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

Gammie, Shane
Sipes, Christopher
Xue, Qinlong
Borde, Quinn
Abrahams, Shimon

Held at: Toronto (virtual)         
From: January 26         
To: February 6, 2026         
By: Bonnie Goldberg, presiding officer for Ontario         
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Shane Gammie         
Age: 35         
Date and time of death: November 24, 2018         
Place of death: Collins Bay Institution, 1455 Bath Road, Kingston         
Cause of death: fentanyl toxicity         
By what means: accident

Name of deceased: Sipes, Christopher         
Age: 51         
Date and time of death: November 21, 2019         
Place of death: Kingston General Hospital, 76 Stuart Street, Kingston         
Cause of death: combined heroin and fentanyl toxicity         
By what means: accident

Name of deceased: Qinlong Xue         
Age: 26         
Date and time of death: November 12, 2020         
Place of death: Kingston General Hospital, 76 Stuart Street, Kingston         
Cause of death: complications of acute fentanyl toxicity         
By what means: accident

Name of deceased: Quinn Borde         
Age: 39         
Date and time of death: March 31, 2022         
Place of death: Kingston General Hospital, 76 Stuart Street, Kingston         
Cause of death: complications of fentanyl and etizolam toxicity         
By what means: accident

Name of deceased: Shimon Abrahams         
Age: 41         
Date and time of death: June 13, 2022         
Place of death: Kingston General Hospital, 76 Stuart Street, Kingston         
Cause of death: complications of fentanyl toxicity         
By what means: accident

(Original signed by: Foreperson)

The verdict was received on February 6, 2026
Coroner's name: Bonnie Goldberg         
(Original signed by presiding officer for Ontario)

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

Inquest into the deaths of: Sane Gammie, Christopher Sipes, Qinlong Xue, Quinn Borde, Shimon Abrahams

Jury recommendations
To the Correctional Service of Canada (CSC):

Health care

  1. Develop and implement a plan to increase the availability of on-site nursing and health care services for persons in custody at Collins Bay Institution (CBI). Examine the feasibility of expanding the hours of service to be 24 hours a day, 7 days a week, and increasing the number of Registered Nurses, Nurse Practitioners and Mental Health Nurses.
  2. Develop and implement a plan to increase evidence-based psychosocial and counselling supports for persons in custody who are enrolled in, referred to or request mental health, addiction or substance use counselling or support.
    1. Take steps to reduce, and within six months eliminate, the waiting lists for the SMART Inside Out and peer-led programs at CBI.
    2. Survey persons in custody at CBI to determine if the psychosocial and counselling needs of inmates are better met in their opinion through group programs and / or one-to-one counselling.
    3. Take steps to improve access to these supports and remove barriers to access.
  3. Take steps to reduce response times for medical requests for pain relief, mental health support, and/or sleeps aids, with particular attention to patients who have a known history of substance use.
  4. Expand the physical capacity of Health Services at CBI to create additional clinic rooms to provide all harm reduction and substance use health services and supports within Health Services and to ensure greater confidentiality during the provision of such services and supports.
  5. Consider making nicotine replacement therapy available through health services.

Policy

  1. Maintain the current priority status assigned to the revision of the Commissioner’s Directive 585: National Drug Strategy to facilitate a timely release.
  2. The update to Commissioner’s Directive 585 should provide clarity to all CSC staff about ways to address the introduction of contraband and provide and support harm reduction approaches to substance use in CSC institutions, to align with the Canadian Drugs and Substance Strategy.
  3. Create a working group of correctional staff, health care staff and people in custody with lived experience of using substances at CBI in preparation for updating CBI’s Institutional Drug Strategy to align with the update to Commissioner’s Directive 585.
  4. The working group will, among other things, develop and implement a new education program for staff and people in custody to accompany the update to Commissioner’s Directive 585 and the update to CBI’s Institutional Drug Strategy. Suggested topics should include but not be limited to:
    1. documented reasons why people use substances, and warning signs that someone may be at risk for an overdose
    2. the roles and responsibilities of all staff as described in the updated policy
    3. the harm reduction programs and services available to persons in custody at CBI and how to access them.
  5. Continue to promote, as a guiding policy principle, the provision of health care services in accordance with professionally accepted guidelines and standards.

Harm Reduction and the Overdose Prevention Service (OPS)

  1. Develop and implement an analysis to meet CSC’s goals for the OPS. Suggested areas of focus include but are not limited to:
    1. provision of point-of-care drug checking for people who use the OPS
    2. permit safer smoking and snorting of substances in the OPS (e.g., set up supervised smoking rooms, provide specialized foil), and tell all persons in custody that this is allowed
    3. expansion of the operational hours of the OPS to between 07:00 and 23:00 every day
    4. enhance confidentiality measures for people who use the OPS
    5. increase the availability of safe prescribed medications to treat opioid use disorder consistent with options that may be available in a health care setting outside of a federal penitentiary
  2. Increase access to naloxone in CSC institutions beyond current availability, including:
    1. equip all correctional officers with naloxone kits and require that nasal spray naloxone be carried on their person while on duty
    2. in alignment with community harm reduction standards, make nasal spray naloxone kits directly available to persons in custody within their cells and common areas throughout the institution
    3. educate people in custody on recognizing the signs and symptoms of an overdose, the safe administration of naloxone and the importance of promptly alerting correctional staff to a potential overdose
  3. Develop and implement a process to identify and safeguard persons at increased risk for overdose with particular attention to:
    1. Issues identified upon admission
    2. Navigating transitions within the institution, between institutions, and to the community, including continuity of health care and wrap around services
    3. The presence of conditions which may exacerbate substance use disorder such as mental health challenges, pain, sleep challenges or interpersonal challenges
    4. Persons who have experienced non-fatal overdoses
    5. Persons who have had previous suicide attempts
  4. Continue to make people in custody aware of the protections that they are entitled to pursuant to the Good Samaritan Drug Overdose Act.
  5. Review existing policies and procedures following a non-fatal overdose and revise policies where necessary to ensure that an automatic assessment of future overdose risk is completed and documented, enhanced monitoring of the patient’s risk level is considered, and a safety and action plan is discussed with the patient.

Enforcement

  1. Develop and implement a plan to prioritize efforts to prevent muscling, financial gain from the sale of all types of contraband and acts of physical or psychological intimidation over detection of illicit substances.
  2. Modernize and upgrade drone detection technology at CBI to address the ongoing threat of “drone drops” at federal institutions.
  3. Explore the efficacy of body scanners in use at CBI to improve their utility.
  4. Review administrative and punitive consequences for people in custody who are found to be in possession of or using tobacco.

