The Senior Coroner for this area is Patricia Harding. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current andprevious year. 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 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. In recognition of the important roles of family and Indigenous communities, offer to involve the family and the Indigenous community of a deceased Indigenous young person in the Pediatric Death Committee Review process where appropriate, having due regard to confidentiality concerns. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. The ministry should require all forms related to the admissions of inmates to be completed in full, including review and signature by a sergeant (or their designate). For a young person in its program, engage with the guardian at the intake stage to set clear lines of responsibility regarding communication of information regarding the youth to those in the youths circle of care, including communication of self-harm attempts and leaving the property without permission. A coroner's inquest . The ministry should ensure that correctional officers investigate cell change requests immediately, and grant same immediately, where merited. Use or continue to utilize neutral, descriptive language to describe young people who leave their place of residence without permission. Held at: OttawaFrom:April 20To: April 29, 2022By:Dr.Bob Reddochhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Babak SaidiDate and time of death: December 23, 2017 at 11:30 a.m.Place of death:Morrisburg, OntarioCause of death:gunshot wounds to the right shoulder and right side of the back.By what means:homicide, The verdict was received on April 29, 2022Coroner's name:Dr.Bob Reddoch(Original signed by coroner). Consider conducting inquests in a timely manner, within 24 months from the incident date. Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a pilot project. The funding formula should reflect the population of Thunder Bay and surrounding areas that uses Thunder Bay as a Hub for medical services. The Ontario Use of Force model should be renamed to accurately capture the intent and purpose of the model, which is a guide to police engagement with the public rather than to suggest that force is inherent in police interactions. 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). The ministry should ensure that Naloxone spray devices deployed in areas accessible to people in custody are positioned in a manner that correctional staff on security rounds may determine that a device has been used or removed. 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. Explore developing and providing all police officers with additional de-escalation training. Report to the Thunder Bay Police Services Board on the above. 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. The Coroner is expected to open an inquest where there is reasonable suspicion that the deceased has died a violent or unnatural death, where the cause of death is unknown or if the deceased. TT sidecar driver had passenger's dog tag - inquest. Implement the National Action Plan on Gender-based Violence in a timely manner. The ministry should position equipment necessary for an emergency medical response close to living units. The jury hears evidence from witnesses under summons (same as a subpoena) in order to determine the facts of a death. 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. 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. Held at:Toronto (virtual)From: December 6To: December 9, 2022By:Mr. Etienne Esquega, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Jose AmaralDate and time of death: November 25, 2015 at 2:40 a.m.Place of death:Musselwhite MineCause of death:blunt force trauma to head and neckBy what means:accident, The verdict was received on December 9, 2022Presiding officer's name:Mr. Etienne Esquega(Original signed by presiding officer), Surname:MilletteGiven name(s):Denis Stanley JosephAge:52. These outcome measures should be supported by key performance indicators (. 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. Clarify and enhance the use of high-risk committees by: Strengthening provincial guidelines by identifying high-risk cases that should be referred to committee. 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. The same expert panel as noted above should provide recommendations to define outcome measures which clearly describe the successful progression of Indigenous youth through the welfare system to independence and adulthood. Compensation should include: cost of medicines or supplies required to facilitate service. Programs are funded at a level that anticipates an increased stream of referrals. Ensure that the employer properly identifies and reviews all potential chemical hazards at the mine site including, but not limited to, the dangers of cyanide. Encourage review and participation in all best practices regarding cyanide safety put forth in the international Cyanide Management Code. Hazard alerts should be distributed in a timely manner after a health and safety concern is made evident. The ministry should explore implementation of harm reduction strategies similar to those used at supervised consumption sites. Section 14.6 states the following: We call upon Correctional Service Canada and provincial and territorial services to provide intensive and comprehensive mental health, addictions, and trauma services for incarcerated Indigenous women, girls, and. Inquests for this area are normally held at Archbishops Palace, Maidstone unless stated otherwise. the cost of transportation for survivors and service providers. The ministry should consult with the Ministry of the Attorney General to determine a process for obtaining summary information about upcoming court appearances for persons in custody and prospective