It is recommended that all Ontario mines actively using metallurgical cyanide establish clearly demarcated cyanide zones wherever cyanide is used or may be reasonably found at harmful concentrations. Consideration of the remoteness quotient used to calculate funding in other social services, such as education and policing. Held at: TorontoFrom:May 16To: June 3, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Marc Diza EkambaDate and time of death:March 20, 2015 at 10:53 p.m.Place of death:3070 Queen Frederica Drive, Mississauga, OntarioCause of death:multiple gunshot woundsBy what means:homicide, The verdict was received on June 3, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:VeilletteGiven name(s):Jean HervAge:48. Conduct a comprehensive, third-party audit of its health and safety system. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Isle of Man inquest hears of father and son's TT sidecar deaths mechanical devices, such as a pin, that can be inserted into a boom or crane to prevent movement into the prohibited zone. Held at:TorontoFrom: September 6To: September 9, 2022By: Dr. Mary Beth Bourne, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Jacob GordonDate and time of death: November 24th, 2015 at 10:23 a.m.Place of death:Mackenzie Richmond Hill Hospital, 10 Trench Street, Richmond HillCause of death:electrocutionBy what means:accident, The verdict was received on September 9, 2022Presiding officer's name: Dr. Mary Beth Bourne(Original signed by presiding officer), Surname: MahoneyGiven name(s): MatthewAge:33. 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. The Coroner cannot make any decisions as to civil or criminal liability, but at the end of an inquest hearing a decision will be made on where, when, and how the person has died. Inject a significant one-time investment into, Realign the approach to public funding provided to. The provision of therapeutic care. That the Thunder Bay Police Service Board consider creating a position of Deputy Chief, Indigenous Relations. Inquest to conclude. That bystander training be provided to police officers so that officers feel more comfortable addressing inappropriate behavior by colleagues. It should have no impact on Ontario Works or Ontario Disability Support Plan payments. Held at: TorontoFrom:June 29To: June 29, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Frank FerranteDate and time of death: July 28, 2015 at 8:34 p.m.Place of death:Southlake Regional Health Centre, 596 Davis Drive, NewmarketCause of death:heat strokeBy what means:accident, The verdict was received on June 29, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:YonanGiven name(s):MettiAge:66. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. 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. . The verdict of the coroner's jury will fall into one of the following five categories: accident, natural, suicide, homicide and justifiable homicide. The reviewers should work with the local health care team to identify gaps and find solutions. Even in countries where the jury system is strong, the coroner's jury, which originated in medieval England, is a disappearing form. 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). Provide professional education and training for justice system personnel on. the cost of transportation for survivors and service providers. Appropriate perpetrator programs and supports needed to accompany electronic monitoring. The ministry should consult with and receive expert advice on remedies to improve living conditions and healthcare delivery and implement any potential life saving strategies on an urgent basis. The data should be standardized, disaggregated, tabulated and publicly reported. Continue to follow the international Cyanide Management Code. What do different Coroner's Conclusions mean? - Enable Law Create guidelines for staff in making decisions regarding whether to issue, review, revoke, or add conditions to. Amend section 232(1) of the Construction Regulations to: Clarify that the walls of an excavation shall be stripped of ice that may slide, roll or fall upon a worker. Coroner training overview - Courts and Tribunals Judiciary 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. Held at:Town of MidlandFrom: October 17To: October 20, 2022By:Dr. Mary Beth Bourne, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Vikram DhindsaDate and time of death: January 18, 2017 at 5:12 a.m.Place of death:Unit 3 A Wing, Cell #16 Central North Correctional Centre 1501 Fuller Avenue, PenetanguisheneCause of death:hangingBy what means:suicide, The verdict was received on October 21, 2022Presiding officer's name:Dr. Mary Beth Bourne(Original signed by presiding officer). 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. Names of the deceased: Culleton, Carol; Kuzyk, Anastasia; Warmerdam, NathalieHeld at:1 International Drive, PembrokeFrom:June 6To: June 28, 2022By:Leslie Reaume, Presiding officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname: CulletonGiven name(s): CarolAge:66, Date and time of death: September 22, 2015. Also in this section Fund for safe rooms to be installed in survivors homes in high-risk cases. 