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Change its name to one that better reflects its purpose. Employers shall create and implement a policy on the appropriate use of cell phones and mobile devices at construction projects that includes methods for complying with 1(a) and 1(b). We recommend that a public awareness campaign be developed that highlights the dangers of working in proximity to overhead power lines and provides information on how members of the public can report seemingly unsafe or non-compliant practices. Held at:25 Morton Schulman Avenue, Toronto (virtually)From:February 28To:March 11, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Quinn EmmersonMacDougallDate and time of death: April 3, 2018 at 4:23 p.m.Place of death:Hamilton General Hospital, 237 Barton Street East, Hamilton, OntarioCause of death:gunshot wound of the torso (right chest)By what means:homicide, The verdict was received on March 11, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:SantosGiven name(s):FernandoAge:59. The ministry should take immediate steps to improve opportunities for persons in custody to access recreation and exercise facilities and programs. arrives at St. Pancras Coroner's Court for a hearing into the singer's . Improve public awareness and knowledge of community-based supports for persons experiencing mental health issues should target young people, and utilize channels of communication that are accessible and suitable for youth. In December a coroner . They contact the survivor to inform her of the offenders living situation, any conditions or limitations on his movement or activities, and what she should do in the event of a possible breach by the offender. They must make enquiries of any death that is reported to them and investigate the death if it appears that: the cause of death is unknown the. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. Held at: TorontoFrom:July 25To: July 27, 2022By:Bonnie Goldberg,Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Ricardo SoaresDate and time of death: November 17, 2017 at 2:37 p.m.Place of death:Ford Drive near Kingsway Drive, OakvilleCause of death:blunt force injuries to the head, chest and abdomenBy what means:accident, The verdict was received on July 18, 2022Presiding officer's name:Bonnie Goldberg(Original signed by presiding officer), Surname: WettlauferGiven name(s): Alexander PeterAge: 21. Specifically, the the ministry should: ensure that all Native Inmate Liaison Officer/Indigenous Liaison Officer (, benefits, that include access to an employee assistance program, opportunities for support following traumatic incidents, create policy and direction that recognizes the role and function of. Inform staff and affected personnel that resources are available to support them with respect to work related stress. Evidence relating to the Five Incidents . Continue to ensure that all young people in care have reasonable access to cell phones or other technologies they may need to communicate with their family, their First Nation and others important to them. Recommend training programs be reviewed on an ongoing basis to maximize employees comprehension of content. The ministry should amend its policies and practices for admissions officer/. As you say modern Coroners' inquests records can be found amongst departmental files at The National Archives including most investigations into air accidents which are open after 30 or so years, however some like the inquest into the 1974 bombing at the Tower of London (MEPO 26/252, which include a transcript of coroner's inquest and statements) is closed for 84 years and others like the . In determining whether an, any history of suicidal behaviours (ideations or attempts), whether the person is in an out-of-home placement at a mental health facility for children and youth. Continue ongoing quality assessments to drive continuous improvement of standard operating procedures and protocols, documentation, and best practices with mental health services: to review and audit core services within Windsor Regional Hospital annually to ensure compliance to standards are met and keeping pace with community demands proactively. When first addressing an employee in medical distress, a full body assessment (head to toe) must be completed. Implement regular reviews to ensure the accuracy and reliability of the information in the records management system available to officers. Most medical treatment-related Inquest hearings are held in public, usually without a jury, and the Coroner decides the verdict having heard all the necessary evidence. Once the ministry completes the consultations on tear-resistant sheets and blankets, if there are viable options, the ministry endeavor to implement the use of such bedding in all provincial institutions. Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors. Consider including a case study focused on falling ice in excavations in future inspector training material. The ministry should adopt Good Samaritan principles in operational policies and practices to encourage persons in custody to call for help or try to help another person suspected of being in medical distress or come forward with information about drugs within the institution, without being subjected to any institutional misconduct proceedings for possession or use of contraband. Acknowledgement of i) and ii) by the competent assistant. Coroner's Officers are police officers who work under the direction of the coroner and liaise with bereaved families, the emergency services, government agencies, doctors, hospitals and funeral directors. That care and services must be provided using a trauma informed approach to ensure that individuals who have suffered complex traumas are not excluded from the services that may assist them. Crowns should actively oppose variation requests to have firearms returned for any purpose, such as hunting. Ensure that the file reviewer position that has been implemented at the, Increase the number of hours for physicians at, Explore options to increase the physical space available at the. Consider the creation of a multidisciplinary mental health services team approach, (including a mental health case manager) for children and their families to support continuity of care throughout their childhood and to provide broad and supportive care. Roger and Bradley Stockton crashed on the second lap of last