and training on how and what types of information they should be sharing with colleagues who may be providing service to the same household, where operationally feasible. The policy guidance and training should include safety risks, including those related to IPV.
  8. Ministry of Health, Ontario Hospital Association and hospitals across Ontario: Consider steps to modernize the delivery of ambulance call reports to ensure that reports can be received electronically and in the timeliest possible manner to assist with patient care, and that the Ministry pursue funding options to assist hospitals with this transition.
  9. Ministry of Training, Colleges and Universities, College of Nurses, College of Physicians and Surgeons,Ministry of Health (Emergency Health Services Branch), Ontario Personal Support Workers Association and Regulators of Health Professionals who provide support in the home: Develop elder abuse and IPV education and include as a mandatory component of training for personal support workers (and regulated health professionals who provide support in the home), paramedics, nurses and doctors.
  10. Ministry of the Solicitor General and all police services in Ontario: Review current police training at the Ontario Police College (basic constable training) and ongoing professional development training to ensure the inclusion of elder abuse and IPV risk assessment training, and how they intersect.
  11. LHINs/HCCSS: Revise current mandatory abuse prevention, recognition and response training to address IPV as a specific form of abuse including in the elderly community and ensure all staff who have contact with clients and the supervisors from whom staff may seek advice receive this training.
  12. LHINs/HCCSS organizations: Require that service provider organizations contracted to deliver home and community care services provide the following training to their staff who have contact with clients, and the supervisors from whom staff may seek advice:
    1. direction on how to identify IPV risk factors
    2. IPV risk assessment and risk management strategies
    3. communicating information with others within the organization and with the LHINs/HCCSS to ensure a coordinated response plan.
  13. Paramedics services across Ontario: Provide training on risk factors related to IPV and seniors to all paramedics, paramedic supervisors, chiefs and deputy chiefs.
  14. Ministry of Health: Work in consultation with all regional LHINs/HCCSS to develop materials on structured risk assessment and risk management strategies as part of a plan of care to deal with IPV in the elderly population.
  15. Ministry of Health: Work in consultation with all regional LHINs/HCCSS to establish minimum training standards for community care service providers, including PSWs, on IPV risk assessment and IPV risk management strategies when caring for the elderly population
  16. Ministry of Health: Work in consultation with all regional LHINs/HCCSS to establish minimum training standards for community care service providers, including PSWs, on identifying IPV risks and how to communicate them to supervisors to ensure the development of a coordinated care plan which will ensure client safety.
  17. Ministry of Health: Develop policies and procedures to assist health care professionals in flagging cases of IPV in the elderly population to ensure a coordinated and integrated approach to providing appropriate health care services.  Provide ongoing funding directed to training health care professionals including care service providers including personal support workers, regulated health professionals and paramedics.
  18. Hospitals in Ontario, paramedic services, LHINs/HCCSS and other members of regional situation tables to develop, in collaboration with local IPV agency/agencies, training and resources on identifying IPV risk factors, responding to victims of IPV, having regard to the circumstances and dynamics of the region and the community.
  19. Hospitals in Ontario: Develop in collaboration with local IPV agency/agencies a robust partnership agreement to respond to the needs of local women victims of IPV who access care through the hospital.
  20. Ministry of Health, Hospitals: Review and ensure that structured screening tools are available to assist hospital triage staff in identifying IPV concerns to ensure patient and staff safety. Develop mandatory training on these screening tools which may be delivered in an interdisciplinary fashion with other health service providers, such as paramedics. Ministry of Health to provide funding to support the recommendation.
  21. Ministry of Health, Hospitals, all Police Services in Ontario: Collaborate on the development and implementation of violent/live fire protocols to clearly identify the roles and responsibilities for ensuring staff and patient safety and to ensure critical information is shared to responding officers immediately. Annual mandatory interactive training to be provided to staff. Joint experiential exercises to be conducted regularly with representatives from all applicable departments, with an invitation to police and paramedics services.
  22. To the Government of Ontario, Ministry of Solicitor General, Ministry of Health, Ministry of Children, Community and Social Services, Ministry of Seniors: Review and provide sufficient funding required for the implementation of the above recommendations directed to the development of screening and risk assessment tools and training of health care professions and police
  23. To Government of Ontario: Provide seed funding through Elder Abuse Prevention Ontario to develop a local network on elder abuse prevention, including intimate partner violence with the elder population.
  24. To Government of Ontario: Ensure coordination of efforts take place between government ministries in charge of violence against women services (Ministry of Children, Community and Social Services) and senior services (Ministry for Seniors and Accessibility).
  25. Ministry of Health: Review opportunities through evolving Ontario health care models and/or regional situation tables for enhanced information sharing across the continuum of care to assist vulnerable, equity seeking/equity deserving groups of patients/clients in navigating and accessing relevant supports and resources in the community. Following review, find funding to support, and provide guidance on implementation of best practices. 
  26. LHINs/HCCSS: Develop and implement a safety screening form to be completed at the time of the initial assessment by care coordinators. The safety screening form will include inquiries on firearms or any weapons in the home, and any identified risks will be shared with home care service providers as it becomes a workplace.
  27. LHIN/HCCSS: Upon being advised that their clients are the subject of a Situation Table discussion, consult with applicable home care service providers to receive information and input to assist in addressing the acutely elevated risk. Home care service providers should also be advised of the outcome of Situation Tables involving their clients to ensure their ability to participate in the coordinated response.
  28. Office of the Chief Coroner: Amend the definition of homicide in the classifications of death in the Coroner’s Rules to include a death caused by another person where the person believed that there was an imminent threat to the safety of themselves and/or others.
  29. LHINs/HCCSS organizations, Hospitals in Ontario, paramedic services: Establish an educational review committee that is responsible for implementing an audit and review process for related policies, procedures and training as required to ensure training is up to date, completed, tracked, and recorded for all employees at least annually.
  30. Office of the Chief Coroner: 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.
  31. Government of Ontario: 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.
  32. Government of Ontario: Formally declare intimate partner violence as an epidemic.

Gratton, Teresa Michelle

Surname: Gratton
Given name(s): Teresa Michelle
Age: 50

Held at:  25 Morton Shulman Avenue, Toronto
From: September 18
To: October 6, 2023
By: Dr. David Eden, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Teresa Michelle Gratton
Date and time of death:  October 30 , 2017, 9:25 a.m.
Place of death: Milton District Hospital, Milton
Cause of death: complications of cardiorespiratory arrest due to mixed toxicity of methadone, other prescribed drugs and ethanol, with ischemic/hypertensive heart disease as a contributing factor
By what means: accident

(Original signed by: Foreperson)

The verdict was received on October 6, 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: Teresa Michelle Gratton

Jury recommendations
Recommendations directed to the Ministry of the Solicitor General (SOLGEN)

Opioid Agonist Therapy (OAT)

