This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools. These roundtables should include representatives of relevant government ministries, including Children, Community and Social Services, Health, Education, and Indigenous Affairs, community-based service providers, societies, Indigenous child well-being agencies, mental health lead agencies, childrens rights experts, educators, youth justice workers, and police as necessary. 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. The ministry shall update policy so that phone calls by persons in custody are not referred to as a privilege. The mnistry should ensure that the Toronto South Detention Centre, and any other detention centres organized in the same manner, have an additional copy of the unit notification card kept on the unit for review by correctional officers while an inmate is absent due to court or other external location. 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. 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. SUMMARY OF CORONER'S VERDICTS AND FINDINGS (KEEGAN J) I. 2022 coroners inquests verdicts and recommendations, other identified organizations may be identified in the recommendations. Derbyshire Police. The ministry should revise both health and, The ministry should consider contracting Elder positions in addition to. Provide additional guidance on how to assess the risk of ice on excavation walls. 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. Unfortunately, we cannot provide any additional information other than what is on the Court List. It simply aims to gather information in order to answer these questions. Require emergency response personnel in plants using cyanide to be provided with basic first aid/. She said: 'I consider that based on the evidence I have heard the failure to report the smear test accurately was a gross failure and the further assessments in both August and . Crowns should actively oppose variation requests to have firearms returned for any purpose, such as hunting. TT sidecar driver had passenger's dog tag - inquest. An inquest is not a trial and does not assign blame or liability. 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 recognition of the fact that law enforcement agencies in the City of Thunder Bay lack the appropriate training, cultural competency, and resources to provide appropriate services to individuals suffering from alcohol/substance use disorder and/or chronic housing insecurity, work to ensure that community-based programs which provide outreach and services to such individuals are maintained and continued, including and not limited to: the Care Bus, operated by NorWest Community Health Centre, the WiiChiiHehWayWin street outreach initiative, operated by Matawa First Nations Management. Ensure that survivor-informed risk assessments are incorporated into the decisions and positions taken by Crowns relating to bail, pleas, sentencing, and eligibility for Early Intervention Programs. Openings. 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. The Toronto Police Service should continue to build a diverse. Ensure that witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports. 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. 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. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. You can also access verdicts and recommendations using Westlaw Canada. Inquests should be completed within 24 months from the incident date unless the circumstances warrant additional time. 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. Coverage of cellular networks, particularly in remote and rural regions. Review the current Use of Force Model (2004) and related regulations, and consider incorporating the concept of de-escalation expressly (both in terminology and visual representation) into the Model as a response option and/or goal. The revised risk assessment factors, as well as search urgency factors, should be evidenced-based and clearly defined. Being accessible by clients voluntarily and via referral,and not just through the criminal justice system. Regular meetings between mine emergency response team and. The difference can be explained as accident reflecting death following an event over which there is no human control where as misadventure is an intended act but with unintended consequence. Probation conditions are appropriate for the level of risk of the client and written in a way they can enforce, and, if not, request a variation. 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 install monitoring equipment of good quality at, The Ministry should ensure that Opioid Agonist Treatment (, Corporate health care with the ministry should continuously monitor wait times for the availability of. 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. In addition, the panel will identify priorities for funding from existing resources to support Indigenous welfare programs and First Nation communities. Names of the deceased: Mamakwa, Donald; McKay, Marlon RolandHeld at: Thunder BayFrom: October 11To:November 4, 2022By:Dr.David Cameron, presiding officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:MamakwaGiven name(s): DonaldAge:44, Date and time of death: August 3, 2014 at 12:03 a.m.Place of death:Thunder Bay Police ServiceCause of death:ketoacidosis, complicating diabetes mellitus, chronic alcoholism, and septicemiaBy what means:undetermined, Surname:McKayGiven name(s):Marlon RolandAge:50, Date and time of death: July 20, 2017 at 1:34 a.m.Place of death: Thunder Bay Regional Health CentreCause of death:hypertensive heart diseaseBy what means: natural, The verdict was received on November 4, 2022Coroner's name:Dr.David Cameron(Original signed by coroner). The implementation plan should be made public in order to ensure accountability. 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 . 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). There are no 'parties' and the Coroner does not make . 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. The ministry should take steps to actively promote awareness of information, services and programs available to persons in custody regarding opioid/other substance use. The provision of medical care including the appropriate dispensing of medications to participants in the program, in recognition that participants may face barriers in accessing medical care and carrying out treatment plans independently. 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. 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 Ministry of Labour shall review and consider whether to amend. 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). 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 ministry should provide direct access to Naloxone spray for people in custody, including within locked cells. Held at: 25 Morton Shulman Ave Toronto (virtually)From:May 16To: May 18, 2022By:Dr.Bob Reddochhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Jean Herv VeilletteDate and time of death:January 17, 2019 at 1:21 a.m.Place of death:Ottawa Hospital General CampusCause of death:hangingBy what means:suicide, The verdict was received on May 18, 2022Coroner's name:Dr.Bob Reddoch(Original signed by coroner). 