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

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.

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.