  1. SOLGEN shall continue to provide OAT) to inmates/patients who will benefit from it, subject to the most current policies and current standards which promote safe OAT.
  2. Consideration should be given to advising nursing staff and correctional officers to make enhanced observations of inmates recently initiated on methadone for signs of methadone toxicity, to document their observations, and to bring them to the attention of the physicians and health care unit management. Correctional officers should be provided with training and education on the signs of methadone toxicity.
  3. SOLGEN corporate health care shall undertake a review of the optimal way medication should be dispensed to inmates to allow the nursing staff responsible for dispensing medication to have the optimal opportunity to make observations and assess inmates. For example, consideration should be given to whether dispensing medication through a door hatch affords nursing staff an adequate opportunity to make observations and assess the inmates medically.
  4. Consideration should be given to anonymizing the known circumstances of Ms. Gratton’s health and subsequent death and sharing those with all physicians and healthcare staff who are providing care within SOLGEN as an illustration of the importance of:
    1. considering Centre for Addiction and Mental Health guidelines for conservation initial dosing given the identified risk factors for methadone toxicity, including periods of opioid use when exercising their clinical judgment
    2. the information which may be provided by interpreting urine drug screen urine drug test results when initiating methadone
    3. the importance of assessing for signs of methadone toxicity during the initiation phase.
  5. SOLGEN corporate health care should explore the opportunities to access community-based health information systems that track which methadone has been dispensed in the community to individuals coming in custody. This information can be considered with making clinical decisions about OAT including dosing while the inmate/patient is in custody. This further promotes continuity of health care.
  6. Once the electronic health care record system within SOLGEN’s provincial correctional centers is operational, the possibility of information sharing with community-based medical information systems that track what methadone has been dispensed to the individual should be explored. This sharing of information may enhance the individual’s continuity of medical care.
  7. SOLGEN’s corporate health care unit should explore opportunities to improve the mental health care services provided to the staff of correctional facilities who have been involved with, or impacted by critical incidents that have occurred within the correctional facility, including but not limited to correctional officers, nurses, physicians and other healthcare staff.
  8. SOLGEN should explore opportunities to improve the mental health care services provided to inmates who have been involved with, or impacted by critical incidents which have occurred within the correctional facility.
  9. Ensure all correctional facility staff have ease of access to medical safety equipment in case of emergencies, i.e. keys, keycards, etc. for access to medical equipment.
Urine drug screen/urine drug test (UDT)
  1. Physicians practicing within SOLGEN 's provincial correctional centres/facilities when considering initiating an inmate/patient on OAT shall be mandated to initiate a UDT with the inmate/patient prior to commencing OAT. In the event of exceptional circumstances or if the inmate/patient declines or refuses to submit to testing, this information shall be thoroughly documented and shall be taken into consideration when determining the medical treatment plan.
  2. Both nurses and physicians practicing within SOLGEN 's provincial correctional centers/facilities shall be able to administer a UDT and read the results of said test. However, only physicians practicing within UDT’s provincial correctional centers/facilities should be mandated to interpret the results of the UDT. The interpretation of UDT results can provide valuable information, including confirming periods of opioid abstinence which may have reduced the inmate/patient’s tolerance to methadone. This can inform clinical judgment regarding how OAT should be initiated.
  3. The Health Care Services Policy and Procedure Manual related to OAT should be reviewed and updated to include the above recommendation clarifying that both the physicians and nurses shall be able to administer and read the UDT results but that only the physician shall interpret these results.  The interpretation of the UDT results and any information clarifying how those results were considered in the physician’s clinical judgment when initiating OAT shall be documented within the inmate/patient’s health care record.
  4. Until the implementation of SOLGEN’s electronic health care record system, a procedure should be established within all provincial correctional facilities to ensure that any nurse who is dispensing methadone to an inmate/patient has access to the medication administration record and shall be alerted that the UDT is required to be collected and interpreted prior to the administration of methadone.
Call button and incident response
  1. The Vanier Centre for Women should undertake a review of the Institutional Inmate “Call Button” system to determine:
    1. Ii there is a need to alert inmates upon admission under which circumstances they should utilize the call button while they are secured within their cells
    2. if there needs to be further direction provided to the correctional officers concerning the priority which should be given to responding to activated call buttons given that it may be a medical emergency
    3. if there can be any improvements made to the technology, such as an intercom system so that the inmates secured in their cells can alert the correctional officers to the nature of the circumstances, so the correction officers can respond with appropriate priority
  2. The SOLGEN should consider, using the circumstances that confronted the correctional officers and registered nurses when responding to the October 30, 2017 medical emergency within the cell, as the basis of “scenario based” cross-training in responding to nighttime/lockdown in-cell medical emergencies of an unknown nature. This cross-training should involve both correctional officers and health care staff.
Electronic health care record
  1. The implementation of an electronic health care record system SOLGEN’s provincial correctional centers/facilities should be continued and fully implemented as soon as feasible to do so. Any such system should allow all physicians and health care staff to access all portions of an inmate/patient’s health care record whenever they are interacting with an inmate/patient.
Information sharing
  1. Consideration should be given to promoting the formal and documented sharing of information between SOLGEN’s health care staff and the social workers, as it relates to providing optimal health care to persons in custody while respecting the privacy interests and requiring the consent of the individual.
Review of medical incidents
  1. SOLGEN’s health care unit should continue its efforts to establish a formal and proactive internal process for reviewing the circumstances of all inmate deaths, in a timely manner using a healthcare perspective. The purpose of this internal review should be to identify if there were any deficiencies in the health care provided to the deceased inmate and to identify any required steps to improve the health care provided to prevent other inmate deaths. This internal review should be distinct from the Correctional Services Oversight and Investigations’ investigation and should not await the outcome of any coroner’s inquest.
  2. Where an issue concerning the Ministry of the Solicitor General healthcare is identified as a factor in an inmate death and an Inquest Jury makes recommendations to avoid similar deaths, consideration should be given to sharing the details of the case with other healthcare providers in all Provincial Correctional Centers/Facilities, to prevent a recurrence of similar deaths.
Canada/Ontario Immigration Detention Agreement
  1. Pending the termination of the agreement between the Canada Border Services Agency (CBSA) and SOLGEN in June 2024, SOLGEN shall make every effort to comply with the terms of the agreement, especially in relation to minimizing the co-mingling of immigration detainees with inmates and to ensure that CBSA be notified if an immigration detainee is placed on suicide watch.
  2. Pending the termination of the CBSA and SOLGEN’s agreement in June 2024, SOLGEN shall take steps to ensure that the provisions of the agreement are known by all provincial correctional centre managers and that the agreement document can be readily referenced.
Recommendations directed to both SOLGEN and to the Office of the Chief Coroner and Ontario Forensic Pathology Service
  1. Once electronic health care record system within the provincial correctional centers becomes operational, SOLGEN and the Office of the Chief Coroner should jointly consider establishing a process of providing the coroner investigating the death of the person detained in custody direct access to the deceased’s entire electronic health care record to enable the collection of relevant information in a timely manner.
  2. If a death occurring within a SOLGEN provincial correctional centre and health care issue is identified as a factor within the death, the Office of the Chief Coroner and SOLGEN should collaborate to ensure that a copy of the autopsy report, toxicology and coroner’s report is provided directly to SOLGEN’s corporate health in addition to the Corrections Services Oversight and Investigations at the earliest opportunity for every inmate death, including any subsequent revisions.
Recommendations directed to the Office of the Chief Coroner and Ontario Forensic Pathology Service
Hospital/ ante-mortem blood
  1. During the investigation of deaths where the circumstances indicate drug toxicity may be a factor, the coroner should attempt to preserve and seize antemortem/hospital blood samples at the earliest opportunity. The coroner should further document whether or not samples were sought and if a sample was available for seizure or was unavailable.
  2. The ongoing education of coroners and forensic pathologists should continue to highlight the valuable information that may be provided by an analysis of antemortem/hospital blood samples when investigating deaths that may have a toxicological component. Timely steps should be taken to preserve those samples so that they are not destroyed.
Correctional records
  1. when investigating a death that has occurred in any provincial correctional centers/facilities, coroners should be encouraged to promptly obtain any and all relevant information as it pertains to the deceased inmate’s records from the institution. These records should include the complete health care record and any medication administration record. If an autopsy will be completed, the coroner should provide a copy of these records to the forensic pathologist as soon as possible.
Information sharing
  1. The Office of the Chief Coroner and Ontario Forensic Pathology Service should continue to promote the benefits of direct consultation and exchange of information amongst the coroner, regional supervising coroner, forensic pathologist, and forensic toxicologist in complex cases when determining the medical cause of death. The importance of providing the forensic toxicologist with all available information concerning the prescription history, medication administration record, and any known illicit substances consumed is so that the forensic toxicologist can further focus their analysis appropriately.
  2. The Office of the Chief Coroner and the Ontario Forensic Pathology Service should continue to improve their electronic record management capabilities in order to facilitate effective and timely information sharing between Coroners and Forensic Pathologists during a death investigation involving autopsies.
  3. Within their improved electronic information sharing system, the Office of the Chief Coroner and Ontario Forensic Pathology Service should consider if there exists any further opportunities to ensure that all relevant information in determining the cause and circumstances of the death is obtained and shared in a timely manner. This may include procedures or technologies to alert all death investigation team members when information, which is initially determined to be potentially relevant has not been received or shared (e.g., a “electronic tickler” or follow-up notification.)
  4. The Office of the Chief Coroner, namely the regional supervising coroner, who chairs any convened case review meeting, should continue to include all persons involved in the death investigation including the forensic toxicologist in case conferences requested by the coroner and/or pathologist and distribute the minutes to all parties in attendance.
Option for peer review
  1. If, within the death investigation for a person who died while in custody, there is a natural cause of death determined, requesting a peer review of the cause of death should still be considered an option to determine if a mandatory inquest is required.

Shaw, Ozama

Surname: Shaw
Given name(s): Ozama
Age: 15

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: September 26
To: October 4, 2023
By: Bonnie Goldberg, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ozama Shaw
Date and time of death:  August 26, 2017, 11:07 a.m.
Place of death: The Hospital for Sick Children, 170 Elizabeth Street, Toronto
Cause of death: complications of gunshot wound to torso
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on October 4, 2023
Coroner's name: Bonnie Goldberg
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Ozama Shaw

Jury recommendations
To the Ministry of the Solicitor General:
  1. The Ministry of the Solicitor General should review the “police challenge” with respect to its efficacy in securing compliance in a variety of circumstances, including with young persons and young adults. This should include a review of the literature and alternate approaches considered in other jurisdictions.
To the Special Investigations Unit:
  1. The Special Investigations Unit should utilize a trauma-informed and culturally competent approach when informing parents, guardians and immediate family of the outcome and findings of an investigation involving the death of their family member.
To the Office of the Chief Coroner of Ontario:
  1. The Office of the Chief Coroner of Ontario should consider conducting inquests in a timelier manner from the date of the death.
To the Peel Regional Police:
  1. The Peel Regional Police 911 Operators should ask callers regarding their impressions of the mental state of the subject of their call and relay those impressions to responding officers.