February

Hashemi, Taher

Held at: virtual, 25 Morton Shulman Avenue, Toronto         
From: February 2        
To: February 4, 2026        
By: Dr. Geoffrey Bond, presiding officer for Ontario         
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Taher Hashemi         
Age: 49        
Date and time of death: August 24, 2021        
Place of death: Ottawa-Carleton Detention Centre        
Cause of death: hanging        
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on February 4, 2026
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: Taher Hashemi

Jury recommendations
We, the jury, recommend to the Ottawa-Carleton Detention Centre (OCDC) and the Ministry of the Solicitor General:
  1. Court dispositions or notable proceedings, events, or results for days in court for inmates who are in the stabilization or health care units should be communicated to the OCDC health care team.
  2. Relevant minutes from health care planning for high-risk inmates should be recorded and documented and available in the health care records so that all members of the inmate's health care team have access.
  3. Recreational materials should be proactively provided to long-term inmates who are in the stabilization or health care units (such as additional reading material, crossword puzzles, sudoku, newspapers, etc.).
  4. For long-term inmates (as determined by OCDC) who are facing persistent mental health challenges, health care plan revisions should take into account an inmate's duration of stay and the period until the next court date.
  5. Room implements (i.e. light fixtures, bedding, anchor points, etc.) should be re-assessed in order to remove any means of an inmate potentially harming themselves.

March

Pyne, Colin

Held at: virtual, 25 Morton Shulman Avenue, Toronto        
From: March 2, 2026        
To: March 11, 2026        
By: Murray Segal, presiding officer for Ontario        
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Colin Pyne        
Age: 26           
Date and time of death: August 17, 2021      
Place of death: Central North Correctional Centre, 1501 Fuller Avenue, Penetanguishene, Ontario      
Cause of death: Complications of Type 1 Hypersensitivity Reaction with a contributing factor of acute ethanol toxicity      
By what means: Undetermined

(Original signed by: Foreperson)

The verdict was received on March 11, 2026
Coroner's name: Murray Segal      
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Colin Pyne 

Mental Health Care

To the Ministry of the Solicitor General (“SOLGEN”) and Central North Correctional Centre (“CNCC”):

  1. To help address and improve the Mental Health Team’s capacity to provide mental health care to mentally ill persons in custody:
    1. Continue efforts to secure access to acute stabilization beds at local hospitals for people in custody at CNCC.
    2. Remind nursing staff of their responsibility to request records of relevant prior Confirmation of this should be reflected in the health care file.
    3. Provide a reminder and/or demonstration to all nursing staff at CNCC to ensure they review relevant records on Clinical Viewer for each patient who is placed in the Behavioural Stabilization Unit on a mental health hold.
    4. Consider implementing a process that would require alcohol and substance-related misconducts be reported to health care staff for appropriate follow-up.
    5. Consider a process by which relevant information provided by family members of persons in custody is documented and shared with the health care team at CNCC.
Acute Care Stabilization Beds 

To SOLGEN:

  1. Take immediate steps to increase the number of beds available at the Lawrence Valley Correctional and Treatment Centre (“SLV”).
  2. Continue to work with stakeholders to advocate for access to psychiatric beds at Waypoint by CNCC in appropriate cases.
  3. Expand the Acute Care Stabilization (“ACS”) bed pilot program to provide specialty psychiatric beds at Waypoint for acutely ill inmates from CNCC who have complex mental health needs and who would benefit most from short-term admission to the structure and secure inpatient setting of the ACS. 
Health Care 

To CNCC:

  1. Implement an oversight and auditing process to ensure that six-month reassessments are completed for every individual in custody. In a case where the patient is also under the care of the mental health team, include a member of the mental health team in the reassessment.
  2. Consider a referral to CNCC’s physician or nurse practitioner when an asthma patient consistently empties their inhalers before the next-scheduled prescription refill. Also consider a referral for asthma patients who consistently refuse daily maintenance-dose asthma medication.
  3. Ensure nursing staff document and promote health teachings and warnings when appropriate.
  4. Explore the feasibility of requiring health care staff to respond to care-related inmate request forms within a specified time.
Staffing

To SOLGEN and CNCC:

  1. CNCC and SOLGEN will take immediate steps, including advocacy where appropriate, to optimize health care staffing levels at CNCC with the goals of:
    1. Increasing the complement of psychiatrists
    2. Increasing the complement of salaried nursing staff
    3. Offering a more competitive salary to fill the long vacant psychologist position
  1. Review and address operational staffing levels to ensure that CNCC is best equipped to run in-person and virtual health clinics as scheduled. 
Managing Food Allergies and Asthma 

To SOLGEN

  1. Review the policy prohibiting keep on person EpiPens and as needed inhalers and consider whether safety and security measures can be implemented to permit people in custody to retain them in their cells for emergency purposes.
  2. Consider introducing an intercom-type system inside each cell to facilitate prompt assistance when an EpiPen or emergency inhaler is required in a medical emergency.
  3. Attempt to obtain a person in custody’s signature on all Diet Authorization Forms.
  4. When a request comes from a person in custody to remove an allergy from their file that flags a life-threatening allergy to nuts or other allergens, the medical team should obtain original allergy tests, and/or order allergy tests.

 To SOLGEN and Canteen Service Providers:

  1. Explore the feasibility of implementing a system to restrict the purchase of canteen items by allergic individuals and/or housing ranges for allergy reasons.
Supports

To SOLGEN and CNCC:

  1. Explore opportunities for mental health check-ins with people in custody who witness a traumatic event, such as the death of a cell mate. Support should also be available for CNCC personnel.
  2. Implement trauma-informed training for correctional staff liaising with next of kin.
Searches and Patrols 

To SOLGEN and CNCC:

  1. Ensure that correctional officers are trained and reminded to look for signs of movement and breathing during rounds, especially at night.
On-Site Alcohol Fermentation 

To SOLGEN and CNCC:

  1. To help address the serious, ongoing issue of alcohol fermentation in correctional centres, provide additional training to correctional staff to help detect signs of alcohol This may include training to increase officer vigilance of persons in custody who have a stockpile of juices, fruits, bread products and/or canteen items.
  2. In cases of multiple alcohol-related warnings and/or misconduct proceedings, ensure that security managers regularly review the individual’s canteen purchase activity reports.
  3. Review the process followed with respect to the storage and distribution of plastic garbage bags.
  4. In an effort to decrease alcohol-making capability among persons in custody, consider eliminating plastic bags and replacing them with rigid wheeled garbage trolleys, such as a tilt truck to collect garbage from cells and rigid bag-less garbage receptacles in common areas.
  5. In an effort to enhance early detection of alcohol fermentation and to deter stockpiling, increase and intensify cell and maintenance searches.
  6. To prevent stockpiling of alcohol-making ingredients, do not permit the use of any coverings that obscure windowsills or other storage areas within a cell.
  7. Consider replacing large plastic bags of fruit juice with small individual carton servings to reduce alcohol-making capability.
  8. Review the range of penalties available for alcohol-related and drug misconduct, and provide training to promote consistency of application among correctional staff.
  9. Enhance the type and level of addiction support and therapy offered at correctional centres.

