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. There are many ways to contact the Government of Ontario. However, unlike other court processes, the Coroner's inquest is an inquiry and not a trial. Prior to commencing work, survey worksites where high temperatures are a concern and ensure that every reasonable precaution is taken to protect workers from heat stress and heat related illnesses. 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. Consider adopting Femicide as one of the categories for manner of death. To support the well-being of children, continue to ensure that, as part of the intake process, staff acquire and review all relevant information and documents relating to a young person, including any plans of care developed by prior residential facilities and any information relating to suicidal behaviour or ideation. The ministry should ensure mental health nurses are available on call 24 hours a day, seven days a week, to see any Inmates waiting for them as soon as possible to allow all assessments to be completed in a timely fashion regardless of whether any given Inmate has temporarily left the institution for court. 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. Increasing program availability and develop flexible options for, Recognize the specialized knowledge and expertise of, Address barriers and create opportunities and pathways to services for, Improve the coordination of services addressing substance use, mental health, child protection, and, As new services are funded, include aims and outcomes associated with building an underlying network of specialized services to address, Endeavour to minimize destabilizing factors for perpetrators of, Investigate and develop a common framework for risk assessment in. Continue to follow the international Cyanide Management Code. Develop an expert panel including Indigenous leaders, researchers, as well as leaders from other provincial child welfare ministries, such as British Columbias Ministry of Children and Family Development who can provide expertise on best practices to revise the child welfare funding formula to address the needs of Indigenous youth. 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. If the cause remains in doubt after a post mortem, an inquest will be held. 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. Coroner's verdict in inquest into . Coroner training overview In conjunction with the Chief Coroner, the Judicial College delivers a varied training programme for all coroners involving induction, continuation and one-day training on specific topics. PDF Judicial Communications Office risk assessment training with the most up-to-date research on tools and risk factors. Require emergency response personnel in plants using cyanide to be provided with basic first aid/. Coroner's inquests - how they work and what it will involve Office opening hours are Monday to Thursday, 8am to 4pm, and . The appropriateness of essential services being provided by private, for-profit partners. A coroner's inquest is a public court hearing where the coroner determines about how, when and where someone died following a post-mortem. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. That access to electronic health records be provided to all paramedics in Ontario, and if such access is available, that Superior North. Once a risk assessment has been completed, ensure that all missing person cases are triaged to determine the appropriate response to a persons disappearance, including whether that response should involve a combination of the police and/or other community organizations and/or a multi-disciplinary response. 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. Coroner's court returns verdict of medical misadventure after inquest into death of Linda Connell (41) five days after minor surgery to remove ovarian cyst Create emotionally supportive debrief sessions for police officers at the division or platoon level for those involved in critical incidents resulting in serious bodily harm or death, with regard for the Special Investigations Unit investigative process. Develop and implement a new approach to public education campaigns to promote awareness about, Complete a yearly annual review of public attitudes through public opinion research, and revise and strengthen public education material based on these reviews, feedback from communities and experts, international best practices, and recommendations from the Domestic Violence Death Review Committee (, Use and build on existing age-appropriate education programs for primary and secondary schools, and universities and colleges. Ensure that persons with lived experience from peer-run organizations are directly involved in the development and delivery of both mental health crisis and de-escalation training. Message from HM Acting Senior Coroner for the City of Brighton & Hove Although the Government has eased most coronavirus restrictions, a number of measures will still be in place at Woodvale Coroner's Court to ensure the continued . Consider conducting an ice management campaign for large construction projects in Eastern Ontario. It would also provide a primary point of communication for emergency response and medical personnel. 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. The ministry should engage in community consultation on the development of Indigenous core programing with Indigenous leadership including First Nation, Metis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres. Review policies to ensure the timely, reliable, consistent, and accurate dissemination of information, including the use of emergency alerts and media releases, where the police are aware of circumstances that could put the public in danger, and that the focus is on safety when developing policies regarding what information to share with whom and when. Inquest jury finds 'undetermined' cause in Oji-Cree man's death in Coroner's inquests | ontario.ca gov.ie - Inquest: an inquiry held in public Sudden death of woman after routine surgery linked to use of blood The ministry should review and if necessary consider enhancing the mechanisms for ensuring that all staff receive their suicide awareness training in accordance with the timelines set out in policy. 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. This is the only information that can be provided at this time. That the Thunder Bay Police Service Board consider creating a position of Deputy Chief, Indigenous Relations. That the use of medically fragile flags be considered for the. The ministry should retrofit all units within. 