October

Gerarts, John Francis

Surname: Gerarts
Given name(s): John Francis
Age: 57

Held at:  virtual, Toronto
From: October 3
To: October 3, 2023
By: Dr. David Creery, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: John Francis Gerarts
Date and time of death:  November 26, 2017, 11:15 p.m.
Place of death: St. Michael’s Hospital, Toronto
Cause of death: atherosclerotic hypertensive heart disease
By what means: natural

(Original signed by: Foreperson)

The verdict was received on October 3, 2023
Coroner's name: Dr. David Creery
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: John Francis Gerarts

Jury recommendations
To Toronto Community Housing Corporation (TCHC)
  1. We recommend that TCHC implement a clear and transparent process regarding the timely follow up of complaints by residents (such as noise complaints etc.) including how the concern will be addressed.
  2. We recommend that TCHC ensure that security officers and other authorized persons can access locations quickly in circumstances where they have an individual in their custody.

Jefferson, Mark

Surname: Jefferson
Given name(s): Mark
Age: 48

Held at:  virtual, Toronto
From: October 16
To: October 19, 2023
By: Dr. John Carlisle, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Mark Jefferson
Date and time of death:  November 12, 2019 at 7:05 p.m.
Place of death: 5th Lake Road and County Road 14, Township of Stone Mills, County of Lennox and Addington, Enterprise, Ontario
Cause of death: gunshot wounds of torso
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on October 19, 2023
Coroner's name: Dr. John Carlisle
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Mark Jefferson

Jury recommendations
To the Ontario Provincial Police
  1. Implement a policy requiring that, in respect of any event, regardless of the event type or priority, involving the indication, display, threatened use of or use of any type of weapon, the dispatcher must ask the officer to confirm that the officer heard the information concerning the weapon, and the officer must so confirm.
  2. Continue to follow the 28 June 2023, Provincial Communications Centre standard operating procedure requiring that a minimum of two officers be dispatched to any event, regardless of the event type or priority, involving the indication, display, threatened use of or use of any type of weapon.
  3. Continue to require that the responding officer who is first on scene at an event involving the indication, display, threatened use of or use of any type of weapon, await the arrival of one or more additional officers before engaging with the person or persons involved in the event unless there is a perceived risk of harm requiring immediate intervention by a single officer.
  4. Continue to require that in all written electronic dispatches sent to an officer’s Mobile for Public Safety application regarding an event involving the indication, display, threatened use of or use of any type of weapon, the key words including “weapon”, “gun”, or other involved weapon are highlighted in a bright colour that is visibly distinct from the background colour of the screen of the officer’s mobile workstation to highlight that the event involves a weapon.
  5. Increase the number of training hours for mental health crisis and de-escalation in the annual block training and include realistic, interactive scenarios.
To the Government of Ontario
  1. Investigate funding mental health supports for families involved in a death that requires an inquest and ensure that these services are delivered in a timely and trauma-informed manner.

Li, Yao Tuan
Moniz Rego, Quim
Mensen, John

Names of the deceased: Li, Yao Tuan; Rego, Quim Moniz; Mensen, John
Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: October 16
To: October 20, 2023
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Li
Given name(s): Yao Tuan
Age: 45

Date and time of death:  November 27th, 2014, at 3:08 p.m.
Place of death: 62 Sunnypoint Crescent, Toronto
Cause of death: blunt force chest trauma with traumatic asphyxia
By what means: accident

Surname: Moniz Rego
Given name(s): Quim
Age: 22

Date and time of death:  October 27, 2017
Place of death: Hamilton General Hospital, Hamilton
Cause of death: craniocerebral blunt trauma
By what means: accident

Surname: Mensen
Given name(s): John
Age: 57

Date and time of death:  July 3, 2018 at 3:35 p.m.
Place of death: St. Michael’s Hospital, Toronto
Cause of death: crush injuries to torso
By what means: accident

(Original signed by: Foreperson)

The verdict was received on October 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 deaths of: Yao Tuan Li, Quim Moniz Rego and John Mensen

Jury recommendations
To the Government of Ontario:
  1. Develop a mandatory certification system for builders who undertake residential renovation projects. The certification system should be directed at ensuring competency in the Ontario Building Code and should apply to any project that requires a building permit. The certification system should be developed in consultation with the Ministry of Municipal Affairs and Housing, Ministry of Labour, Immigration, Training and Skills Development, municipal building departments, and other stakeholders.
  2. The certification system referred to in Recommendation 1 should be reflective of most recent edition of the Ontario Building Code.
  3. Permits for residential projects should require at least one worker with mandatory certification on site at all times.
  4. All builders should be encouraged to have this certification.
To the Special Investigations Unit:
  1. Implement the proposed amendments to the Ontario Building Code by calendar Q2 of 2024 that would require:
    1. an engineer to design the foundation of a building if underpinning of the foundation is to be undertaken
    2. an engineer to review the construction of a foundation where underpinning of the foundation is to be undertaken
  2. Amend the Ontario Building Code to require an engineer to develop a process to maintain the stability of a foundation while underpinning work is being performed.
  3. Amend the Ontario Building Code to require a building permit and inspection if underpinning of a foundation is to be undertaken.
  4. In consultation with MLITSD, develop strategies to provide home builders with information about applicable health and safety regulations when they apply for building permits.
  5.  Implement an advisement level system similar to the MLITSD to encourage inspectors to notify builders of potential/impending hazards outside of immediate inspection scope of work:
    • Level 1 Forthwith Advisement
      • small building code concern
      • recorded on file
    • Level 2 Timed Advisement
      • larger concern
      • recorded on file
      • return at follow up date to confirm concern was corrected
      • mandatory timeline to correct infraction, otherwise escalated to level 3
    • Level 3 Stop Work Advisement
      • becorded on file
      • notify Occupational Health and Safety Act/MLITSD as required
      • building must halt until infraction corrected

Kyereh, Douglas Amankona

Surname: Kyereh
Given name(s): Douglas Amankona
Age: 35

Held at:  virtual, Toronto
From: October 30
To: November 17, 2023
By: Dr. Mary Beth Bourne, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Douglas Amankona Kyereh
Date and time of death:  June 13, 2016
Place of death: Credit Valley Hospital, Mississauga
Cause of death: methanol and cocaine toxicity
By what means: accident

(Original signed by: Foreperson)

The verdict was received on November 17, 2023
Coroner's name: Dr. Mary Beth Bourne
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Douglas Amankona Kyereh

