The ministry should explore the use of a scoring metric to determine risk in areas such as mental health and violence, assessed first at Intake and re-evaluated on a continuous basis. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. Names of the deceased: Frenette, Steven;Foreman, Daniel;Bullen, David;McConnell, Jonathan; Borja, SusanHeld at:virtual, Office of the Chief CoronerFrom:November 14To: December 1, 2022By:Dr.Robert Reddoch, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:FrenetteGiven name(s):StevenAge:35, Date and time of death: September 20, 2018 at 7:38 p.m.Place of death: Ross Memorial Hospital, LindsayCause of death:central nervous system depression due to (or as a consequence of) combined fentanyl toxicity and diazepamBy what means: accident, Surname:ForemanGiven name(s):DanielAge:39, Date and time of death: October 3, 2018 at 9:10 p.m.Place of death: Central East Correctional Centre, LindsayCause of death:fentanyl intoxicationBy what means: accident, Surname:BullenGiven name(s):DavidAge:50, Date and time of death: December 29, 2018 at 7:52 a.m.Place of death: Central East Correctional Centre, LindsayCause of death:acute fentanyl toxicityBy what means: accident, Surname:McConnellGiven name(s):JonathanAge:36, Date and time of death: April 28, 2019 at 8:40 a.m.Place of death: Central East Correctional Centre, LindsayCause of death:carfentanil toxicityBy what means: accident, Surname:BorjaGiven name(s):SusanAge:50, Date and time of death: August 10, 2019 at 6:26 a.m.Place of death: Central East Correctional Centre, LindsayCause of death:toxic effects of oxycodone, methadone, quetiapine and pregabalinBy what means: accident, The verdict was received on December 1, 2022Coroner's name: Dr. Robert Reddoch(Original signed by presiding officer), Surname:CouvretteGiven name(s):Gordon DaleAge:43. That where an individual dies in cells, all officers involved in the arrest or monitoring of the deceased be provided information about the cause of death, and training on symptoms that may be related to this cause of death, as soon as reasonably possible following the death. These reviews should analyze relevant health care files and assess quality of care. In partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, establish multisectoral, multidisciplinary roundtables at local, regional, and provincial levels accessible to community members and service providers to problem-solve regarding service to young people with complex needs. 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. That the sobering center meet the criteria for the designation of an alternate level of care by the Ministry of Health to permit paramedics to transport patients to the sobering center rather than an emergency room. This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools. We recommend that the frequency of required refresher courses/training for Constructors, Employers, Supervisors, and Workers, who work in proximity to overhead power lines. Consider extending the recommendations 10-22 to include all municipal police forces across Ontario. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services. These solutions should be communicated to relevant staff and stakeholders in a timely manner. In partnership and in consultation with bands and First Nation communities, and affiliated Indigenous stakeholders, provide direct, sustainable, equitable, and adequate funding accessible to childrens aid societies and residential service providers to access Indigenous-led cultural services, culturally restorative practices, cultural competency, and educational supports and other cultural supports within the child welfare system. The task force should focus these reviews on the most vulnerable patients, particularly those diagnosed with moderate to severe mental illness, especially schizophrenia and/or schizophrenia-related disorders. Evidence relating to the Five Incidents . Which justice participants should have access to the findings made by a civil or family court. Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. 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. 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 In consultation with civil society child rights experts and Indigenous rights experts, undertake a Child Rights Impact Assessment with respect to all proposed regulations made under and amendments to the. Re-evaluate the capacity of Community Outreach and Support and Mobile Crisis Rapid Response teams to meet the growing need for these services in the Region of Peel. 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. the cost of transportation for survivors and service providers. 42. Implement the Spirit Bear Plan through collaboration with. II. Report to the Thunder Bay Police Services Board on the above. 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. These outcome measures should be supported by key performance indicators (. If there is any information relating to suicidal behaviour or ideation, it must be flagged so any other society workers are immediately aware of that aspect of a particular young persons history. Nine jurors reached unanimous decisions on all but one of the 14 questions at the inquests into Britain's worst sporting disaster. The ministry should seek funding to implement these recommendations. However, if a coroner feels the investigation shows existing circumstances pose a risk of further deaths and that actions should be taken, the coroner is under a duty to make a report. The reviewers should work with the local health care team to identify gaps and find solutions. Formally declare intimate partner violence as an epidemic. This training should be designed and delivered by Indigenous people. Ensure that adequate staffing is provided at each institution to implement recovery plans. Implement recommendation #5 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Provide Indigenous-led cultural competency and cultural safety training to all officers. The open verdict is an option open to a coroner's jury at an inquest in the legal system of England and Wales. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. If not already provided, the ministry should explore the availability of substance abuse treatment programs for all Ontario detention centres such as Narcotics Anonymous, and if not available, explore alternatives to that. Consideration should be given to disseminating information through alternative methods where cellular service is not consistently available. Revise the provincial Use of Force Model (2004) as soon as possible. The inquest jury consists of five people selected by the coroner's constable from a list of jurors from the community. Office opening hours are Monday to Thursday, 8am to 4pm, and . 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. In any new detention centre builds, consideration should be given in the design to allow for timely access for emergency personnel. Mandate that all police service officers receive annual implicit bias and cultural competency training to address stereotyping of Black people, and the existing research on anti-Black racism in policing. We recommend that locates in the vicinity of power lines should include underground, on grade, and above grade utilities or hazards, as well as current, voltage and distance from grade to the high-power line. Ensure that health care transfer summaries are completed in compliance with provincial policies when inmates are transferred between institutions. 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. 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). Develop further therapeutic activity programming for youth that reflects a wide variety of interests. How is it different from an inquest? Held at:virtual inquestFrom: September 26To: October 7, 2022By: Murray Segal, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Victor OgundipeDate and time of death: January 26, 2017,10:14 p.m.Place of death:36 Queen Street East, TorontoCause of death:a) Hemoperitoneum, due to b) rupture of liver, due to c) blunt force injury to abdomen.By what means:accident, The verdict was received on October 7, 2022Presiding officer's name:Murray Segal(Original signed by presiding officer), Surname:FreemanGiven name(s):Devon Russell James (Muskaabo)Age:16. Information on Coroners openings and hearings. The ministry should ensure cooperation between. Held at:TimminsFrom: December 12To: December 20, 2022By:Dr.David Eden, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Denis Stanley JosephMilletteDate and time of death: June 3, 2015Place of death:Detour Lake MineCause of death:acute cyanide intoxicationBy what means:accident, The verdict was received on December 9, 2022Presiding officer's name:Dr.David Eden(Original signed by presiding officer). 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. In recognition of the seriousness of alcohol/substance use disorder as a medical condition which may mask the appearance of other serious medical conditions, a program should be established in the City of Thunder Bay to provide medical alert bracelets to individuals at high risk for adverse medical outcomes. A coroner's inquest is a public court hearing where the coroner determines about how, when and where someone died following a post-mortem. State detention includes people in immigration detention centres. Peer support and appropriate circles of support. Coroners will look to establish the medical cause of death. Inquests for this area are normally held at Archbishops Palace, Maidstone unless stated otherwise. Rename crisis hotline services and create awareness campaigns to educate the public about their existence to make the public aware that these services are available before a person reaches the point of crisis. Inquests are held at HM Coroner's Court in Woking. Recognition that, in remote and rural areas, funding cannot be the per-capita equivalent to funding in urban settings as this does not take into account rural realities, including that: economies of scale for urban settings supporting larger numbers of survivors, the need to travel to access and provide services where telephone and internet coverage is not available. Try to find out: the date the. IV. 4:33 p.m. - April 28, 2022. Develop, establish, and provide regular training to, circumstances in which the policy is applicable, including when an individual would be considered potentially dangerous, involving a supervising officer in the planning of the arrest, when possible, completing an arrest decision tool, which may include a checklist of criteria, how to identify possible factors that could complicate an arrest, such as possible mental health issues, unpredictability, past incidents with police, and violent history, In support of the planning process, develop and provide guidance and training on circumstances where it may be appropriate to contact a subject to ask them to attend a police detachment for the purpose of effecting an arrest. The Board will consider yearly public reports setting out the initiatives taken by the Board, the progress of those initiatives and an expected timeline for completion of the initiatives. Mandatory skid steer operation certification and re-certification process. 