Fellinger, Jennifer

Held at: virtual, 25 Morton Shulman Avenue, Toronto        
From: March 2, 2026        
To: March 6, 2026        
By: Dr. Jennifer C. Tang, Presiding Officer for Ontario        
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jennifer Fellinger        
Age: 31           
Date and time of death: February 12, 2019      
Place of death: Niagara Health System Hospital, 1200 Fourth Ave, St. Catharines, Ontario      
Cause of death: Combined toxic effects of fentanyl, methamphetamine, and amphetamine      
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on March 6, 2026
Coroner's name: Dr. Jennifer C. Tang      
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Jennifer Fellinger 

To Vanier Centre for Women (“VCFW”), Ministry of the Solicitor General

  1. A criteria should be developed to determine when a Substance Use Alert on Offender Tracking Information System (“OTIS”) is no longer relevant and when it is to be removed. Once entered on OTIS, Substance Use Alerts should only be removed if the criteria for removal is met and only by the appropriate Alerts that have been removed will remain visible on OTIS print out as historical information.
  2. Explore and evaluate the practice of body scanning inmates prior to boarding transport vehicles to Consideration should be given to body scanning inmates prior to leaving the institution for any destination whilst they are in custody.
  3. Develop and implement a drug amnesty program at VCFW, allowing inmates to voluntarily surrender illicit substances before, during, and after admission without punitive Inmates should be informed of this program upon arrival.
    1. Study and, if feasible, implement an amnesty bin system where inmates may anonymously dispose of illicit substances without penalty.
  4. To raise inmate awareness of the protections offered by the Good Samaritan Act and its limitations, notices shall be posted in high visibility areas of the institution noting that inmates at risk of drug overdose who report the ingestion or insertion of illicit drugs in their bodies shall not be charged under the Controlled Drugs and Substances Act for possession of such drugs if not for the purposes of trafficking.
    1. Institutional Addiction counsellors to engage in inmate education on the Good Samaritan Act.
  5. Explore the implementation or use of an Institutional Security Team at VCFW as a tool for the interception interdiction of illicit drug contraband in the institution.
  6. Correctional staff and nursing staff to include relevant information on inmate OTIS documentation, including physical health, mental health, medications, and substance use.

 To Ontario Provincial Police (“OPP”), Ministry of the Solicitor General

  1. The management of the OPP Special Constables should consider the development and establishment of mandatory performance feedback and lessons learned during a critical incident debrief in the spirit of quality improvement.

 To the Regional Municipality of Niagara Police Service Board (“the Board”) and Chief

  1. To raise inmate awareness of the protections offered by the Good Samaritan Act and its limitations, notices shall be posted in high visibility areas of the courthouse cells and other secure areas for persons in custody, noting that inmates at risk of drug overdose who report the ingestion or insertion of illicit drugs in their bodies shall not be charged under the Controlled Drugs and Substances Act for possession of such drugs if not for the purposes of trafficking.

To the Regional Municipality of Niagara Police Service Board (“the Board”) and Chief, Ontario Provincial Police, Ministry of the Solicitor General

  1. All OPP Offender Transport program and NRPS Special Constables who deal with persons in custody should receive:
    1. Mandatory annual training in recognizing signs, symptoms, and effects of drug use, intoxication, overdose, and withdrawal, as well as appropriate first response measures, including the use of Such training should include regularly updated education on recent and current street drug trends and a scenario-based component, including, when possible, video examples of various overdose situations with appropriate permissions granted.
    2. Mandatory training with respect to the Good Samaritan Act and how to communicate information about that legislation to a person in custody that is suspected to be under the influence of a substance(s), and/or of having ingested or harbouring drugs in their body.
  2. Jointly coordinate training for NRPS and OPP Special Constables with consideration to using the facts surrounding the death of Jennifer Fellinger as a case scenario for the recognition of drug toxicity or overdose, with the aim of enhancing communication, clarity, and understanding between the police services and their respective capacities in responding to medical emergencies in the context of custodial transfers.
  3. Using the facts surrounding the death of Jennifer Fellinger, the management teams of NRPS and OPP Special Constables should collaborate in the joint development of a documentary checklist to assist in custodial transfer between police services to include a mandatory review of OTIS documentation, which could include, but not limited to: medical issues, concerns regarding drug toxicity, and concerns regarding drug or other To confirm custodial transfer has occurred, a time of transfer should be clearly documented.
  4. With consideration to using the facts surrounding the death of Jennifer Fellinger, the management teams of NRPS and OPP Special Constables should jointly review custodial transfer issues between police services and other lessons learned to prevent future deaths in similar circumstances. Both police services should, in collaboration with the other, consider establishing a clear policy that clarifies the transfer of custody and responsibilities of each service which should be disseminated to all Special Constables.

Martorino, Dominick John

Held at: virtual, 25 Morton Shulman Avenue, Toronto         
From: March 23          
To: March 25, 2026         
By: Murray Segal, presiding officer for Ontario         
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Dominick John Martorino        
Age: 43        
Date and time of death: April 6, 2021        
Place of death: Highway 25 and Bonnet Road, Castleton        
Cause of death: gun shot wounds of torso        
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on March 25, 2026
Coroner's name: Murray Segal        
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Dominick John Martorino

Jury recommendations
To the Ontario Provincial Police:
  1. Consider providing enhanced training to frontline officers on critical incident response. This training should be directed at equipping frontline officers with enhanced skills to respond to high-risk scenarios while waiting for a critical incident commander to arrive on scene.
  2. Consider implementing a system establishing a scene commander at scenes which involve multiple responding units, ensuring that all responding personnel are aware of and adhere to command structure to promote effective co-ordinated and controlled responses.
  3. Consider implementing a system to indicate the date or age of a flag that has been entered on the OPP records management system.
  4. Complete implementation of the mental health crisis response training required by the Community Safety and Policing Act and its regulations.