Jury recommendations
Toronto Transit Commission (TTC)
  1. Review existing training of TTC supervisors and TTC Control Center/Central Information System (dispatch), with a view to enhancing their ability to recognize symptoms of potential medical issues and consider more specifically a checklist of symptoms, developed in collaboration with a medical professional. Relevant staff should be trained on the checklist and consider when assessing the state of a passenger.
  2. The training should include consideration of the fact that a passenger who has remained non-rousable for an extended time, despite auditory stimuli, may be experiencing a medical emergency and emphasize the importance of conveying such information to transit control, as a way of ensuring the most appropriate response.
  3. Continue efforts with the TTC Diversity Department to ensure that policy and training provided to frontline staff, supervisors, and Transit Control (dispatch) reflect an approach that is trauma informed and anti-racist.
  4. Issue a (yearly) reminder to all TTC frontline staff and (customer facing) supervisors of the policy not to physically touch passengers and review the appropriate de-escalation policies.
Toronto Police Service, and all police services in Ontario
  1. Circulate a reminder to all police officers engaged in report writing for show cause hearings that emphasizes the importance of all reports and recommendations being factual, objective, professional, and free from editorial comments, such as: assumptions, speculation, stereotypes and/or arbitrary views of the author.
  2. Provide training to police officers on appropriate report writing and implement a review, or quality control, system to ensure that all show cause reports are reviewed and signed by a senior officer prior to reports being finalized and attached to the Crown Brief. The review will ensure all narratives and recommendations are factual, objective, professional, and free from editorial comments, such as: assumptions, speculation, stereotypes and/or arbitrary views.
Ministry of Solicitor General, Toronto Police Service, and all police services in Ontario
  1. Develop a case study, in collaboration with medical experts, for training purposes, utilizing the specific circumstances of Mr. Kyereh’s death, that emphasizes the potential significance of the various symptoms he presented and reported. The case study will emphasize the consideration of immediate medical intervention, and/or the need to triage the patient to the hospital. All people interacting with a prisoner should participate in this training.
  2. Collaborate with relevant stakeholders on the development and implementation of health assessment protocols at the time of transfer to the receiving institution, to clearly reinforce the roles and responsibilities for ensuring the timely identification of health risks, and to ensure critical information is recorded and shared, both written and verbally, with receiving officers immediately upon transfer. Consider involving a registered nurse to observe the prisoners arrival at the Admission and Discharge unit to perform a visual assessment in order to triage urgent health risks.
  3. Develop training to be provided to both operations and healthcare staff emphasizing specific observations about a prisoner at the time of hand off that should result in an immediate health care assessment. Joint experiential exercises should be conducted regularly (for example, mandatory during onboarding and annual renewal) with representatives from all applicable departments. Consider inviting relevant police services to this training. This training should include, the following: comprehensive health screening process for prisoners upon admission, including mental health assessments, to identify any pre-existing conditions or potential health risks.
  4. Continue to ensure that training is provided to all levels of police and correctional services including: police officers, court officers, correctional officers, supervisors, and executives. This training will be trauma-informed, intersectional, address anti-racism, and should be mandatory. Trauma-informed policing is a form of educational training for police to interact with community members with the assumption that they have experienced trauma. This can help to eliminate unnecessary harm. This training should be accompanied by practical tools to operationalize trauma-informed policing. This training should highlight:
    • Trauma-informed services and practices are best described as understanding the psychological and physiological impacts of trauma in a strengths-based framework. Having trauma-informed services may provide staff with the skills to identify and address issues early on to work towards getting the necessary supports for clients.
    • When encountering someone who appears to be experiencing symptoms of trauma, law enforcement must first address the victim's safety and security needs.
  5. Consult with relevant stakeholders, including experienced front-line staff, to establish a recurring (for example, quarterly) review process of the current information sharing procedures during transfers between organizations. For example, between Toronto Police court service officers and correctional staff in the admitting and discharge areas. The review process should include an analysis of success metrics to track progress and inform any necessary improvements. These procedures should ensure that all relevant information, inclusive of the proposed Kyereh form, is shared among the parties at the time of transfer of custody of a prisoner.
Toronto Police Service and Toronto Police Court Services Operations, and all police services in Ontario
  1. When a Justice of the Peace or Justice directs that a warrant of remand be marked for medical attention, the court officer, or designate, should make reasonable inquiries through crown or defence, as to the specifics and urgency of the court direction. The court officer should document these details in their notebook, and in the proposed Kyereh form, and notify the relevant supervisor on duty. The supervisor should ensure those details are acted on as appropriate, including ensuring that said details are highlighted for the sergeant and/or supervising officer at the receiving correctional institution to ensure proper consideration and assessment occurs, prior to acceptance of custody at the receiving institution. If at any time, the court officer or designate identifies a potential medical emergency, they should be empowered to contact EMS.
  2. Amend CRT 13-02 (Memorandum Books) to require court officers to record, during each tour of duty, any placement into a dry cell, and any observable symptom or report of any symptom made by any prisoner. In addition to any recording, immediately report same to a supervisor. This amendment should be added to the TPS 13-17 for Notes and Reports.
  3. Conduct a feasibility study on retaining a medical professional onsite at the courthouse and/or police station.
The Ministry of the Solicitor General, the Toronto Transit Commission, the Toronto Police Service and all police services in Ontario
  1. The Ministry of the Solicitor General will work with the Toronto Police Service to create a hand-off form for operational staff transferring custody of a prisoner. This form will document inmate health changes during their time in custody inclusive of: police, court services, and correctional facility. This should include the symptom checklist and training that was recommended for the TTC. This is intended to inform all personnel involved in the care and custody of the prisoner, including medical personnel. Documentation to commence upon arrival, during custody, through to departure of police custody, noting whether symptoms have improved, worsened, or remained the same, and will include free text space for observations and the name and contact information of the observer. This form is to follow the prisoner at each transfer. Consider calling this form The Kyereh Form.
  2. Continue efforts to apply a diverse and inclusive lens to ensure that institutional anti-racism policies promote active efforts to eliminate all forms of racism. These policies should be developed in consultation with local Black and racialized communities.
    The stakeholders should also provide training to all members, with a particular focus on executive leadership. This training should include specific biases regarding Black and other racialized communities.
  3. Ensure that the institutional policies addressing anti-racism have clear and transparent consequences in the event of a breach in a manner that complies with provincial labour and employment laws including collective agreements.
  4. Continue training for all front-line staff, on what to look for regarding mental health problems.
  5. Additional training on life threatening medical conditions and when to escalate care.
Ministry of the Solicitor General
  1. If there are any observations that cause concern for the prisoner’s health, staff that come in contact with the prisoner should notify the supervisor and/or medical staff immediately, and then ensure the unit cards/OTIS are updated, so that any subsequent staff are able to view those updates and act on them if necessary.
  2. Amend the suicide prevention checklist to include a third column of “no response” to reflect answers to questions that a prisoner did not in fact provide a response to. Add a free text section for observations or comments.
  3. Conduct regular health and safety audits within correctional facilities, with a specific focus on the medical care provided to prisoners, to identify areas for improvement and ensure compliance with established standards.
  4. Foster collaboration between correctional facilities operational staff and healthcare professionals. The goal is to improve communication and understanding the needs of each party in order to address the health requirements of prisoners.
  5. Develop clinical training for nurses that outline baseline competencies associated with correctional facilities. Consider making this a mandatory qualification.

November

Barron, Dale

Surname: Barron
Given name(s): Dale
Age: 55

Held at:  virtual, Toronto
From: November 14
To: November 16, 2023
By: Dr. Richard McLean, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Dale Barron
Date and time of death:  May 5, 2018, 4:51 a.m.
Place of death: Hamilton General Hospital
Cause of death: hypoxic ischemic encephalopathy
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on November 16, 2023
Coroner's name: Dr. Richard McLean
(Original signed by presiding officer for Ontario)

Inquest into the death of: Dale Barron

Jury recommendations

The jury agrees with the joint recommendation, with the included modifications:

  1. For the Ministry of Solicitor General to consider providing training to correctional officers on the use of bag valve mask ventilation as an extension of current CPR modalities.
  2. For the Ministry of Solicitor General to consider reassessing suicide risk when known risk factors emerge such as change in liberty or family matters.
  3. For the Ministry of Solicitor General to give consideration to developing a structured incident reporting form to ensure that critical data points are documented.

Pinto, Luis

Surname: Pinto
Given name(s): Luis
Age: 44

Held at:  virtual, Toronto
From: November 14
To: November 16, 2023
By: Dr. Robert Boyko, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Luis Carlos De Oliveira Pinto
Date and time of death:  May 25, 2013, 4:26 p.m.
Place of death: St. Michael's Hospital, 30 Bond Street, Toronto
Cause of death: crush injuries of torso
By what means: accident

(Original signed by: Foreperson)

The verdict was received on November 16, 2023
Coroner's name: Dr. Robert Boyko
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Luis Pinto

Jury recommendations
To the Ministry of Labour, Immigration, Training and Skills Development
  1. Mandate under the Occupational Health and Safety Act regulations that curb making machines be equipped with a backup camera system that also shows, if possible, the ground below the vehicle.
  2. Mandate under the Occupational Health and Safety Act regulations that workers who deliver construction equipment to construction sites, and their employers, acknowledge on an annual basis the requirements enumerated in section 104 of the, Construction Projects Regulation, 213/91 and maintain a record of these attestations
  3. That the Ministry of Labour work with its safety partners to ensure that a province-wide bulletin and/or public awareness campaign is issued forthwith, specifically targeting transport drivers who deliver heavy equipment to construction sites and their respective employers, re-emphasizing the requirements and importance of section 104 of the Construction Projects Regulation, 213/91.
  4. That the Ministry of Labour work with its safety partners to ensure that a province-wide bulletin and/or public awareness campaign is issued forthwith to advise about the risk of using trailers that are not appropriate for the heavy machinery that they are carrying. This bulletin or campaign should include examples of best practices (preferably with diagrams), including an example of a curb making machine with offset wheels.
To the Provincial Labour-Management Health and Safety Committee (PLMHSC)
  1. That the PLMHSC review the requirement to have an operating manual available on a construction site and consider the feasibility of requiring that a copy of the operating manual to be kept with the equipment for ease of reference by the operator who delivers the equipment to the site.
  2. That the PLMHSC and any of its partners, including the heavy civil committee, review the adequacy of training for drivers/operators who deliver heavy construction equipment to construction sites, targeted specifically on the safe operation of road-making equipment during loading and off-loading on construction sites.