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). Regularly consult with bands and First Nation communities and Indigenous stakeholders on program implementation and service delivery for new and existing initiatives; and report back within a reasonable period of time. Consider applying other ministry resources to support health care staff recruitment at the, Monitor how often inmates on suicide watch at the, Ensure that if any inmates on suicide watch at the, Provide an anonymized public report on the number of inmates on suicide watch at the. After 11 years, Diana the verdict: killed by a combination of Henri The ministry should provide direct access to Naloxone spray for people in custody, including within locked cells. Encourage all fixed term Nurse Practitioners at the, Reinstate funding for an embedded Kawartha Lakes Police Service detachment inside the Central East Correctional Centre. An 'investigation' is a new way a Coroner can handle a case that was introduced in reforms of the legislation in July 2013. Appropriate perpetrator programs and supports needed to accompany electronic monitoring. Fund for safe rooms to be installed in survivors homes in high-risk cases. These solutions should be communicated to relevant staff and stakeholders in a timely manner. The Toronto Police Service should continue to explore the feasibility of implementing body-worn cameras for all. The pilot whose plane crashed at the Shoreham Airshow in 2015, killing 11 men, has asked for permission to judicially review the inquest into their deaths. Visual signage should be placed in the booking area and cell blocks. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented. 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. Prioritizing the development of cross-agency and cross-system collaborative services. Utilize the resources generated by the Ministry of Labour, Immigration, Training and Skills Development and Infrastructure Health & Safety Association to develop a comprehensive safety plan for when a skid steer (owned or operated by Green Star or one of its employees) is in use at a construction site. 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. 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 The Ministry of Labour shall review and consider whether to impose a renewal requirement on Common Core Underground Certification. The ministry should ensure that all correctional officers are trained regarding recognizing behaviour of Inmates that might pose a risk to the Inmate or others. The inquest will then be adjourned to be resumed at a later date. Amend the Construction Regulations to include a mandatory requirement for training of Health and Safety Representatives who work on construction projects. Consider providing cognitive behavioural therapy, and/or other evidence-informed clinical interventions, for inmates who may be at risk of suicide. Continue to be accountable to the child, the childs family and the childs First Nation community to ensure First Nations children in out-of-home placements maintain connection to family, community, and culture and that plans are reflective of the childs physical, mental, emotional, and spiritual identities through the regular review of all First Nations children in care. Consideration should be given to the United Kingdoms Domestic Abuse Commissioner model in developing the mandate of the Commission. Name of deceased. Designated funding for transportation for those receiving, Funding to ensure mental health supports for. The following failures on behalf of the hospital charged with his mental health care contributed to his death: (1) As a result of inadequate attempts to obtain a full medical . Lakanal House Coroner Inquest | Lambeth Council 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. Ensure that Probation Services reviews and, if necessary, develops standardized protocols and policies for probation officers with respect to intake of. 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. We recommend that the frequency of required refresher courses/training for Constructors, Employers, Supervisors, and Workers, who work in proximity to overhead power lines. TT sidecar driver had passenger's dog tag - inquest. 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). Inquest Procedures: The Purpose of an Inquest Osbornes Law The Coroner can hold an inquest even if the death happened abroad. The ministry should ensure that any of the Indigenous Liaison Officers and Indigenous elders are engaged in the provision of health care information and treatment when requested by patients. Older verdicts and recommendations, and responses to recommendations are available by request by: You can also access verdicts and recommendations usingWestlaw Canada. 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). What verdicts can a coroner give? - The MDU - Medical Defence Union The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model. The hazard alert should identify cyanide, in all of its forms, as a potential workplace hazards. It also ruled Don Mamakwa's death in 2014 had an . Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. 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. Prohibiting the use of skid steers in reverse unless it is operationally necessary. Tel: 1-877-991-9959. Provide support for training and capacity building for childrens aid societies and licensed residential facilities to meet the consultation requirements with bands and First Nation communities under sections 72 and 73 of the. Consider how the concept of Safety by Design has been implemented in other jurisdictions and assess whether these concepts can be incorporated into Ontarios health and safety regulations. Health and safety representatives are selected in a manner that ensures independence. The ministry should embrace an evidence-based approach to harm reduction in a manner that protects the mental and physical health of persons in custody. 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. Develop health and safety materials and for all workers and train workers, including temporary workers, on health and safety protocols prior to them undertaking any work. State detention includes people in immigration detention centres. A list of the inquests scheduled for hearing in the Oxford Coroner's Court. There are no fees attached to this service. Try to find out: the date the. 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. The ministry should implement dedicated and centralized real time monitoring of cameras at. Require cyanide distribution lines be painted purple for identification and dye be added to cyanide solutions during mixing to make it red/purple in colour. In order to support fulsome assessment, information sharing within the child welfare system and ensuring a holistic approach to caring for children and young people, develop future amendments to. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. The ministry should prioritize the completion of its project to implement electronic health records for patients living in correctional facilities. all health care staff will have access to, Develop an action plan to ensure that there is adequate physical space at the, Upgrade the physical infrastructure at the, Increase the physical space available for inmate programming at the. We recommend that Occupational Health and Safety be amended to allow Health and Safety representatives and Joint Health and Safety committees authority to keep confidential the name of any workers who report unsafe conditions. Reconvene one year following the verdict to discuss the progress in implementing these recommendations.