Winterstein, Heather Ashley

Held at: virtual, 25 Morton Shulman Avenue, Toronto        
From: March 30        
To: April 22, 2026        
By: Dr. David Eden, presiding officer for Ontario         
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Heather Ashley Winterstein        
Age: 24        
Date and time of death: December 10, 2021        
Place of death: Niagara Health, Marotta Family Hospital, 1200 Fourth Avenue, St. Catharines        
Cause of death: Septic shock, sepsis with delayed treatment        
By what means: accident

(Original signed by: Foreperson)

The verdict was received on April 22, 2026
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: Heather Ashley Winterstein

Jury recommendations

Cultural safety and anti-bias

To the Ministry of Health:
  1. To build trust between Indigenous communities and healthcare institutions, and pursuant to Call to Action 22 of the Truth and Reconciliation Commission (TRC) of Canada:
    1. Mandate and fund provision of Indigenous Healing practices, including traditional Indigenous medicine and spiritual practices, and resources to Indigenous patients in Ontario hospital settings, when Indigenous patients request them.
    2. Require each Ontario hospital to co-develop its protocols for provision of Indigenous Healing in consultation with proximate Indigenous communities, ensuring that the Indigenous medicine and spiritual practices provided are aligned with the traditional Indigenous Healing practices of the particular local Indigenous communities.
    3. Require each Ontario hospital to co-develop protocols for Indigenous Healing with Indigenous Elders, Knowledge Keepers, and traditional healers.
    4. Require each Ontario hospital to have policies and practices for the purpose of informing identified Indigenous patients of the availability of Indigenous Healing resources within the hospital.
  2. To mandate continuous and evolving training modules covering Indigenous cultural safety, substance use, and mental health stigma for all Emergency Medical Services (EMS) staff across Ontario. The Ministry of Health will have a responsibility to publish annual reports that identify EMS participation in training and identify challenge and/or barriers to uptake.
  3. In the spirit of reconciliation, to explore and study mandating continuous and evolving Indigenous cultural safety and substance use and mental health stigma training for all frontline workers, administrative staff, and executive leadership in Ontario public hospitals.
    1. This includes exploring the implementation of legislative and regulatory amendments like to the Public Hospitals Act to ensure these trainings are produced province wide.
    2. External arms-length Indigenous organizations should be given the opportunity to monitor the effectiveness via the collection and reporting of performance indicators in relation to training initiatives implemented through this process.
    3. The Province of Ontario should ensure an ongoing evaluation process of its own progress to determine if cultural safety and substance use and mental health stigma training initiatives are actively implemented.
To Niagara Health:
  1. The protocol should balance clinical reasoning with consideration to the social determinants of health.
  2. To research and consider the literature on the value and utility of an evidence-based pain management protocol to assist care team in assessing the pain management needs of patients known or perceived to have substance use disorder using standardized clinical criteria, and to
  3. Should commit to continuous improvement in providing and facilitating culturally appropriate spiritual care and ceremonial support options for the families of Indigenous patients who pass away in the hospital, co-developing relevant protocols with Indigenous Elders, Knowledge Keepers, and traditional healers.
  4. Develop culturally safe and informed policies around visitation, support, and next-of-kin notifications for Indigenous patients.
  5. Develop a prompt requiring the emergency department care team to flag and treat repeat department visits as a clinical risk factor heightening the need for prompt and thorough care.
  6. To collaborate with community partners to implement and evaluate anti-bias training to be delivered on an ongoing basis for leadership, personnel who are in contact with patients and their managers.
  7. Further to TRC Call to Action #23, continue to develop and implement strategies to increase the recruitment and retention of Indigenous healthcare professionals.
  8. To continue to review and collaborate with third party peer advocacy (such as QUEST) and navigation services to ensure that third party and clinical staff are trained on the process of referral, access, engagement, and escalation of patient or peer concerns and challenges to clinicians.
  9. Formally communicate to all emergency department employees including 3rd party workers (such as security, cleaners, etc.) an acknowledgment that the fast-paced, high-stakes realities of emergency medicine create conditions that increase risk of patient harm from unconscious bias. Acknowledge that such bias exists on a systemic level and does not require individual intent to harm. The statement should reiterate Niagara Health's commitment to reduce patient harms resulting from unconscious bias and support staff in doing the same.
  10. Should develop and provide training for emergency department frontline staff on best practices for working with patients with substance use disorder (who misuse drugs intravenously). This training should also address confronting and mitigating bias against Indigenous people, patients with substance use disorder and other patients vulnerable to being harmed by bias.
  11. Continue to generate opportunities to expose Indigenous youth in the Niagara Region to careers in healthcare and first response, and to encourage them to join these professions.
  12. Continue to make best efforts to increase Indigenous representation on the Niagara Health Board by:
    1. Including more than one Indigenous member or demonstrating significant efforts towards the recruitment of more than one Indigenous member and a plan for successful future recruitment.
    2. Ensure continuous improvement of community engagement with the Indigenous Health Services and Reconciliation (IHSR) team, including engagement with Indigenous community agencies in Niagara with a standing report from the team to the Quality and Patient Experience Committee of the Board.
    3. Demonstrate significant effort toward recruitment of Indigenous people for executive roles.
  13. Co-design visual tools with Indigenous leaders, clinicians, and advocates to trigger awareness of anti-Indigenous bias in the emergency department. Placed in high-traffic staff areas, these tools leverage cognitive psychology and behavioral nudges to provide immediate, memorable cues for productive clinical decision-making.
  14. Consider implementing highly visible signage and accessible signaling tools, such as a 'Call for Help' button or red-flag system, that empower patients to alert staff if they perceive their clinical condition or another patient is deteriorating.
  15. To improve patient outcomes and reduce readmission rates, ensure that a hard copy of the personalized treatment plan and discharge summary is provided to every patient to support successful at-home recovery.
  16. Implement a sensitivity training program led by a third-party peer support (e.g. Quest) for all emergency department staff, utilizing workers with lived experience (ex unhoused, substance use disorder, mental health disorder, etc.) to provide insights into compassionate care and patient advocacy.