Ferreira, Nelson

Surname: Ferreira
Given name(s): Nelson
Age: 44

Held at:  virtual, Toronto
From: November 14
To: November 20, 2023
By: Dr. John Carlisle, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Nelson Ferreira
Date and time of death:  May 21, 2015, approximately 7:12 a.m.
Place of death: 169 Enterprise Boulevard, Markham
Cause of death: multiple blunt force trauma
By what means: accident

(Original signed by: Foreperson)

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

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

Inquest into the death of: Nelson Ferriera

Jury recommendations
To the City of Markham:
  1. The City of Markham will review its municipal access agreements with utility companies to consider:
    1. a requirement that utility companies provide product specifications and/or safety information about grade- level utility boxes on municipal rights of way to the municipality and others
    2. a requirement that utility companies consider marking new grade level vault covers being installed with:
      1. load tolerance and year of manufacture, or
      2. additional warning language and/or graphic that alert of the hazards of operating heavy machinery on or over the cover
To the Ministry of Labour, Immigration, Training and Skills Development (MLITSD):
  1. Review and consider amending construction or training-related regulations to establish provincial standards for certifying elevating work platform (EWP) trainers and the content for EWP training. Such training shall include content regarding the danger of grade level or flush to grade utility vault covers, the use of a signal person, and appropriate measures to protect work surfaces. In addition, consider adding a requirement that users, in addition to operators, have training on the EWP prior to use.
  2. Develop safety guidelines and training for use of elevating work platforms in the construction industry, including:
    1. training for signal people regarding the danger of grade level or flush to grade utility vault covers
    2. training for users and operators to identify area hazards before using the machinery
  3. Amend existing Construction Sector Hazard Alert posted on MLITSD website, titled “Loading Limitations of Utility Service Covers,” by updating guidance on directing an inspection of the area around any grade level service cover, and taking appropriate measures, which could include: use of a signal person; appropriate covering of the utility vault or other measure; do not drive near or over a cover wherever possible since heavy machinery may exceed the load bearing capacity of the cover as it may not always be possible to determine or guarantee the load capacity of the cover.
To Canadian Standards Association (CSA):
  1. Review existing safety guidance for using EWP including CSA Standard B354.2 for Self-Propelled Elevating Work Platforms, in s. 6 “safe operating practices”, to require a signal person be used when moving an EWP; provide information respecting the potential hazard of a grade level cover. Hazard information should include the risk of operating heavy machinery on or near a grade level cover.
To Infrastructure Health and Safety Association:
  1. Review existing safety guidance for construction industry in Ontario in its Construction Health and Safety Manual for using EWP to require a signal person be used when moving an EWP during its operation; provide information respecting the potential hazards of a grade level cover and taking appropriate measures. Hazard information to include the risk of operating heavy machinery on or near a grade level cover.
To Bell Canada & other utilities companies in Ontario:
  1. Consider marking new grade level vault covers being installed with additional warning language/ graphic to alert of the hazards of operating heavy machinery on or over the cover.

    Consider marking new grade level vault covers being installed with the load tolerance and date of manufacture.
To utility companies:
  1. That utility companies operating in Ontario follow Bell's updated practice by implementing and/or reinforcing internal policies and procedures to specify a minimum strength requirement of 33,750 lbs. (Tier 22) when a grade level utility cover is installed.

Thornhill, Renee

Surname: Thornhill
Given name(s): Renee
Age: 33

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: November 27
To: December 8, 2023
By: Dr. Mary Beth Bourne, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Renee Lisa Thornhill
Date and time of death:  May 21, 2018, at 6:54 a.m.
Place of death: The Ottawa Hospital, North Psychiatry
Cause of death: aspiration, secondary to methadone toxicity, exacerbated by pharmacokinetic drug-drug interaction
By what means: accident

(Original signed by: Foreperson)

The verdict was received on December 8, 2023
Coroner's name: Dr. Mary Beth Bourne
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Renee Thornhill

Jury recommendations
To the Ottawa Hospital:
  1. The Ottawa Hospital (TOH) shall maintain one or more substance use consult teams that must consist of at least one physician trained in substance use health and methadone maintenance treatment (MMT) as well as a nurse trained in substance use health. This physician must always be available for consultation with other treatment providers within TOH.
  1. TOH shall develop a methadone administration protocol (MAP) that applies when a patient presents to hospital participating in an MMT program. This protocol shall be in writing and shall specifically state in the preamble that the protocol has been created as a result of an inquest jury’s recommendations made at the conclusion of an inquest into the death of Renee Thornhill.
  1. The MAP shall include a requirement that the Most Responsible Physician (MRP) consult with the physician on the substance use consult team and with a clinical pharmacist, prior to prescribing MMT. The MRP, in consultation with the substance use consult physician and clinical pharmacist, shall develop a documented plan for monitoring the patient for any signs of toxicity including but not limited to ataxia, heavy snoring, slurred speech, “nodding off” and emotional lability.
  1. TOH shall provide mandatory addiction services training to all nursing staff, personal care assistants and physicians who may care for patients on methadone within the mental health units of TOH. The training shall include education on the medical risks associated with commencement, resumption, or continuation of MMT, particularly during the first two weeks of commencement or resumption, and the signs and symptoms of potential methadone toxicity. This training shall also include education on the risks of pharmaceutical interactions between methadone and other prescribed medications. Finally, this training shall include education to reduce stigma associated with substance use health. Consideration should be given to directly involving personal support workers and nursing staff employed at Ottawa Inner City Health in this training.
  1. TOH should conduct periodic reviews of nursing charting and personal care assistant rounds documentation to ensure that they are completed in accordance with hospital policies. TOH should consider a graduated response in cases of non-compliance including possible disciplinary action in repeat cases of non-compliance.
  1. TOH shall explore means of reducing patient length of stay within Psychiatric Emergency Services. This should include an examination of triage practices based on patient needs as well as increasing bedspace on the mental health inpatient unit by expanding the use of transitional care and/or surge capacity. Current hospital budgets should be reviewed to make additional resources available for an increased number of psychiatric beds and prioritization should be given to seeking additional funding through the Ministry of Health.
To Ontario Health and TOH:
  1. TOH should work with Ontario Health to enhance patient access to primary care providers upon patient discharge from TOH, including the use of existing mental health support programs at TOH to aid in patient transition to primary care.
To Accreditation Canada:
  1. Accreditation Canada should consider implementing an accreditation standard for tertiary care hospitals, to maintain substance use consult teams with at least one MMT-trained physician who is available seven days a week, 24 hours a day.
To the Ministry of Health:
  1. Should provide increased targeted funding to TOH to reduce patient length of stay on Psychiatric Emergency Services and to increase bedspace and surge capacity within the mental health inpatient unit and increase transitional care.
  1. Should provide increased targeted funding to TOH to support the substance use consult team, including a physician on call at all times.
  1. Should expand the current Electronic Medical Records to include all medical records prepared by all health care providers and pharmacists in Ontario.
  1. Should examine the feasibility of automatic electronic notifications in the Electronic Medical Record to notify a family physician when a patient has been admitted to or discharged from a hospital.
  1. Consider developing a targeted education campaign to inform families and caregivers of mental health patients of the programs, resources and support available for patients.
To Ontario Health:
  1. Consider expanding funding for and use of specialized Community Health Care Centres in order to provide increased access to primary care services for individuals experiencing mental health and substance use health issues. These centres should provide wrap-around, integrated health care involving peer support, and patient navigation services. Ontario Health should provide sustainable long-term funding, based on the model used at Ottawa Inner City Health, for the community health care centres.
  1. Consider providing financial incentives to family physicians to accept patients with substance use disorders such as the Mental Health Management Incentive that exists in British Columbia.
  1. Provide funding to Opioid Agonist Therapy (OAT) clinics to improve coordination and connection of people with opioid use disorder to primary care through integration of social workers and/or other wrap around services. This should include transition of care plans and supports to find a family physician with clear pathways for continuity of care during the transition period between the OAT clinic and the primary care provider.
  1. Consider providing funding to improve coordination of care within hospitals and between hospitals and primary care. This should include expansion of Addictions medicine consult services in tertiary care hospitals across Ontario to support appropriate continuation and/or initiation of treatment for patients as well as transitions to community. Addiction medicine consult services should include physician services as well as social workers and peer support workers who can assist with patient navigation, advocacy, and community care transitions. Funded tertiary care hospitals should provide regional support to other hospitals.
To the College of Family Physicians of Canada, the College of Physicians and Surgeons of Ontario and the Royal College of Physicians and Surgeons of Canada:
  1. Develop and deliver educational programs within medical schools and as a component of ongoing physician professional development to address stigma surrounding vulnerable patients, including those with mental health and substance use disorders.
  1. Develop and deliver educational programs to enhance physician knowledge of substance use treatment including education on MMT, its benefits and risks, drug interactions as well as the risks of toxicity and how to recognize and manage these risks.
  1. Develop and deliver educational programs on pharmacology for physicians in training and, as a component of physician continuing professional development, to improve physicians’ knowledge of potential drug-drug interactions with methadone.
To the College of Nurses of Ontario
  1. Develop and deliver educational programs within nursing schools and as a component of ongoing nursing professional development to address stigma surrounding vulnerable patients, including those with mental health and substance use disorders.
  1. Develop and deliver educational programs to enhance nurses’ knowledge of substance use treatment including education on MMT, drug interactions, risks, and how to recognize and manage these risks.