length of time in custody, and rapidly provide this information to health care and programming staff. The ministry should prioritize the completion of its project to implement electronic health records for patients living in correctional facilities. Inclusion of and consultation with Indigenous communities/agencies is essential. These reviews should analyze relevant health care files and assess quality of care. In addition to posting hazard alerts on the ministrys website, develop and implement a system of communication to distribute hazard alerts so that they are sent directly to constructors and employers. It is most commonly used when none of the other verdicts are appropriate. Funding to be provided on an annualized basis, with adequacy assessed and considered after the first three years. Review the process and criteria for issuing a media release to ensure that, where appropriate, timely media releases are issued in missing person investigations, and that due consideration to issuing a media release occurs within set time periods during an investigation. Show entries That bystander training be provided to police officers so that officers feel more comfortable addressing inappropriate behavior by colleagues. The coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . Provide adequate and sustainable funding and resources to ensure that a range of placement options and transition services, including independent and semi-independent living arrangements, are available for children and young people receiving services from childrens aid societies and Indigenous well-being agencies. 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. Enhance policies and procedures to support collaborative communication and planning with First Nations communities when providing services to an Indigenous family/child/youth by building upon the work of the specialized Indigenous service team, the Sharing Circles for Indigenous youth in care developed in partnership with Catholic Childrens Aid Society, the Hamilton Regional Indian Center and Niwasa Kedaaswin Teg, and the recommendations from the Societys Child Death Update (Exhibit 24). That the use of paper green sheets be discontinued, that the booking process and prisoner management systems be digitized, and that documentation used for charges in court be separated from the documentation used to manage and care for individuals in custody. 2.30pm Andrew Phillips, aged 56, from Altrincham, died 31/05/22 in JRH. For conductive energy weapons consider high visibility markings (colour) to differentiate them from firearms. That the Thunder Bay Police Service review its jailer academic programming and, if not already included, incorporate an educational component on the Human Rights Code and training on cultural sensitivity. Try to find out: the date the. Institute a policy to mandate regular debriefs with officers involved with incidents that engage the Special Investigations Unit to ensure that supports are in place and the incident to be used as a learning tool so that future incidents can be prevented. It should be clear that it is broadly accessible and not limited to a particular kind of relationship. 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. These solutions should be communicated to relevant staff and stakeholders in a timely manner. All correctional staff and nurses have full access to, All correctional staff and nurses perform a thorough review of. Indigenous people must be able to access spiritual rights as well as programs with regularity and without unreasonable delay. The Coroner's officer will usually inform interested parties to the Inquest who is to give evidence at the hearing. Continue to prioritize the recruitment, hiring, and retention of workers with First Nations identity and from other equity-deserving groups, recognizing skills related to Indigenous knowledge and cultural identity alongside traditional mainstream credentials. Held at:TorontoFrom:November 21To: November 24, 2022By:Dr.Jennifer Tanghaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased: Craig BlackettDate and time of death: 17:08 - May 27, 2016Place of death: 3058 Lakeshore Blvd West, Toronto, OntarioCause of death:Multiple blunt force injuriesBy what means:accident, The verdict was received on November 24, 2022Coroner's name: Dr.Jennifer Tang(Original signed by coroner), Surname:DavisGiven name(s):Murray JamesAge:24. Call us on 020 7632 4300 or make an enquiry online. Appropriate perpetrator programs and supports needed to accompany electronic monitoring. The purpose of an inquest is to establish who the deceased person was, and when, where and how they died. 05/09/2022. Identify all ongoing construction projects involving Claridge Homes group of companies in Ontario and conduct proactive inspections of those sites. The ministry shall update policy so that phone calls by persons in custody are not referred to as a privilege. Ensure that all health care staff are trained in suicide prevention policies and documentation. We recommend that all construction projects that utilize booms or cranes in proximity to overhead power lines, be required to make a written request to the owner of the power lines, to facilitate compliance with sections 187 and 188 of Regulation 213/91 for Construction Projects. Provide Indigenous-led cultural competency and cultural safety training to all officers. That an accessible sobering centre with a locally developed model of care appropriate to meet the needs of Thunder Bay and surrounding communities be established. 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). 