Triage and reassessment

  1. Provide support and advocacy for Indigenous patients in the emergency department and throughout Niagara Health at large, including by:
    1. expanding the IHRS team as necessary to include clinicians and ensure that the team can appropriately service Indigenous patients
    2. posting and enhancing signage within the emergency department to advise Indigenous patients of the IHRS patient advocate program and to provide instructions on seeking patient advocate assistance.
    3. enhancing Indigenous patients' cultural safety through their journey within and outside the hospital (e.g. ensuring patient-informed consent, contesting a diagnosis or a patient's Friendship Centres, to co-develop pathways and mechanisms to support Indigenous patient journeys outside the hospital.
  2. The hospital should:
    1. ensure sufficient staffing in the emergency department to meet operational demands, including triage assessments and reassessments
    2. communicate the expectation that triage nurses will take their own vitals, including from patients brought to the hospital by EMS paramedics, and ensure necessary protocols are in place to monitor compliance
    3. expand responsibilities of the waiting room Nurse Practitioner to include responsibilities for reassessments in the emergency department waiting room, based on patient's acuity at the intervals suggested in Canadian Triage and Acuity Scale / National Emergency Nurses Association Standards
    4. Communicate all expectations regarding triage assessments and reassessments to nurses
    5. Ensure extra nurses and physicians are available for on call situations where staffing levels are low, and emergency department volume is high
  3. To implement a prompt on the electronic medical record system for waiting room reassessments appropriate to acuity level, directed, at a minimum, to the nurse responsible for reassessments in the emergency department waiting room.
  4. To implement a prompt on the electronic medical record system for triage nurses to identify whether a medical directive is being initiated, the hospital should provide ongoing and refresher training on the Standards of Emergency Nursing and expectations relating to triage assessments and reassessments.
  5. To commit to a communication and education campaign to frontline staff and physicians relating to all implemented recommendations arising from this inquest.
  6. Optimize the Emergency Department seating layout by prioritizing the placement of high-acuity patients in treatment bays with direct line-of-sight to the Triage or Nursing stations.
  7. Designate a specific nurse, such as the charge nurse or triage nurse, to oversee all EMS transfers of care.

Quality assurance

  1. To gather data relating to the experiences of Indigenous patients with a view to assessing patient experiences and outcomes at the hospital, including in the emergency department.
  2. Data collection should be based on a self-identification model, be in keeping with Indigenous data sovereignty principles, and overseen by an Indigenous Data Advisory Committee made up of representation of local First Nations communities, health-related Indigenous organizations, and
  3. The hospital will collect and analyze the experiences of Indigenous staff and physicians at Niagara Health, using a third-party survey and analytics team with experience gathering narratives of Indigenous people.
  4. The hospital to collect and analyze Indigenous patient data and experience using the survey tool recommended by the Ontario Hospital Association, in collaboration with Indigenous Data Advisory Committee.
  5. Within one year of these recommendations, the hospital should report on its data collection efforts on its website.
  6. After one year of data collection and on an annual basis thereafter, the hospital is required to share on its website transparent information about the experiences of Indigenous patients in the emergency department.
  7. The hospital, with the participation of a member of the Diversity, Equity and Inclusion Team and the IHRS team, to review hospital policies to assess their ability to deliver and contribute to the provision of culturally safe healthcare to Indigenous patients. The hospital will undertake this review and report back on their progress within one year.
  8. The hospital to continue to undertake quality reviews aimed at preventing and reducing harm as required by legislation.
  9. The hospital to enact the necessary policies to strongly encourage that staff involved in patient care participate in these reviews, including by referencing that these reviews can lead to meaningful change after adverse patient outcomes. If they are unable to participate, their knowledge, information and beliefs with respect to the care they provided will be solicited and provided to the review committee.
  10. The hospital will continue to support its IHRS team in order to support challenging systemic barriers, addressing anti-Indigenous racism within the health system, resolving complaints, and protecting and advocating for patients. This includes working with Indigenous patients to ensure patient-informed consent (i.e., understand the risks and benefits of medical interventions), advocating for patients contesting a hospital discharge, coordinating and supporting patients' journey through outpatient care, referrals, and discharge planning, and enhancing Indigenous patients' cultural safety throughout their journey within and outside the hospital.
  11. To develop and implement a policy regarding transportation at discharge from the emergency department, which ensures that:
    1. the means of transportation is appropriate relative to the patient's condition
    2. individuals requiring assistance to ambulate (who normally do not require assistance ambulating and/or a mobility aid) are not discharged without (a) someone in attendance to assist the individual; (b) a taxi chit; or (c) the documented consent of the individual
  12. Deploy accessible feedback boxes at strategic points throughout the emergency department to capture patient experience. Designated staff will review these comments daily to ensure patient voices are heard and addressed promptly.
  13. Conduct regular policy reviews to verify that all performance standards remain attainable; where gaps exist, provide the necessary resources and support to ensure full organizational compliance.

Wellness

  1. Continue and enhance the Code Lavender, Be Well and Peer Support processes established by Niagara Health to provide immediate debriefing and support to staff involved in critical, other traumatic incidents, or a series of moderately traumatic events in the course of providing health services.
  2. Outside the circumstances of a Code Lavender, Niagara Health should consider establishing a process for proactively reaching out to staff known to have been involved in a critical, other traumatic incident, or a series of moderately traumatic events to:
  3. ensure they are aware of the Employee Assistance Program and other available resources
  4. offer an individual and/or group debrief with those involved, including third party peer support (e.g. QUEST), to promote emotional processing, self-reflection and reflective professional practice, and identify potential lessons learned at an individual and institutional level