Ryskamp, Hendrik Pieter

Surname: Ryskamp
Given name(s): Hendrik Pieter
Age: 31

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: November 20
To: November 24, 2023
By: Dr. Richard McLean, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Hendrik Pieter Ryskamp
Date and time of death:  March 18, 2019, 6:27 a.m.
Place of death: Lennox and Addington County General Hospital, Napanee, Ontario
Cause of death: Fentanyl toxicity
By what means: accident

(Original signed by: Foreperson)

The verdict was received on November 24, 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: Hendrik Pieter Ryskamp

Jury recommendations
To the Quinte Detention Centre (QDC):
  1. Ensure that the history, risks, vulnerabilities, and other flagged information in records related to a person in custody, including in the Offender Tracking Information System (OTIS), are current and are considered when decisions are made about the living unit and cell where the person will be housed in QDC.
  1. Work with Kingston, Frontenac and Lennox and Addington (KFL and A) Public Health to share information, and educate institutional staff and persons in custody at QDC, about opioids and illicit substances in the following manner:
    1. Explore becoming a partner with the KFL and A Community Drug Strategy.
    2. Subscribe to KFL and A Public Health email notifications and information provided to KFL and A Public Health partner agencies related to drug use and trends; work with KFL and A Public Health to determine which information would be appropriate to provide to persons in custody; and share trends and other information about drug use and suspected overdoses at QDC with KFL and A Public Health.
    3. Develop and deliver posters, information brochures and bulletins that can be posted throughout QDC and provided to persons in custody at admission, while in custody and upon discharge to assist in increasing safety of QDC staff, and persons in custody both while in custody and upon reintegration into the community upon release.
    4. Explore the creation of a discharge strategy that incorporates the community reintegration officer, the parole officer, and any other person involved in the reintegration of persons in custody to community.
    5. Explore having KFL and A Public Health provide in-person education sessions to staff and inmates on a regular basis on dangers of illicit substance use, and how to promote harm reduction.
  1. In consultation with the Native Inmate Liaison Officer (NILO) and appropriate Indigenous community members, integrate an Elder into the programming provided for Indigenous persons in custody on a regular and consistent basis and provide funding for an Elder to attend Quinte Detention Centre (QDC) at least twice a month and when specifically requested by a person in custody.
  1. In consultation with the NILO, healthcare staff, other institutional staff at QDC, and relevant stakeholders review practices related to the placement of persons in custody who have a history of mental health and behavioural challenges, illicit substance use and abuse, and who are known to be facing stressors over and above those related to criminal charges and being in custody.
To the Ministry of the Solicitor General:
  1. Ensure that the Electronic Medical Record (EMR) system currently being introduced into provincial correctional institutions allows for all health care professionals who see and treat persons in custody at QDC to access and input clinical information related to persons in custody as they are currently able to do with the paper health care file of a person in custody.
  1. Provide all health care professionals who see and treat persons in custody at QDC with the ability to access and input clinical information into the provincial EMR database to assist in the continuity of care of persons in custody upon leaving QDC.
  1. Provide physicians who see and treat persons in custody in provincial correctional institutions access to the Level Service Inventory - Ontario Revised (LSI-OR) for a person in custody upon request. Ensure that physicians are aware that they may request access to the LSI-OR for their patients.
  1. Explore providing QDC correctional staff with increased use of canine units for searching for contraband, and explore allowing canine units, either the Ministry of the Solicitor General canine unit or another canine unit in Ontario, to conduct searches of persons in custody and upon admission for contraband.
  1. Explore increasing the availability of Field Intelligence Officers and institutional security teams to assist QDC in the detection and confiscation of contraband drugs.
To the Quinte Detention Centre and the Ministry of the Solicitor General:
  1. Explore becoming a partner with the KFL and A Community Drug Strategy.
  1. The Ministry of the Solicitor General to explore options to increase access to naloxone such as increasing locations where it is available, including considering providing all correctional officers at QDC with at least a single dose of intranasal naloxone, and require that this dose be carried by correctional officers on their person at all times during their shift, and ensure that all persons in custody are aware that correctional officers carry naloxone.
  1. Consider making changes to open bar cells that would allow full visibility, but prevent passing of contraband between inmates.

December

Teskey, Derek

Surname: Teskey
Given name(s): Derek
Age: 48

Held at:  virtual, Toronto
From: December 4
To: December 7, 2023
By: Dr. John Carlisle, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Derek Teskey
Date and time of death:  June 14, 2019, at 9:46 p.m.
Place of death: Windsor Regional Hospital – Ouellette Campus
Cause of death: gunshot wound of the chest
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on December 7, 2023
Coroner's name: Dr. John Carlisle
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Derek Teskey

Jury recommendations
To the Ontario Ministry of the Solicitor-General:
  1. Analyze the feasibility of providing frontline Ontario Provincial Police (OPP) officers with additional non-lethal use of force options, including shields, that can be used when responding to calls involving individuals who are experiencing mental health or drug induced crises.
  2. Develop a strategy to increase the complement of frontline OPP officers who receive crisis negotiation training with the eventual goal to have all frontline officers trained.
  3. Develop strategies to increase the availability and response time of OPP crisis negotiators with the goal to have at least one trained person on shift at any given time within each detachment.
  4. Integrate a scenario into Basic Constable Training at the Ontario Police College and annual OPP block training that draws from the circumstances of this inquest.
  5. Analyze the feasibility of providing frontline OPP officers with survelliance equipment for the purpose of discreetly gathering more information of a sealed off environment.
  6. Develop a formal method for internal communication for critical incidents and lessons learned from debriefings, to be disseminated throughout the OPP organization.

Faqiri, Soleiman

Surname: Faqiri
Given name(s): Soleiman
Age: 30

Held at:  via video conference
From: November 20, 2023
To: December 12, 2023
By: Dr. David Cameron, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Soleiman Faqiri
Date and time of death:  December 15, 2016
Place of death: Central East Correctional Centre, 541 Kawartha Lakes County Road 36, Lindsay, Ontario
Cause of death: prone position restraint and musculocutaneous injuries sustained during struggle, exertion and pepper foam exposure in the setting of cardiomegaly and worsening symptoms of schizophrenia
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on December 12, 2023
Coroner's name: Dr. David Cameron
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Soleiman Faqiri

Jury recommendations
To the Government of Ontario:

The Government of Ontario, specifically the Ministry of the Solicitor General and, where applicable, the Ministry of Health and the Ministry of the Attorney General, should: 