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. Advise all workers that they should report health and safety concerns to their health and safety representative, joint health and safety committee, to Fermars Health and Safety Department, or directly to the. Explore, with community mental health partners, the feasibility of extending the availability of Mobile Crisis Rapid Response Team (. To improve outcomes for First Nations children and youth, continue to work, through the Child Welfare Redesign Strategy, on potential further changes to the funding allocation and the child welfare service delivery model, including consideration of the following: continue monitoring the effectiveness of annualized funding announced in July 2020 as part of the Child Welfare Redesign Strategy to provide access to prevention-focused customary care for bands and First Nation communities, support the implementation of models of service to enable children and youth to have meaningful, lifelong connections to their family, community and culture; a sense of belonging; a sense of identity and well-being and physical, cultural and emotional safety; and that plans of care are reflective of the childs physical, mental, emotional, spiritual and cultural identities beginning from the time a case is opened by a society, continue to review the Ontario Eligibility Spectrum, the need for verification, and adopt a needs-based approach (instead of a caregiver deficits approach) to supporting and protecting the well-being of children and youth informed by Indigenous experts. Consideration should be given to two-way information sharing including of case notes, and opportunities to order treatment in institutions for those with existing probation orders who are on remand. 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. You can also access verdicts and recommendations using Westlaw Canada. Specifically: ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the, Conduct a comprehensive post audit to determine the correctional staffing levels needed at the, Analyze the causes of correctional staff absenteeism at the, Complete an action plan based on the results of the post audit and staff absenteeism analysis. Continue to facilitate learning events related to the youth presenting with complex suicide needs and remain an active community participant in the Youth with Complex Suicide Needs (. Take all reasonable measures to ensure workers are educated, understand and avoid the hazard. 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. These programs must also consider service coordination when a young person transitions to a new community to avoid the young person being placed on a waiting list to receive assistance. Ensure that police officers can accurately identify their own, Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (. Funding for mobile tracking system alarms and other security supports for survivors of, Funding for services dedicated to perpetrators of, Develop a plan for enhanced second-stage housing for. Risk assessments and risks of lethality are taken into account when making enforcement decisions. When designing new correctional facilities, the ministry shall: minimize the construction of indirect supervision units, consider needs-based housing for women and woman-identifying mental health clients. An inquest is a judicial process and a Coroner's Court is a court of law. Reconvene one year following the verdict to discuss the progress in implementing these recommendations. Provide professional education and training for justice system personnel on. 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. [1] Training should be given to establish who should lead the call when dealing with a potentially violent incident or crisis. 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). If you are planning to attend an Inquest listed below, could you please either phone - 01823 359271 - or email - coroner@somerset.gov.uk It helps to have an indication of attendance in advance to ensure that we continue to comply with fire regulations and health and safety matters which apply to the court building. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones. We recommend that an industry wide Hazard Alert be published, alerting end-users, and manufacturers of remote-control devices for booms and cranes, to the risk of inadvertent boom or crane movement associated to the OMNEX T300 Wireless Remote Control, or any similarly designed remote control used for boom or crane operation. Held at:HamiltonFrom: September 26To: October 21, 2022By: Jennifer Scott, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Devon Russell James Freeman (Muskaabo)Date and time of death: April 12, 2018 (October 7, 2017 April 12, 2018)Place of death:831 Collinson Rd, FlamboroughCause of death:hanging by ligtureBy what means:suicide, The verdict was received on October 21, 2022Presiding officer's name:Jennifer Scott(Original signed by presiding officer). Ensure all health care providers, including nurses, physicians, psychiatrists, and psychologists, are trained on the revised Recovery Plan policy. If the examination shows death to have been a natural one, there may be no need for an inquest and the Coroner will send a form to the registrar of deaths so that the death can be registered by the relatives and a certificate of burial issued by the registrar. The implementation plan should be made public in order to ensure accountability. 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. Implement recommendation #6 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors. The coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . January Ensure that police officers responding to a mental health crisis are aware that police have responded previously to incidents involving the same parties, and facilitate access for responding officers to significant information regarding previous calls.
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