Paramedic care

To Niagara Emergency Medical Services (NEMS):
  1. Continue its efforts to ensure the quality of its services by providing refresher training to all paramedics in its upcoming fall training and on a regular basis thereafter about the importance of:
    1. taking a baseline set of vital signs and assigning a CTAS score after vitals have been taken as part of the initial patient assessment in accordance with basic life support standards
    2. the disproportionate risks faced by individuals who misuse drugs intravenously and the importance of gathering information, including vital signs, in a timely manner consistent with the basic life support standards, including to determine whether the criteria on the Sepsis Prompt Card are met
  2. Continue its efforts to mitigate against bias in the provision of services to the community by conducting refresher anti-bias training relating to, among other things, patients who are Indigenous, unhoused or under-housed, and/or experiencing substance use disorders, and implementing an evaluation component in respect of same.
  3. Evaluate and consider how its investigative practices can be enhanced to ensure issues relating to systemic discrimination and unconscious bias are considered when allegations of discrimination and bias are made.
  4. In collaboration with Hamilton Health Sciences, Centre for Paramedic Education and Research and medical director: (a) consider updating the criteria on the current Sepsis Prompt Card to include intravenous drug use as a potential indicator of occult infection; and (b) educate all paramedics on any changes made.
  5. At its upcoming fall training and on a regular basis thereafter, NEMS will advise paramedics that in certain circumstances, it may be appropriate to update a patient's support person about a patient's status and destination, with specific reference to the circumstances relating to Heather Winterstein in December 2021, recognizing that paramedics have no obligation to collect contact information in the course of their duties.
  6. Evaluate and consider a policy requiring emergency communications nurses to log any information they collect about differences in a patient's presentation as compared to their baseline (including, for example, skin colour, ambulation, breathing, speech) in MARVLIS.
  7. Investigate voice-to-text tools that can read EMS notes aloud, ensuring the setup uses private audio to protect patient confidentiality to improve paramedic awareness of incoming notifications.
  8. Evaluate and consider technology solutions for vital testing and monitoring technologies designed to filter out vehicle vibration, ensuring reliable patient data and safety while in transit by ambulance.
  9. Ensure EMS keeps patients hooked up to their vital sign monitors throughout the intake process to allow for instant clinical assessment upon arrival.
To NEMS, Niagara Health and Niagara Regional Police Service (NRPS):
  1. Work together to evaluate and consider technology solutions and policies that would enhance the transfer of pertinent patient information between them, including the possibility of transferring vital signs and other pertinent information obtained from EMS to triage nurses, so that they have a fuller picture of a patient's health and the stability of vital signs.

Physician care

To Niagara Health:
  1. Provide training to emergency room physicians clarifying that sepsis screening tools, such as Systemic Inflammatory Response Syndrome / National Early Warning Score 2, are not designed to detect every case of sepsis and are not a replacement for physicians' clinical judgment. The training should guide physicians on the limitations of the SIRS screening tool when a white blood cell count is not obtained.
  2. Provide training to emergency room physicians with respect to withdrawal symptoms to support the application of differential diagnosis to patients who may be experiencing withdrawal.
  3. Provide training to physicians on the value of establishing a thorough differential diagnosis, as a means of confronting and mitigating bias against Indigenous patients, patients with substance use disorder, and other patients vulnerable to being harmed by bias.
  4. Implement a process of reviewing patient complaints against physicians with hospital privileges on
  5. Update the annual performance appraisal system for physicians with hospital privileges that would incorporate performance evaluations, patient complaints and other relevant metrics.
  6. Continue to provide adequate private examination space and attendant chaperones to facilitate physicians conducting assessments of disrobed patients.

Implementation

To the Ministry of Health:
  1. Ensure that sufficient funding is provided to Niagara Health and NEMS to enact the recommendations above.
  2. Provide dedicated funding to support Niagara Health's IHRS Team.
  3. To further allocate dedicated funding to Indigenous organizations (e.g. Friendship Centres, grassroots local organizations, Indigenous Primary Care Organizations, regional advocacy bodies, etc.) as well as First Nations, Métis, and Inuit communities to support the creation and/or expansion of Indigenous-led primary health services and mental health and addiction treatment programming.
  4. To fund NEMS's Street Outreach/Community Paramedics Team on a permanent basis.
  5. Consistent with Truth and Reconciliation Commission Call 23, the Ontario Ministry of Health should provide dedicated funding and support to “provide cultural competency training for all health professionals”. Such training should be consistent with Call 24 regarding the substance of training provided by medical and nursing schools, namely: “Aboriginal health issues, including the history and legacy of residential schools, the United Nations Declaration on the Rights of Indigenous Peoples, Treaties and Aboriginal rights, and Indigenous teachings and practices, as well as skills-based training in intercultural competency, conflict resolution, human rights, and anti-racism”.
  6. Request that the Provincial Ministry of Health secure federal grants to expand Indigenous cultural awareness programs, ensuring healthcare staff are equipped to provide culturally safe and inclusive care.
To Niagara Health and NEMS:
  1. Release an annual public report on the implementation of the inquest recommendations, beginning May 1, 2027, for 5 years.
To Niagara Health, NRPS, NEMS:
  1. Participate in a healing ceremony with the family and community of Heather Winterstein.

Legacy

To Niagara Health:
  1. Establish a plaque and picture dedicated to Heather in the Healing Garden, with content of plaque to be determined in collaboration with the Family of Heather Winterstein.
  2. The Hospital will create a healthcare related education fund with a local post secondary institution in Heather Winterstein's name, with priority given to Indigenous students
To the College of Nurses of Ontario:
  1. Consistent with Calls 23 and 24 of the Truth and Reconciliation Commission, the College of Nurses of Ontario should enhance the learning resources and tools available to nurses to practice cultural safety and cultural humility as required by Principle 2 of the College's Code of Conduct. Such resources should be skills-based and draw from resources, best practices and lessons learned by nursing regulators in other jurisdictions, such as the British Columbia College of Nurses and Midwives, and be developed with input from relevant experts in unconscious bias in health care, Indigenous nurses, and health-related Indigenous organizations.

April

Beskorowany, Mark

Held at: virtual, 25 Morton Shulman Avenue, Toronto        
From: April 8        
To: April 14, 2026        
By: Bonnie Goldberg, presiding officer for Ontario         
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Mark Beskorowany        
Age: 54         
Date and time of death: August 21, 2019         
Place of death: Health Sciences North, Sudbury        
Cause of death: pelvic crush injury         
By what means: accident

(Original signed by: Foreperson)

The verdict was received on April 14, 2026
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: Mark Beskorowany

Jury recommendations
To Ministry of Labour, Training, Immigration and Skills Development (MLTISD)
  1. Conduct proactive inspections of multiple Consbec workplaces to determine and assess the adequacy of Consbec’s work procedures and risk assessments related to tramming rock drills on sloped surfaces. This is to be done within one year of the conclusion of this inquest.

  2. Conduct a review of the Mining Regulation and develop a plan to strengthen measures to protect workers operating rock drills at surface mines. The review should include analyzing regulations from other jurisdictions.