Oversight and Accountability 
  1. Develop and issue a public position statement within 60 days of this verdict recognizing that correctional facilities are not an appropriate environment for persons in custody experiencing significant mental health issues. 
  2. Take immediate steps to ensure that any person in custody experiencing an acute mental health crisis is admitted to hospital for assessment and, when appropriate, treatment, in a therapeutic setting that is suitable, secure, and safe. 
  3. Adopt, as Provincial Policy, the principle of equivalence, which requires that persons in custody receive the equivalent quality and standard of healthcare services as is available in the community. 
  4. Immediately institute a provincial implementation committee (“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 annually report to a Deputy Minister and include senior members of relevant ministries central to the issues raised by this case, representation from the Ontario Public Service Employees Union, and an equal number of community experts and people with lived experience. It should be chaired by an independent expert who could speak freely on progress made on implementation, including an annual public update on implementation. 
  5. Establish an Independent Provincial Correctional Inspectorate or equivalent body (“Correctional Inspectorate”) led by a person appointed by Order in Council.  This body’s authority should include the authority to: 
    1. Investigate individual and systemic complaints in correctional facilities with the necessary powers to summon and interview people with relevant information and examine people under affirmation, 
    2. Initiate its own investigations, 
    3. Review operations and identify non-compliance with any applicable legislation, regulations, correctional policies, and procedures, 
    4. Review and report on the use of segregation and restrictive confinement, 
    5. Direct that remedial or preventative actions be taken,  
    6. Make recommendations that shall be considered by government,  
    7. Directly engage the responsible Minister, 
    8. Have a special report tabled in the Legislature, and 
    9. Publicly and annually report on its investigations, collected data, and the correctional system.   
  6. Establish an Independent Advisory Committee (“Advisory Committee”) at all correctional facilities with members from all job groups and the community, including people with lived experience, representation from the Ontario Public Service Employees Union, and families of persons who have died in custody. The Advisory Committee should: 
    1. Be co-chaired by a person with lived experience, 
    2. Meet on an ongoing and regular basis to review the conditions of the facilities and the management of persons in custody with mental health issues,  
    3. Receive and provide advice on issues raised by facility staff, persons in custody, families, and advocates, 
    4. Provide advice on effective functioning with all elements of the correctional system, with the goal of enhancing workplace culture and communication, 
    5. Consider and advise on recommendations from inquests and other review bodies, 
    6. Prepare reports, as appropriate, which should be posted publicly. 
  7. Continue to take immediate steps to ensure that persons in custody experiencing significant mental health issues are identified, are not housed in conditions of confinement that constitute segregation, and that all segregation placements are properly tracked and reviewed. 
  8. Upgrade infrastructure to ensure adequate programming, interview space, and single cell accommodation are available at each correctional facility. 
  9. Establish an independent Rights Advisor and Prisoner Advocate (“Advocate”) at all correctional facilities for all persons in custody, regardless of security classification, status, or placement. The Advocate should be responsible for providing advice, advocacy, and support to persons in custody, including regarding corrections policy and practice, appropriate use of force, segregation, seclusion, and the right to proper healthcare. The Advocate must be notified immediately upon any increased restrictions on the person in custody’s conditions of confinement. 
  10. Take immediate steps at all correctional facilities, including Central East Correctional Centre (CECC), to create special needs units with appropriate and consistent staffing levels and specialized staff to support the needs of people with mental health issues who cannot be housed in the general population. The Rights Advisor and Prisoner Advocate should be readily accessible to persons in the special needs units. 
  11. Implement all recommendations from the Report from the Expert Panel on Deaths in Custody issued by the Office of the Chief Coroner in January 2023. 
  12. Regularly review the existing accountability process pertaining to correctional management, including institutional and regional management, to ensure fair, transparent, and equitable consequences for work-related conduct. Following the review, share a report with all correctional employees setting out the review process, information gathered, conclusions, and any resulting changes. 
Correctional Healthcare Governance and Healthcare Capacity 
  1. Take immediate and urgent steps to establish a Provincial Agency within the mandate of the Ministry of Health and in liaison with the Ministry of the Solicitor General to directly deliver and oversee healthcare services in correctional facilities, including responsibility for quality improvement, capacity-building, and system planning. The establishment of a Provincial Agency should have, at minimum, a net neutral impact on Ontario Public Service employment. Any other recommendation regarding healthcare and governance is in addition to, and not in place of, a Provincial Agency. 
  2. Establish formalized partnerships among all provincial correctional facilities and appropriate specialized psychiatric hospitals, with forensic psychiatry units, ensuring access to services equivalent to the Acute Stabilization Unit provided at St. Joseph’s Health Care in partnership with the Hamilton Wentworth Detention Centre. 
  3. Require and establish standardized practices, consistent with best practices in community mental health care, in the treatment and care of persons in custody with mental health issues across all correctional facilities, including the consistent use of screening and assessment tools by trained mental health professionals. 
  4. Implement a quality assurance cycle to continuously identify problems with respect to healthcare provided to persons in custody and develop and test solutions. 
  5. Improve the effectiveness of healthcare at correctional facilities through: 
    1. A targeted recruitment strategy for doctors, nurses, nurse practitioners, social workers, and healthcare staff in correctional facilities, focusing on specialized training in correctional healthcare, 
    2. A protocol for all correctional facilities defining the role and responsibilities of the Most Responsible Provider, which should provide clarity on who is responsible for a patient in custody, and make such assignment clear and obvious with instructions on whom to contact during off-hours,  
    3. Increase the salary and benefits for physicians, psychiatrists, psychologists, nurses, social workers, and other healthcare staff to ensure their compensation is equal to the compensation paid to healthcare workers in the community. This is to attract and increase staffing to ensure services equivalent to those received in the community, 
    4. An increase in the number of hours for primary care physicians and psychiatrists at correctional facilities, and 
    5. Requiring all healthcare managers and administrators to have appropriate healthcare education and experience. 
  6. Ensure that persons in custody have a mechanism to raise complaints to the Correctional Inspectorate or other oversight body about their healthcare while in custody. 
  7. Ensure that healthcare and operations staff and management are made aware of their authority to take persons in custody with mental health issues to the hospital. 
  8. Ensure that all correctional facilities obtain and maintain accreditation through Accreditation Canada and make public the reports and results of their most recent accreditation reviews. 
  9. Provide the necessary leadership, coordination, and resources to local hospitals relied upon by correctional facilities for the healthcare of persons in custody experiencing an acute mental health crisis, including Ross Memorial Hospital, to allow for: 
    1. A clear understanding that hospitals and correctional facilities must engage in effective communication and coordination to ensure appropriate and responsive healthcare of persons in custody experiencing acute mental health crises, 
    2. Hospitals having sufficient capacity to admit people who require hospitalization for inpatient mental health care, without having a negative effect on the hospital’s budget or the hospital’s capacity to serve its community, 
    3. Better coordination and effectiveness of transfers from the correctional facility to local hospitals, and 
    4. An improved working relationship between hospital and correctional facilities. 
  10. Ensure that all physicians and nurse practitioners in correctional facilities are registered users of eConsult Ontario and able to access the service from within correctional facilities to ensure quick access to an external roster of psychiatrists and other medical specialists. 
  11. Require that eConsult Ontario implement a triage process that would categorize incoming requests by level of urgency and provide a service commitment for urgent requests that would ensure a response within 12 hours of receipt. 
Mental Healthcare Approach in Corrections  
  1. Require that healthcare staff and operations staff create an individualized care plan for all persons in custody with mental health issues, as early as possible after admission or upon detection, which should include: 
    1. A case-management, individualized approach to the care of persons with mental health issues from the point of admission to discharge,  
    2. Inter-disciplinary staff engagement in understanding and addressing the healthcare of persons with mental health issues, 
    3. Discharge planning with appropriate community agencies, and 
    4. Culturally safe, respectful engagement that ensures a safe environment free of racism and accommodates religious expression.  
  2. Require that healthcare staff develop a healthcare plan, integrating information from community mental health providers, if applicable and available. 
  3. Require that appropriate operations staff and healthcare staff hold regular inter-disciplinary team meetings to discuss the ongoing care of persons in custody with mental health issues and their care plan, which should include a written guideline articulating a person-centered approach to care decisions. This guideline should include: 
    1. The circumstances that would require consultation with healthcare staff and management, corporate healthcare, other medical specialists, community-based mental health services, and family, 
    2. The need to reduce the use of a single gatekeeper in making decisions about taking a person in custody to hospital, which should instead be the result of a comprehensive and collaborative healthcare process, 
    3. When this guideline would not apply. For example, when there is a risk to delaying care such as an emergency requiring immediate hospitalization, and 
    4. The guideline being shared with all correctional staff. 
Coordination between Sectors 
  1. Implement evidenced-based integrated mental healthcare pathways between hospitals, correctional facilities, and community-based mental health services to ensure timely transfer, communication, information-sharing, and continuity of care for persons with mental health issues who may come into contact with the law. 
  2. Develop and make public educational materials for community healthcare providers concerning their authority to share medical records regarding people in custody with health care professionals working in correctional facilities.  This should include engaging relevant healthcare entities, such as the Ontario Hospital Association, the Human Services and Justice Coordinating Committee, and healthcare professional associations, in developing these materials. 
  3. Increase resources to support consistent implementation, evaluation, and standardization of best practices in community-based mental healthcare, such as assertive community treatment and/or case management, supportive housing, mental health court support, and prison in-reach teams to provide ongoing support to persons with mental health issues who are involved in the justice system. 
  4. Establish formalized partnerships with community mental health agencies to be able to provide mental health services and resources within correctional facilities after appropriate training. 
  5. Explore the possibility of using video recordings to enhance accountability in correctional facilities. This should include engaging appropriate expertise to understand human rights and privacy interests.  
Courts and Mental Health Assessments 
  1. Fund and appropriately resource mental health support programs and develop best practice guidelines and standards for supporting and accommodating persons with serious mental health issues who come before the criminal courts, including those who are not referred to mental health diversion. 
  2. When the court makes an order for a fitness assessment when someone is charged with a criminal offence, strive toward a best practice of having such assessment occur within 24 hours.   
  3. Expand the Forensic Early Intervention Service, currently available in Toronto, throughout the province. 
  4. Develop standardized protocols and pathways, when a court makes an order for a mental health assessment, for a direct transfer of the person to a hospital rather than awaiting such assessment in a correctional facility.  
  5. Ensure access to mental health assessments by a mental health professional for persons in custody with serious acute mental health issues within 24 hours of a court order or remand.  This could include engaging in partnerships with mental health providers who are funded to deliver such care.  
  6. Consider expanding access to mental health courts throughout the province and eligibility for such courts based on a person’s mental health needs, rather than the nature of the alleged criminal offence. This should include: 
    1. Monitoring ongoing appropriateness of these courts, ensuring cultural competency and outcomes, and being led by an advisory group including persons with lived experience, and 
    2. In jurisdictions without mental health courts, implement an informal mental health strategy based on a mental health court’s therapeutic goals for accused persons, where appropriate. 
  7. Educate justice system participants, including judges, justices of the peace, and lawyers, and hospital administrators regarding the availability of assessments and options under the Mental Health Act beyond assessments for fitness and criminal responsibility. 
  8. Strongly consider establishing special designated beds in psychiatric facilities for court-ordered assessments under the Mental Health Act beyond assessments for fitness and criminal responsibility.  
Training and Education  
  1. Provide correctional staff and management with mandatory, specific, and regular training on understanding mental health issues to better equip them to manage persons in custody presenting with mental health issues. Such training should be evidence-based, approved by, and delivered by experts in mental health. The training should include the participation of persons with lived experience who are appropriately supported such that they can participate safely and effectively. The training should include:  
    1. Understanding when mental health issues require immediate attention,
    2. Regular seminars featuring mental health and psychiatric experts, and persons with lived experience, to educate correctional staff about the experiences of people in crisis, and the importance of effectively communicating with such persons and treating them with empathy and respect,
    3. Trauma-informed de-escalation and disengagement strategies and techniques, with mandatory emphasis on de-escalation or disengagement as the first intervention before any use of force,
    4. The respectful care of persons with mental health issues,
    5. Scenario-based training specific to interacting with persons in crisis, including de-escalating situations in use of force training,
    6. Reviewing scenarios specific to their job duties, including one involving the circumstances surrounding the death of Soleiman Faqiri, and
    7. Understanding of legislation that intersects with professional responsibilities, including the Mental Health Act and the Personal Health Information Protection Act.
  2. Enhance awareness of the importance and significance of psychological health and safety for all those working in correctional facilities.
  3. Review and evaluate the effectiveness of all mental health-related training, which could include using multiple assessment methods, such as performance reviews, simulation exercises, and pre- and post-assessments.  
  4. Provide correctional staff and management with mandatory annual training on human rights, anti-racism, anti-bias and stereotyping, cultural safety, and intersectional barriers.  Training on these matters should also be integrated into other areas including de-escalation, use of force, and scenario-based training. 
Use of Force
  1. Raise awareness of the mandatory bystander intervention policy that directs all correctional staff and management to intervene, which could include stopping, in a situation involving an excessive use of force and report such use of force. This should be accompanied by: 
    1. Mandatory scenario-based training and mandatory annual refresher courses for all correctional staff, and 
    2. Educating staff that there will not be repercussions for intervening, stopping, or reporting such conduct, but that there will be accountability for failing to intervene or report with potential repercussions up to and including dismissal.  
  2. Monitoring and evaluating the effectiveness of the bystander intervention policy, which should include collecting and publicly reporting disaggregated data on the number of times correctional staff and correctional management report that they have intervened and circumstances that warranted such interventions.  
  3. Ensure that healthcare staff receive mandatory bystander intervention training, which requires them to intervene and report on excessive use of force, to help them understand their own roles and responsibilities in this regard. 
  4. Review, evaluate, and improve policies and training related to use of force, including the risk of the use of pepper foam, spit hoods, and restraint, with an emphasis on the specific danger of positional or restraint asphyxia. Training must include the differential impact of using any form of force on a person in mental health crisis with mandatory and annual regular refresher training. Revisions to spit hood policies and training should include a requirement that a correctional officer be continuously present with any person on whom a spit hood is applied.  
  5. Review and refresh current de-escalation training in consultation with people with lived experience.  The renewed de-escalation training should be mandatory for all correctional staff and should be subject to recertification every two years. 
  6. The Use of Force Report should include a means of noting whether the force was used on a person with mental health issues and disaggregated data, including demographic information, should be collected, and publicly reported. 
  7. Require that a use of force on a person with mental health issues be reported to and reviewed by the correctional facility’s superintendent and corporate healthcare, and that senior management conduct a comprehensive debrief with affected and involved staff and persons in custody, focusing on the event's details, responses, outcomes, and learning points. 
  8. Provide trauma-informed mental health support for persons in custody and correctional staff directly or indirectly affected by a use of force to assist them to effectively manage and recover from any resulting impact. 
  9. Ensure that healthcare staff receive mandatory use of force training to help them understand the roles and responsibilities of operations staff. 
  10. Review current use of force policies and training, and revise to ensure clarity on the designation of the highest-ranking officer on scene during an emergency (code blue) situation, how and when the Institutional Crisis Intervention Team (ICIT) is engaged, planned use of force, and defensive and offensive techniques.  Provide mandatory and repeated training following appropriate revisions that should include ICIT-level team co-ordination tactics. 
  11. Consider developing a community-based crisis intervention alternative to an Institutional Crisis Intervention Team to address mental health crises, with staff specifically trained in de-escalation and disengagement. 
  12. Review and update the Inmate Handbook. The handbook should include the use of force policies.  This handbook should be provided to persons in custody upon request and inmates should be made aware that it is available to them during the admission process. 
Family Support
  1. Implement a family-centered approach for continuous information flow and provide compassionate support for family members of persons in custody with mental issues. This should include: 
    1. Designating a family liaison as a direct line of contact for a family that is responsible for keeping the family informed of any developments in the person in custody’s care and well-being, 
    2. Eliminating unnecessary barriers to family visitation,  
    3. Virtual communication options when in-person visits are not possible or appropriate, 
    4. Considerations for appropriate cultural and religious burial practices of the person in custody who has died, and 
    5. Dignified notification approaches when the person in custody has died, which should ensure the presence of a person who is able to provide information regarding the circumstances of the death. 
Implementation
  1. Seek and allocate funding and resources adequate to implement the above recommendations with no negative impact on Ontario Public Service employment and resources. This funding should be sought in the 2025 provincial budget or before. 