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. That all police officers be trained that paramedics cannot medically clear any person, and that an assessment by a paramedic does not mean that a patient does not require medical treatment. The arresting officers and jailers must clearly indicate/communicate verbally and with diverse signage the procedures and rights of people in custody. The ministry should explore safer alternatives to wooden pencils being provided to Inmates. The inquest into father and son Roger and Bradley Stockton, who died in a sidecar crash June 10 2022, closed this afternoon. Being accessible by clients voluntarily and via referral,and not just through the criminal justice system. It is recommended that the Ministry of Labour, Training & Skills Development take steps to amend the. It would also provide a primary point of communication for emergency response and medical personnel. The inquest heard from 278 witnesses and is estimated to have cost the taxpayer more than 6.5m. 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. All physician assistants and doctors are trained on all medical equipment available at the worksite. The Internal Responsibility System, with an emphasis on the importance of promoting a no-blame workplace safety culture that encourages an open relationship to discuss workplace safety. The summary should be placed at the front of each health care record and should list all serious medical diagnoses, including opioid use disorder. The following recommendations are made in recognition and acknowledgement of the following principles: Surname:BruneauGiven name(s):OlivierAge:24. Fund for safe rooms to be installed in survivors homes in high-risk cases. 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. 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. That mandatory training for all first responders and all staff of both services be provided on an ongoing basis that addresses issues around impacts of systemic and structural racism. The Toronto Police Service should provide emergency task force (. 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. Explore the capability of the information management systems to track the deployment of alternative responses to assist a person in crisis and the outcomes. That the Board create a process for regular review of board policy to determine which policies need to be updated or created. 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 Government of Ontario should enhance supports for families of persons who die in a police encounter, and ensure that those services are delivered in a timely and trauma-informed manner. In consultation with organizations like Hamilton Childrens Aid Society and other agencies servicing high-risk youth, develop a joint process whereby, Establish the role of an Indigenous Liaison within the. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented. The Toronto Police Service should continue to explore the feasibility of implementing body-worn cameras for all. EASTWOOD, Claire Louise. the health care needs of the inmate population, compliance with provincial policies and professional standards, record keeping and communication of health care information, an audit of a meaningful selection of inmate health care files, interviews with health care staff to determine the causes of any deficiencies uncovered in the review. The availability and use of weapons prohibition orders in. Include in those best practices training requirements or other criteria for achieving competency regarding the assessment of ice on excavation walls as a hazard. The ministry should ensure and enforce through training that all correctional staff ensure that any important information, including historical information, is entered into. 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. Review the current Use of Force Model (2004) and related regulations, and consider de-emphasizing use of the term "force" and employing alternative terminology. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. 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. The ministry should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. In partnership with the urban Indigenous community, continue active membership on the Indigenous Child Welfare Collaboration Committee established in January 2018 to strengthen relationships, develop pathways and strategies for a coordinated approach to services and wraparound support for First Nations Inuit and Mtis children and families involved in child welfare services in Hamilton. 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. That training be delivered to police officers and jailers relating to medical issues that may mimic intoxication, or that may be concurrent with intoxication, and that this be provided both at the Ontario Police College and to serving officers. Reconvene one year following the verdict to discuss the progress in implementing these recommendations. Clear communication of the transfer of supervision; Clear communication of the scope of supervision; and. 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. . Ensure that all safety plans are written down and shared with Lynwood staff, the young persons guardian, and other members of a young persons circle of care where appropriate and consistent with privacy legislation and rights. Develop strategies on prescribing and dispensing medications in a manner that would assist with protecting patients from being coerced into diverting the medication to other inmates. Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors. 12/09/2022. An inquest is a judicial process and a Coroner's Court is a court of law. Fund a full range of Indigenous-led mental health services and facilities in the Hamilton region and other regions in Ontario to meet the need for culturally safe and restorative mental health and healing services for Indigenous children, youth and families. Review whether one on one supervision needs to be provided to individuals in custody who pose particularly high risk, such as individuals who expressed suicidal ideation.