    As part of this review, the MLTISD should consider:

    1. Regulatory and non-regulatory measures to protect workers from uncontrolled movement of a drill. This should include measures to protect workers from being positioned in a manner that may endanger the worker and phasing out older drills that are configured in a manner that may endanger the operator. This review is to include the development of an industry-wide safety certification standard for rock drills. The review will include a proposed date wherein all rock drills sold, purchased, manufactured, imported, or operated in Ontario meet an industry-wide safety standard with features included but, not limited to, rollover cages, remote control options, etc.
    2. Amending the regulation to provide that all equipment shall be used in accordance with the most current version of the manufacturer’s instructions and those instructions should be available to the worker.
    3. Increasing the requirements for supervisors to conduct in-person examinations of work areas where drilling or blasting is taking place.
    4. Conduct an industry-wide assessment determining whether there is an adequate volume of supervisors to support workers and adhere to safety standards.
  3. In consultation with relevant stakeholders, update the Common Core for Surface Miner training standard and specialty modules to include safe work procedures for operating and tramming a drill on sloped surfaces and develop refresher training modules for workers who are already in the industry.
  4. Encourage inspectors to advise workplace parties that they can consult with their safety association for guidance to assist with compliance with orders.
  5. Issue a refreshed alert relating to safe operation of rock drills which will be updated and available on its website.
To Infrastructure Health and Safety Association (IHSA)
  1. In collaboration with Surface Mining and Aggregates Working Group:
    1. Update the Safe Work Practices for the Aggregates Industry guidelines, to include a chapter on safe work procedures for operating and tramming a drill on surfaces, sloped and otherwise.
    2. Distribute an updated alert relating to safe operation of rock drills.
    3. Create a Safety Talk on safe work practices for surface rock drilling focused on operating drills on uneven ground.
  2. Continue to promptly inform the surface mining and aggregates industry when it is notified or becomes aware of a critical injury or fatality within the sector. Where appropriate and permitted, share available information and direct industry stakeholders to relevant resources, tools, and best practices aimed at preventing similar incidents.
To MLTISD, IHSA and Workplace Safety North
  1. Collaborate on a public campaign to promote an alert related to safe operation of rock drills and distribute the alert in newsletters, communication channels and social media.
  2. Incorporate the circumstances of this inquest into training modules, safety talks and/or public campaigns about safe operation of rock drills.

Diodati, Michael

Held at: virtual, 25 Morton Shulman Avenue, Toronto        
From: April 13         
To: April 24, 2026        
By: Dr. Richard McLean, presiding officer for Ontario        
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Michael Diodati        
Age: 61           
Date and time of death: November 11, 2021        
Place of death: Niagara Health System Niagara Falls Hospital, 5546 Portage Rd, Niagara Falls        
Cause of death: complications of Group A streptococcus sepsis        
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on April 24, 2026
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: Michael Diodati

Jury recommendations

Reporting of critical results

To Niagara Health System (NHS):
  1. Continue work on the Emergency Department Call Back Protocol to finalize written instructions to all staff who work in the emergency departments (EDs) and urgent care centres (UCC) of Niagara Health System on the requirements for completing call backs to patients. The policy must include the following:
    1. Clearly state the roles and responsibilities of each staff member in the ED and UCC in relation to receiving and recording lab results, reviewing lab results and providing instructions, contacting patients where instructed, and recording actions taken.
    2. Require that laboratory results deemed "critical" to be flagged by ED staff for physician or nurse practitioner review within 15 minutes of receiving the result.
    3. When the ED physician or nurse practitioner instructs the staff to contact a patient to advise them of a "critical" lab result and any instructions, assigned staff member(s) must make at least two (2) telephone calls to the patient within eight hours of the instructions being provided by the ED physician or nurse practitioner.
  2. Implement a process where a reminder flag can be added to the electronic medical record software if no telephone call has been made within four hours of the ED physician or nurse practitioner instructing staff to tell the patient to return to the ED. That reminder flag should repeat every 15 minutes until a call attempt has been made and recorded.
  3. Implement a defined escalation process with an electronic trigger (e.g. a flag) that provides directions to staff in the ED and UCC who are responsible for contacting patients with laboratory results, of permitted alternative options for contacting the patient if the patient has not been contacted verbally via telephone (voice mail not considered as a direct contact, direct contact is required), within eight hours of the instructions being provided by the ED physician or nurse practitioner. Alternative options will respect all applicable privacy laws and may include:
    1. contacting any secondary address or phone number for the patient that is included in the patient's medical chart
    2. contacting all emergency contacts for the patient
    3. contacting all next of kin listed for the patient
    4. seek further guidance from an ED physician or nurse practitioner or ED manager/director
    5. contact the Niagara Regional Police Service for assistance
  4. Audits of the Emergency Department Call Back Protocol should be conducted to ensure it is being followed by all staff. The audits will be completed with the following frequency:
    1. in the first year after the protocol is completed, there will be four audits done quarterly
    2. in the second year after the protocol is completed, there will be two audits done within six months of each other
    3. starting in the third year after the protocol is completed, there will be one audit per year

The frequency of the audits may be increased at any time if issues are identified.

  1. Until the Emergency Department Call Back Protocol is finalized, provide clear direction to all staff who work in the EDs and UCCs, including any agency nurses or locum physicians, of the protocol requirements as outlined in recommendations 1 and 3 above.
  2. To ensure continuity of care, remind all health care providers in the EDs and UCC that all Niagara Detention Centre (NDC) Consultation forms that come with a patient referred by NDC to the EDs or UCC must be completed and signed, must list pending test results, and be provided to the correctional officer(s) with the patient so that they may be returned to NDC. Whenever feasible, NHS should attach a paper copy of physician notes, orders and lab results to the completed NDC Consultation form.
  3. Ensure patient charts allow for ED and UCC records to indicate that the patient has been "discharged to a correctional facility".

NHS Registration System

To NHS:
  1. An annual reminder needs to be made to all NHS registration staff that registration clerks are expected to verify that a patient's contact information is current. This includes verifying that all of the following contact information is current: patient's address, patient's telephone number, identity of the patient's next of kin and telephone number, and identity of the patient's emergency contact and phone number.
  2. Audits of the registration system will be conducted to ensure that all registration staff are following the registration process for any patient who arrives from a correctional facility or juvenile detention centre. The audits will be conducted at the same frequency as stated in recommendation #4 above.

Staffing

To the Ministry of the Solicitor General and NDC:
  1. Continue to review security measures at NDC and explore ways to increase monitoring and surveillance of blind spots within the medium security dorms.