42. The ministry should take steps to actively promote awareness of information, services and programs available to persons in custody regarding opioid/other substance use. Constructors, employers and supervisors shall ensure that workers are not endangered by cell phone use on construction projects. The relevant coroners office will contact you if this is the case. IV. The committee should include senior members of relevant ministries central to, Require that all justice system participants who work with, Explore incorporating restorative justice and community-based approaches in dealing with appropriate. Joint health and safety committee to include a refresher of. The circumstances in which judges can lead inquests and details of notable inquests overseen by a judge. Deliver training to frontline officers on the purpose of the Crime Abatement Program, the information included in Crime Abatement Program records, and how to access such records. Verdicts and Coroner's recommendations. 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). 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 . Assess the feasibility and impact of establishing a mental health advocate role (or enhancing the abilities of social workers) to be the point person helping patients and families coordinate mental health services: this advocate assists with scheduling follow-up sessions after appointments; check-ins, and visits; support after medication changes; recommends community services; collecting collateral information from relevant parties, based on demand and proper funding, this advocate will be required to manage multiple concurrent cases effectively within a framework of flagging and following up with the highest-risk outpatients, consistently offer a family meeting within 48-72 hours of hospital admission, regardless of the patients status in hospital, to collect collateral information, documented offer of a meeting with family members or support team occurs prior to discharge from hospital to ensure a patient with mental health issues has support, provide mental health services 24 hours a day to better assist communities by expanding self-help services to those in need through online, hybrid, or in-person supports, The Ministry of the Solicitor General (ministry) should review the Offender Tracking Information System. Coroners' inquests - The National Archives Advocating for survivors and their families having regard to addressing the systemic concerns of survivors navigating the legal system. Presiding Coroner: Witness List: Livestream Instructions: Note or copy the passcode BEFORE clicking on the Livestream Link Click on the link above When prompted, enter passcode, your name and email address You will automatically be connected when the Inquest is in session In addition, the panel will identify priorities for funding from existing resources to support Indigenous welfare programs and First Nation communities. Prioritizing the development of cross-agency and cross-system collaborative services. It is recommended that the North Bay Police Service and the North Bay Police Services Board consider policy and training amendments that require officers to notify Emergency Medical Services (, It is recommended that the North Bay Police Service and the North Bay Police Services Board consider steps that are required to ensure that, It is recommended that the North Bay Police Service, the North Bay Police Services Board and the Special Investigations Unit, review the process for data extraction from a Conducted Energy Weapon (, Assessthe feasibility of requiring a constructors supervisor (as required by section 14 of, Post in a conspicuous place the name of the current constructors supervisor, Require a written delegation of supervisory authority, Review the supervisor awareness training required by section 2 of. Whether the tool exacerbates risk factors and contributes to recidivism. An inquest jury examining the cases of two Oji-Cree men has released 35 recommendations after a four-week hearing in Thunder Bay, Ont. Improved supervision of high-risk perpetrators released on probation, including informed decision-making when applying or seeking to modify conditions that impact the survivors needs and safety. Strengthen annual education for Crowns regarding applications for Dangerous and Long-term Offender designations in high-risk, Commission a comprehensive, independent, and evidence-based review of the mandatory charging framework employed in Ontario, with a view to assessing its effect on, Review and amend, where appropriate, standard language templates for bail and probation conditions in, plan for removal or surrender of firearms and the Possession and Acquisition License (, possibility of a "firearm free home" condition, past disregard for conditions as a risk factor, When evaluating the suitability of a prospective surety in. 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. How is it different from an inquest? Introduction . This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools. The coroner's inquest verdicts must not be framed in a way that might determine any question of civil or criminal liability on the part of a named person. Led by the Chippewas of Georgina Island First Nation, support the development and delivery of a case study training module for childrens aid societies and residential service providers regarding the lessons arising from Devon Freemans life and death and incorporate information from the Narrative document (with the exclusion of personal identifiers or information that may identify individuals or otherwise assign blame). Physicians should be encouraged to communicate with a patients community health care providers when discontinuing or amending a prescription for an opioid