year's final sidecar race. Encourage all fixed term Nurse Practitioners at the, Reinstate funding for an embedded Kawartha Lakes Police Service detachment inside the Central East Correctional Centre. Seek and allocate adequate funding and resources to implement these recommendations. Clarify and enhance the use of high-risk committees by: Strengthening provincial guidelines by identifying high-risk cases that should be referred to committee. Consult with the Ontario Anti-Racism Directorate to analyze race-based data collected by police services to measure and evaluate police service performance on use of force, take corrective action to address systemic discrimination and provide clear and transparent information to the public on bias and discriminatory use of force. We recommend that significant and automatic fines should be levied against any company/constructor that fails to ensure that a dedicated Signaller be assigned to Hydro-vac crews and/or any crane operation when working in the vicinity of overhead powerlines. Enhance procedures for increasing communication and service coordination contained within the signed protocol between child welfare services and the services provided by urban Indigenous agencies, including but not limited to: De dwa da dehs nye s (Aboriginal Health Centre), Hamilton Regional Indian Center, Niwasa Kedaaswin Teg, the Native Womens Centre and the Niagara Peninsula Aboriginal Area Management Board (, Continue to prioritize the Child Welfare Sector Commitments to Reconciliation by transparently sharing data (without personal information and in accordance with Part X of the. A list of the inquests scheduled for hearing in the Oxford Coroner's Court. When the coroner's jury could not determine a cause of death, an "_" will appear in the verdict category. Implement the National Action Plan on Gender-based Violence in a timely manner. On the second day of an inquest at Dublin District Coroner's Court today, counsel for Mr Sweeney's family, Roger Murray SC, said the net effect of the patient being discharged from the high . (Note: this is included in both mining industry and Ministry of Labour section). Possible outcomes include: natural causes; accident; suicide; unlawful or lawful killing; industrial disease and open verdicts (where there is insufficient evidence for any other verdict). Develop workable practices to improve contact and connection of individual young people with safe adults in their circle of care, to reduce circumstances where children are absent and their whereabouts are unknown. Ensure that police officers can accurately identify their own, Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (. Provide annual reports, accessible to the public, on ongoing research findings through the Chief Prevention Officer. The ministry should explore the feasibility of creating and implementing a plan for mental health assessments to be completed by a qualified professional within six hours of the admission, and for all other admissions procedures to be completed within 24 hours of the inmates admission. . development of an integrated Plan of Care focused on the social determinants of health for the family and child that follows them through community services when they are in the community and also when they are in the care of a childrens aid society and incorporate the cultural and spiritual needs of the child; and. This unique intersection of Blackness and lived experience of mental health issues must be specifically addressed in any training on use of force, de-escalation, and police interaction with such persons. For the purpose of assisting clinicians in directing patients to receive timely mental health services and promoting accountability of community mental health services, a direction requiring that all hospital and community-based mental health services that receive funding from the Government of Ontario: collect and publish monthly non-identifying data regarding: wait times for treatment (i.e., actual receipt of mental health services by mental health professionals as opposed to waiting times for intake) and patient volumes, days and hours of mental health services provided, provide the resources to allow hospitals and community-based mental health services to provide this data, increase mental health awareness and promotion of initiatives within communities to address the lack of familiarity of services and options available for persons and families dealing with mental health situations. All physician assistants and doctors are trained on all medical equipment available at the worksite. The OCC distributes all verdicts and recommendations to organizations for them to implement, including: 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. There are no fees attached to this service. Review the mandate of Probation Services to prioritize: Require that probation officers, in a timely manner, ensure: There is an up-to-date risk assessment in the file. The ministry shall consult with an expert in trauma-informed care to review the current care programs to provide specific suggestions for institutional changes to promote trauma informed practices within the detention centre. Review, in consultation with stakeholders, the discretionary nature of inquests into the deaths of children in care and consider advocating for legislative change requiring said deaths to be the subject of mandatory inquests. To ensure open and full communication, data collection, knowledge, and relationship-building regarding the children, youth, and families transferred to ongoing service, consider implementing a one care team per family system with consideration to the file loads of workers. The ministry shall actively facilitate meaningful social interaction and prioritize face-to-face and direct human contact without physical barriers, empathetic exchange, and sustained social interaction. The Coroners' Courts Support Service (CCVS) is an independent voluntary organisation whose trained volunteers offer emotional support and practical help to bereaved families, witnesses and others. Consider using specialized care units for inmates who have been removed from suicide watch. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. Provide Indigenous-led cultural competency and cultural safety training to all officers. The coroner has a degree of discretion to call a jury in any case that is in the public interest, but a jury must be called if the death occurred in prison; in police custody; by accident, poisoning or any disease that requires other government departments to be notified; or when circumstances exist that might affect the health and safety of the Hearings. The revisions should require correctional institutions to ensure that: one or more staff member is designated to develop a recovery plan when an inmate is removed from suicide watch, one or more staff member is designated to oversee the plan and ensure it is implemented, placement of inmates in recovery is reviewed with health care staff and this review is documented, The recovery plan is available for health care and operational staff. Reconvene one year following the verdict to discuss the progress in implementing these recommendations. A physician and/or nurse practitioner should be available to provide in-person health care services on weekends at the, Addictions counselors, discharge planners and social workers should be available to provide in-person services on weekends at the. It should be clear that it is broadly accessible and not limited to a particular kind of relationship. The ministry should update all forms to remove the term North American Indian in favour of First Nations/Inuit/Mtis on any admission or information forms used with people in custody. As inquest concludes seven years after incident, coroner says pilot should have abandoned a manoeuvre he was undertaking Caroline Davies and agency Tue 20 Dec 2022 11.47 EST Last modified on Wed . Explore options for privacy screens or barriers around toilets in cells to avoid the need for inmates to fashion their own privacy sheets. Ensure that security patrols are completed during shift changeovers. Explore the possibility of developing and including crisis intervention training as part of the mandatory curriculum for police recruits at the Ontario Police College and the requirement that all officers re-qualify at a determined interval. This decision is made by the Coroner. Mandatory skid steer operation certification and re-certification process. The Solicitor General of Ontario should study the phenomenon of individuals attempting to induce police officers to use lethal force, to improve best police practices across the province. The ministry shall update policy so that phone calls by persons in custody are not referred to as a privilege. What is an 'investigation'? Health and safety representatives are selected in a manner that ensures independence. A-Z of records. Be staffed 24 hours a day and 7 days a week. Immediately institute a provincial implementation committee dedicated to ensuring that the recommendations from this Inquest are comprehensively considered, and any responses are fully reported and published. In compliance with its by-laws, the Board will create terms of reference for its governance committee and make the terms of reference public. In consultation with residential homes and child and youth mental health facilities like Lynwood, develop a common joint responsibility protocol governing the process, roles and responsibilities when it comes to searching for youth who have left congregate settings without permission. In recognition of the shortage of beds in detox/treatment (rehabilitation) facilities in the City of Thunder Bay, the number of beds in such programs should be increased to adequately meet the needs of the community. The verdict was received on December 1, 2021 Coroner's name: Dr. Steven Bodley (Original signed by coroner) We, the jury, wish to make the following recommendations: Inquest into the death of: Mark King Jeffrey Jury recommendations Correctional Services of Canada should: make the Anijaarniq: A Holistic Inuit Strategy publicly available In order to promote, protect, and prioritize worker health and safety, road-resurfacing contracts should be reviewed with attention to how time limits on construction work and limits on allowable lane closures are established. The implementation plan should be made public in order to ensure accountability. These reviews should analyze relevant health care files and assess quality of care. Create guidelines for staff in making decisions regarding whether to issue, review, revoke, or add conditions to. In most cases, no further action is required, and the death can be registered as normal. Mandatory use of a signaller when operating a skid steer. Tailboard meetings/forms must be completed. Please note inquests can be changed at the last minute, please check before attending. The ministry shall consult with the federal government and other provinces and territories to determine if there is bedding that is less susceptible to tearing for use by persons in custody not on suicide watch. Implement recommendation #20 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. In jury inquests, the coroner directs the jury on matters of law and the jury decides the appropriate verdict . If none already exists, explore with community mental health partners, the feasibility of establishing and adequately resourcing joint mental health-police response teams to assist with person in crisis calls for service. This will require consultation with and inclusion of a diverse group of Indigenous communities/agencies, in recognition of the fact that Indigenous cultures/traditions/ways of being are not monolithic and that Thunder Bay is home to Indigenous peoples from across the North who possess a spectrum of cultural values/languages/ways of being. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. models in other jurisdictions that identify relevant. whether the missing person is an Indigenous youth. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. Implement recommendation #6 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Require all police services to immediately inform the Chief Firearms Officer (, Create a Universal RMS records management system accessible by all police services (including federal, provincial, municipal, military and First Nations) in Ontario, with appropriate read/write access to all. To ensure the safety and ongoing wellness of the children in its care, where a youth has disclosed suicidal behaviours or ideation, make best efforts to bring together all those involved in a youths circle of care to discuss and assess the youths situation and participate in safety planning for the youth (including the youths self-identified support, youths guardian, First Nation if applicable, medical team, supportive community members and family where appropriate). Share those best practices with construction sector employers and constructors. The ministry should undertake a study to identify the effects of overcrowding, and other living conditions on inmate populations especially those with addictions and/or pre-existing mental illness and to take any appropriate corrective measures. Provide direct, sustainable, equitable, and adequate joint funding from the named Ministries and Government of Canada to First Nations, off-reserve Indigenous service providers, and non-Indigenous service providers serving off-reserve First Nations children, youth and families to increase the capacity for collaboration in the provision of child welfare and mental health services. Date of inquest. This should include funding for more dedicated officers who can conduct drug investigations and share information with appropriate. In addition, such education should be repeated quarterly. Implement recommendation #5 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. The Ministry of the Solicitor General is committed to overall public safety and ensuring Ontarios communities are supported and protected by effective and accountable law enforcement, correctional services, death investigations, forensic science services, emergency management operations and animal welfare services. Held at: WindsorFrom:June 20To: June 30, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Delilah SophiaBlairDate and time of death: May 21, 2017 at 8:58 p.m.Place of death:Windsor Regional Hospital Ouellette CampusCause of death:hangingBy what means:suicide, The verdict was received on June 30, 2022Coroner's name:Dr.David Eden(Original signed by coroner), The term SWDC/ministry means SWDC and the ministry, Surname:FerranteGiven name(s):FrankAge:44. It is recommended that construction associations, including without limitation those listed at subparagraph 2.1, incorporate and promote a best practice for dump truck operators exiting haulage trucks to adhere to the following steps: position wheel chocks in appropriate locations, refrain from placing yourself between tires and/or axles, 2.1 Infrastructure Health and Safety Association. The coroner must investigate a death, known as an inquest, if they think that: someone died a violent or unnatural death, the cause of death is unknown, or someone died in prison, police custody or state detention. The ministry should use the Indigenous led study to create and implement a policy on using Indigenous cultural practices as solutions to combating the opioid crisis at. Research and, if appropriate, develop and integrate additional flags into the records management systems that accurately identify an active, serious threat to officers and the public, including behavioural and mental health flags, and a numerical measurement of risk. Inquests are held at HM Coroner's Court in Woking. We recommend that, absent exceptional circumstances, claims should be processed within 30 days of receipt of the documentation from the correctional facility. The Coroner's officer will usually inform interested parties to the Inquest who is to give evidence at the hearing. The verdict of the coroner's jury will fall into one of the following five categories: accident, natural, suicide, homicide and justifiable homicide. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. Specifically, they should consider the length or passage of time since a volunteer had any criminal convictions and the nature of the criminal conviction to determine criteria that would increase Indigenous volunteers participation in Indigenous programing and to provide peer resources in an effective way. The ministry should seek funding to implement these recommendations. This training should also include periodic or ongoing refresher training. Date inquest concluded. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. The summary should be placed at the front of each health care record and should list all serious medical diagnoses, including opioid use disorder. Explore the capability of the information management systems to accurately capture the number of calls for service which are initially reported and dispatched as another type of call but are later assessed by the responding officers to be a call which has a significant person in crisis component. The Toronto Police Service should continue to explore the feasibility of implementing body-worn cameras for all. The coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . Funding for services provided to survivors that allows for the hiring and retention of skilled and experienced staff so that they are not required to rely on volunteers and fundraisers in order to provide services to survivors. Fund for safe rooms to be installed in survivors homes in high-risk cases. Include coercive control, as defined in the. Ensure that the employer continues to properly identify and review Potential Chemical Hazards of cyanide at the mine site and modify the training, procedures and medical response as required. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. Increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. The Toronto Police Service should review research and studies in regard to use of non-lethal tools to incapacitate a subject in possession of a firearm. Require employers to develop and implement cyanide awareness training that meets requirements set out in the Regulation for the content of such training and frequency of refresher training. That the Thunder Bay Police Service Board retain an expert consultant for the purposes of providing an independent assessment of the level of staffing required of the Thunder Bay Police Service. Responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth. support for the development of programs that are flexible and able to respond to a range of needs including chronic and acute needs in a range of health and well-being domains. That sufficient staff be hired and maintained to allow for constant visual monitoring of the living units and to adequately and immediately intervene in any circumstances of drugs or other contraband being found. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. A coroner's inquest is a public court hearing where the coroner determines about how, when and where someone died following a post-mortem.