Communication and outreach

  1. Continue efforts at information sharing and improvement of communication with NHS and other stakeholders.
  2. Initiate outreach efforts to educate NHS' frontline clinical staff with respect to the nature and extent of health care services at NDC.
  3. Conduct a review of information sharing between NDC and NHS to consider whether existing protocols need to be updated so that all relevant and pertinent information regarding the patient is available in a timely manner to healthcare staff at both NDC and NHS.
  4. To ensure continuity of care for persons in custody at NDC who are transported to hospital, continue to ensure that a NDC Consultation Form is completed and sent with the person when they are transported to the hospital.
  5. Increase use of Clinical Viewer and Clinical Connect, to improve the sharing of relevant patient medical information. A trained Clinical Viewer and Clinical Connect user is to be available on all shifts.
  6. Consider ways to improve communications with family members of a person in custody when the person in custody is facing a serious or life-threatening health care or medical situation so that family members know about the severity of the situation.
  7. Ensure that all critical laboratory results that are received at NDC are communicated immediately to a primary care provider.
  8. Remind healthcare staff who are responsible for administering medications that when a person in custody refuses to take medication, the healthcare staff must receive a verbal refusal and document the refusal reason from the person in custody.

Post-assault follow-up

  1. Healthcare staff must complete a head-to-toe assessment of a patient who has been the victim of an assault, and recording details about the assessment in the patient chart so any injuries and/ or wounds can be monitored and tracked.

Assessments

  1. Establish a suitable area for an infirmary that is in close proximity to the nurse station at NDC.
  2. Include a mandatory observation/ follow up with a NDC doctor/nurse practitioner after release from a hospital visit.

May

Bourassa, Justin

Held at: virtual, 25 Morton Shulman Avenue, Toronto  
From: May 4, 2026
To: May 12, 2026
By: Murray Segal, presiding officer for Ontario  
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Justin Bourassa  
Age: 29     
Date and time of death: August 17, 2021
Place of death: London Health Sciences Centre – Victoria Hospital (800 Commissioners Road East, London, ON)
Cause of death: Gunshot wound of the Neck and Chest
By what means: Homicide

(Original signed by: Foreperson)

The verdict was received on May 12, 2026
Coroner's name: Murray Segal 
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Justin Bourassa 

Recommendations To: London Police Service (LPS), Ontario Police College (OPC) and LPS Board TRAINING
Investigative Detention Guidelines
  1. Develop scenario-specific guidelines to support de-escalation and conflict prevention in investigative These guidelines should:
    1. Recognize the distinction between risk supported by specific and articulable indicators and situations involving uncertainty, incomplete information, delayed compliance, or ambiguous behaviour;
    2. encourage the prioritization of communication and assessment;
    3. recognize that individuals may need time to understand, process, and respond to police direction;
    4. emphasize the Relational Policing Approach as tool that can improve assessment, officer safety, and the range of available responses;
    5. affirm that time, distance, and containment are tactical options that may assist officers in gathering information and managing the urgency of an interaction;
    6. recognize that communication, time, distance, and rapport-building may assist in conflict prevention, de-escalation, and supporting safer outcomes; and
    7. provide guidance distinguishing situations calling for immediate physical control from those where communication, observation, containment, or delayed detention may safely be considered.
  2. Police training (including Block Training) and investigative detention guidelines should recognize that fear, hesitation, confusion, delayed compliance, non-responsiveness, questioning, freezing, or startled movement may, in some circumstances, reflect stress, uncertainty, or efforts to process sudden police intervention, rather than resistance or
Maintaining Situational Decision-Making in Use-of-Force Encounters
  1. Police training should address the potential effect of prior use-of-force experiences, stress, and situational pressures on officer perception and decision making.

Training should include:

  1. awareness of how prior traumatic or high-stress experiences may influence situational assessment;
  2. guidance on how time pressure and perceived urgency may influence perception and decision-making, and how awareness of these factors may support measured responses and reduce the potential for escalation; and
  3. encouraging officers, where appropriate and safe to do so, to slow encounters, gather information and reassess threats before escalating police-public interactions.
Training
  1. Review and enhance training and coaching programs, including scenario-based and annual block training and/or an Advanced Defensive Tactics Training module, to incorporate lessons learned and emerging issues drawn from inquests, critical incidents, use-of-force reviews, and significant use-of-force events.

    Training should include:
    1. relational policing during investigative detentions;
    2. officer presence in relation to de-escalation and conflict prevention;
    3. safe handcuffing techniques;
    4. ground control techniques, grappling situations, and officer rescue from rear neck restraint or other high-risk positions;
    5. recognition and avoidance of vulnerable, high-risk positions including strategies to reduce the likelihood of rear-neck restraint situations and other positional disadvantages;
    6. development of decision-making skills and recognition of viable non-lethal intervention options during rapidly evolving close-contact encounters;
    7. officer and civilian rescue interventions where lethal and less-lethal options may be limited; and
    8. simulation exercises that allow officers to practice and assess non-lethal intervention options in close-contact or third-party scenarios, including the use of mannequins, controlled simulations, or other safe training methodologies (such as video simulation) where live replication would create unnecessary risk. Where unsafe or impractical, could watch video situations and or simulations.
Recommendations To: London Police Service (LPS) and LPS Board Best Practices for Police
Radio Use
  1. In consultation with dispatchers and experienced officers with expertise in police radio use and police communications, develop and disseminate best practices for police radio communication to improve safe, effective, and efficient operational communication.
Maintaining Situational Decision-Making in Use-of-Force Encounters
  1. Ensure existing use-of-force reporting, review, and wellness processes support cumulative review of officer use-of-force involvement and facilitate timely intervention, monitoring, assessment, training, and support where repeated high risk exposures or notable patterns are identified.
Post-Use-of-Force Assessment
  1. Require a mandatory, post-incident psychological and fitness-for-duty assessment following any police use of force resulting in death or serious bodily harm. Assessments should be conducted by qualified mental health professionals with appropriate clinical independence.
Review of Return to Work and Reintegration Program
  1. Implement a formal evaluation and assessment process for the Reintegration Program to support ongoing improvement, including the collection and review of anonymized participation data to monitor program use.
Review of Fit for Duty Policy
  1. Provide supervisory officers with enhanced training on recognizing potential mental health concerns and appropriate options to address and support such concerns.
Post-Incident Tactical Debriefing and Organizational Learning
  1. Implement mandatory, post-incident, tactical debriefing processes following critical incidents involving death or serious injury, to occur at the earliest opportunity following SIU and all other related investigations (civil, criminal, inquests, etc). Findings and lessons learned should be shared with training units and incorporated into future training, policy review, and scenario development.

Debriefs should review:

  1. police communications;
  2. police-public interactions relating to de-escalation and conflict prevention;
  3. investigative detention practices;
  4. officer wellness considerations;
  5. lessons learned; and
  6. opportunities for training enhancement.