medication, when consent is provided by the patient. Roger and Bradley Stockton, from Crewe, crashed on the second lap of the sidecar race on . Understanding any impacts after an order for such technology expires. Challenging a Coroner's Decision - Saunders Law Such programs should include: violence prevention, recognizing healthy and abusive relationships, identifying subtle indicators of coercive control, understanding risk factors (such as stalking, fear caused by, Ensure teachers are trained to deliver the, Develop a roster of resources available to support classroom teachers in the delivery of primary, secondary, and post-secondary programming where local. Ensure that the Central East Correctional Centre (. That the Ministry of Health immediately address patient flow at the Thunder Bay Regional Health Sciences Center emergency department to address police and ambulance off-load delays and code black events. In particular, the Model should explicitly include an emphasis on de-escalation as a foundational principle, and de-escalation techniques should be embedded within the Model. Held at: Thunder BayFrom:June 13To: June 13, 2022By:Dr.Steven Bodleyhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Gabriel McKayDate and time of death:November 6, 2017 at 11:20 p.m.Place of death:St. Josephs Care Group, 35 Algoma Street North, Thunder Bay, OntarioCause of death:complications related to a severe brain injury sustained as the result of a workplace fall suffered September 14, 2016By what means:accident, The verdict was received on June 13, 2022Coroner's name:Dr.Steven Bodley(Original signed by coroner), Surname:LepageGiven name(s):RonaldAge:59. At the end of an inquest, the Coroner will read out a formal verdict to record: the identity of the deceased; how the death happened ; . To ensure the safety of the children in its care, Lynwoods psychiatric nurse practitioner shall meet with staff upon admission of each new client regarding any diagnosis and/or mental health needs. Once the data is gathered and analyzed, in partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, seek authority and any necessary funding to implement and act upon the data recommendations to support better outcomes for children and youth, including seeking the necessary authority to make any legislative and regulatory changes to support changes for better outcomes. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers). Programs and other initiatives to address drug addiction and abuse should be encouraged, prioritized and promoted in prominent places throughout the facility where they are likely to come to the attention of persons in custody. Work with Indigenous communities to support the creation of residential treatment options that are Indigenous-run and Indigenous-informed with Indigenous-specific programming. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. State detention includes people in immigration detention centres. Continue to work with bands and First Nation communities, including First Nations and urban Indigenous service providers, and Indigenous child well-being agencies to develop regulations as soon as possible that would support implementation and proclamation of amendments to the, In accordance with subsection 1(2), paragraph 6, of the, Strongly recommend as part of the five-year review of the, mandatory notification to a child or youths band or First Nation community when a child or youth is absent from their residence without permission for more than 24 hours (and upon their return), mandatory notification to a child or youths band or First Nation community when a child who is a resident in a childrens residence dies, and in the event of any other serious occurrence, as listed at subsection 84(1) of the. The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model. 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. Review whether the policy for the care and handling of individuals in custody needs to be clarified, particularly in relation to which individuals in custody should be considered high risk. . The ministry should ensure that spiritual elders, knowledge keepers, and helpers are provided honoraria or financial compensation for their important work delivering cultural programming and access to their spiritual rights. The ministry shall ensure that wherever a serious mental illness is suspected or identified through mental health screening, that the person in custody will not be placed in conditions of segregation. Bereavement Advice Centre | Coroner's Inquests Reconvene one year following the verdict to discuss the progress in implementing these recommendations. Sources of Evidence and Disclosure . If a police service has a joint mental health-police team, give studied consideration to implementing a police policy that provides, once police officers attending a call identify a potential mental health concern and provided it is safe to do so, that the joint mental health-police team should be engaged. What verdict can a coroner give? Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. Coroners and mortuary | LBHF However, the Coroner may decide to hold an inquest to establish the facts. Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards. Coroner's verdict in inquest into . Held at:Ottawa (virtual)From: October 11To: November 10, 2022By:Dr. Geoffrey Bond, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Olivier BruneauDate and time of death: March 23, 2016 at 8:08 a.m.Place of death:Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, OntarioCause of death:blunt force chest injuryBy what means:accident, The verdict was received on November 10, 2022Presiding officer's name:Dr. Geoffrey Bond(Original signed by presiding officer), Surname:DhindsaGiven name(s):VikramAge:34. When a community prescription for an opioid medication is discontinued or amended by a. Coroners' appointments . Conduct scans of other jurisdictions use of emerging technologies and partnerships in the proactive reduction of workplace injuries and fatalities. The ability to respond immediately with risk management services in collaboration with. Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission. Construction projects should be planned and organized so that no cellular phones or similar cellular devices shall be used on the worksite except in case of an emergency or where use is restricted to occur inside of a designate structure, stationary vehicle, or other designated area away from any area in which construction work is occurring or ongoing. Older verdicts and recommendations, and responses to recommendations are available by request by: e-mail: occ.inquiries@ontario.ca. It is recommended that training related to the management of change process take place on a regular basis (annual as a minimum) to ensure that all employees are continually informed as to what requires the initiation of the management of change process. 2022 coroners inquests verdicts and recommendations, other identified organizations may be identified in the recommendations. A variety of group-based interventions augmented with individual counseling and case management sessions to assess and manage risk and to supplement services, as needed, to address individual needs. To the extent that this training is not already provided, that educational institutions such as colleges and universities provide training for first responders on the history of colonization; residential schools; trauma informed approaches; anti-Indigenous racism; cultural safety, and unconscious bias. Isle of Man inquest hears of father and son's TT sidecar deaths Ensure that gaps or compliance issues identified during investigations into inmate deaths (including by Correctional Services Oversight and Investigations) are communicated and reinforced to relevant staff and healthcare providers. The ministry should implement dedicated and centralized real time monitoring of cameras at. The ministry should take immediate steps to improve opportunities for persons in custody to access recreation and exercise facilities and programs. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. Consider retroactive compensation for the security clearance review period for those candidates that successfully obtain security clearance and sign an employment agreement with the. The ministry should ensure that people in custody receive training concerning the use of Naloxone within a custodial setting, including the need to engage an emergency medical response following its use. Coroners' courts - Courts and Tribunals Judiciary Blackburn. 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. Explore adding the term Femicide and its definition to the, Consider amendments to the Dangerous Offender provisions of the, Undertake an analysis of the application of s. 264 of the. Time of death could not be determined.Place of death: Foymount, OntarioCause of death: shotgun wound of the chest and neckBy what means: homicide, The verdict was received on June 28, 2022Presiding officers name: Leslie Reaume(Original signed by presiding officer). Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a pilot project. These reviews should analyze relevant health care files and assess quality of care. Show entries The ministry shall support the National Inquiry into Missing and Murdered Indigenous Women and Girls' Call to Justice 14.6 as it applies to provincial corrections services. Service providers provide one annual report for all funders across government to account for the funds received, articulate results and highlight key challenges, learnings, and accomplishments. The inquest would be held in the district where the death occurred. Firearm risks, including the links between firearm ownership and, Opportunities for communities, friends, and families to play a role in the prevention and reporting of, Provide specialized and enhanced training of police officers with a goal of developing an, Establish a province-wide 24/7 hotline for men who need support to prevent them from engaging in, Provide services aimed at addressing perpetrators of. Include coercive control, as defined in the. The coroner will open the inquest in order to issue a burial order or cremation certificate (if not already issued immediately after the post-mortem examination) as well as hearing evidence confirming the identity of the deceased. Follow a study to determine the scale and volume of increase that is necessary to address the shortage of beds in Thunder Bay for all communities that access Thunder Bay for services. It is recommended that the chief coroner take steps to expedite the hearing of coroners inquests, if feasible that they be held within three years. This should include the provision of adequate space within, The ministry should conduct a review of the barriers to accessing, The ministry should conduct a needs assessment to determine whether patients at.

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