 

Burkholder, Daniel
Guilbeault, Ronald
Lauzon, Bernard
Kouchil, Mykhailo
So, Kung Wing
Joyner, Melvin
Rouen, Paul

Names of the deceased: Burkholder, Daniel; Guilbeault, Ronald; Lauzon, Bernard; Kouchil, Mykhailo; So, Kung Wing; Joyner, Melvin; Rouen, Paul
Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: November 29
To: December 6, 2023
By: Dr. Geoffrey Bond, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Burkholder
Given name(s): Daniel
Age: 61

Date and time of death:  July 20, 2018
Place of death: Sunnybrook Health Sciences Centre, Toronto
Cause of death: multiple blunt trauma
By what means: accident

Surname: Guilbeault
Given name(s): Ronald
Age: 46

Date and time of death:  July 31, 2019
Place of death: Ottawa Hospital Civic Campus, Ottawa
Cause of death: traumatic brain injury
By what means: accident

Surname: Lauzon
Given name(s): Bernard
Age: 66

Date and time of death:  July 19, 2018
Place of death: Ottawa Hospital Civic Campus, Ottawa
Cause of death: saddle pulmonary embolism
By what means: accident

Surname: Kouchil
Given name(s): Mykhailo
Age: 60

Date and time of death:  December 24, 2018
Place of death: St. Michael’s Hospital, Toronto
Cause of death: traumatic head and brain injury
By what means: accident

 

Surname: So
Given name(s): Kung Wing
Age: 63

Date and time of death:  November 14, 2019
Place of death: Sunnybrook Health Sciences Centre, Toronto
Cause of death: multiple blunt force injuries
By what means: accident

Surname: Joyner
Given name(s): Melvin
Age: 58

Date and time of death:  January 20, 2018
Place of death: St. Michael’s Hospital, Toronto
Cause of death: blunt force brain injury
By what means: accident

 

Surname: Rouen
Given name(s): Paul
Age: 68

Date and time of death:  February 27, 2018
Place of death: Lakeridge Health Ajax Pickering Hospital, Ajax
Cause of death: multiple blunt force injuries
By what means: accident

(Original signed by: Foreperson)

The verdict was received on December 6, 2023
Coroner's name: Dr. Geoffrey Bond
(Original signed by coroner)

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

Inquest into the deaths of: Daniel Burkholder, Ronald Guilbeault, Bernard Lauzon, Mykhailo Kouchil, Kung Wing So, Melvin Joyner, Paul Rouen

Jury recommendations
To the Ministry of Labour, Training, Immigration and Skills Development (MLITSD):
  1. Develop a campaign to increase public awareness of the initiatives and resources that MLITSD has to support small businesses in the construction sector in ensuring workers have appropriate knowledge of health and safety laws and regulations and the skills required to follow safe work practices.
  2. Ensure that small businesses with five or fewer workers are eligible to take and receive reimbursement for Health and Safety Representative training through the MLITSD Small Business Health and Safety Training Program. Include that businesses with five or fewer employees are eligible to be reimbursed for health and safety representative training in the campaign described in recommendation #1.
  3. Develop a strategy for making information regarding who has completed working at heights training and the expiry date of training certificates as contained in the MLITSD's database available to members of the public who may hire a person to perform work at heights. Consult with third parties regarding the creation, implementation and maintenance of such databases while ensuring privacy legislation is followed. The strategy should include effective means to communicate to the public that the database exists.
To the Government of Ontario and the MLITSD:
  1. Provide additional funding to the Infrastructure Health and Safety Association (IHSA) to:
    1. Continue and expand campaigns and initiatives directed toward increasing public awareness of occupational health and safety for small construction businesses.
    2. Continue and expand campaigns and initiatives directed toward increasing public awareness of the hazards of working at heights, especially among small construction businesses and people who do work for these businesses.
    3. Continue the current promotion to provide IHSA's e-learning courses free of charge for small construction businesses beyond the current funding deadline of March 31, 2024.
    4. Implement the recommendations from this inquest, if necessary.
To the IHSA:
  1. Develop an electronic tool similar to the “Silica Control Tool” for the IHSA's Fall Protection Work Plan resource, and market that tool to all construction businesses and through the Working at Heights training.
  2. Prominently display on the IHSA’s main training webpage the mandatory training standard requirements and clearly indicate in the training catalogue which training courses are mandatory.
To the MLITSD, IHSA and the Workplace Safety and Insurance Board (WSIB):
  1. Explore requiring individuals and businesses that do any type of construction work to provide their contact information to the WSIB even if they are not currently required to register for WSIB or purchase WSIB coverage. The WSIB would provide this contact information to IHSA at agreed upon intervals so that the IHSA could provide health and safety resources to these individuals and businesses.
  2. Review the existing process of data sharing between MLITSD, WSIB and IHSA on occupational health and safety incidents to inform the timely implementation of effective safety initiatives, campaigns and training.