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 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. The Boards Governance Committee will consider creating an implementation plan that includes but is not limited to: a timeline for implementation of all recommendations received through various reports, inquests and inquiries; a plan for how the recommendation will be implemented; and how consultation and follow-up with Indigenous community will take place. Inject a significant one-time investment into, Realign the approach to public funding provided to. 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. 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. The ministry should review the suicide awareness training to ensure that it includes a robust individual evaluation component for comprehension of the course materials. 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. 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. Ensure that any arrest planning course delivered by the, Develop a mandatory training course for sergeants delivered by the, Provide dedicated mandatory mental health training as part of the annual block training delivered to officers through the, Ensure, where there are no legal impediments to doing so, that debriefs are held for involved officers after every major arrest, event, or unique policing scenario to gain insight on lessons learned, and that such lessons are shared with other. Consider engaging the private sector to assist in developing recruitment and retention strategies and provide current labour market data and analysis. 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). To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. The role of the coroner is to investigate sudden deaths that have been reported to them, and to hold inquests where appropriate. Health and safety representatives are selected in a manner that ensures independence. Explore options for privacy screens or barriers around toilets in cells to avoid the need for inmates to fashion their own privacy sheets. Ohio, Stark County Coroner's Records, 1890-2002. Continue working with partners to provide public awareness campaigns and educational materials in a greater variety of media formats (billboards, bus shelters, Utilizing the resources publicly provided by the. 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. Work with the Infrastructure Health and Safety Association to develop guidance material for employers and constructors on how to address the hazard of falling ice. Crowns should also consider a history of, Study the best approach for permitting disclosure of information about a perpetrators history of, Explore the implementation of electronic monitoring to enable the tracking of those charged or found guilty of an. It should be clear that it is broadly accessible and not limited to a particular kind of relationship. All physician assistants and doctors ensure that workplace hazards are incorporated into the assessment of any medical emergency. 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. The orientation should include hazards, work processes and medical issues, that may be unique to that work site. All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. To ensure that First Nations children benefit from their legal entitlements under, In the spirit of recommendations made in the past in other settings, including those in the, residential treatment resources for Indigenous communities, service coordination for children with complex trauma and complex needs to ensure safety, continuity of care, and the avoidance of long wait lists. The open verdict is an option open to a coroner's jury at an inquest in the legal system of England and Wales. We recommend that, absent exceptional circumstances, claims should be processed within 30 days of receipt of the documentation from the correctional facility. Refresher training should be delivered annually. If it cannot be done immediately, the correctional officers should then bring the Inmate to admit and discharge pending re-assignment to a cell. Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission. When first addressing an employee in medical distress, a full body assessment (head to toe) must be completed. The Toronto Police Service should provide emergency task force (. Evidence relating to the Five Incidents . 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. Advocating for survivors and their families having regard to addressing the systemic concerns of survivors navigating the legal system. 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 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. Where gaps exist, the ministry should explore and research means to increase actual programing at Detention and Correctional Centres: Analysis of data collection or research of Indigenous core or other programing should include identification of gaps, steps taken to resolve gaps, improvements and best practices; This analysis and research should be reported, maintained and disseminated to Ontario`s correctional Institutions, service providers and for use with consultation with First Nation, Metis and Inuit community; The ministry should consider evaluating and modifying their policies on allowing volunteers into the facility that have a criminal record. Review and improve training to housing support personnel on cultural competency, anti-Black racism, implicit bias, mental health and its intersectional nature. The ministry shall implement a policy requiring the inclusion of a letter describing what is contained in the return of property of an individual that has died in custody. It is essential that services provided by all institutions listed below be reflective of Indigenous cultural needs. 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. 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. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. Continue to follow the international Cyanide Management Code. 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. 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. 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. 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. Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing. The ministry should develop guidance to determine criteria by which. It is recommended that the Ministry of Labour, Training and Skills Development take steps to amend the. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights. The ministry should ensure that healthcare and correctional staff at correctional facilities receive additional training about building rapport and resolving challenging encounters with persons in custody. Sources of Evidence and Disclosure . 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. The Coroner can hold an inquest even if the death happened abroad. Consideration should be given to disseminating information through alternative methods where cellular service is not consistently available. 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. provide mandatory standardized training bi-annually on de-escalation strategies and empathy for community mental health-related situations. The ability to respond immediately with risk management services in collaboration with. Review existing training for justice system personnel who are within the purview of the provincial government or police services. The Office of the Chief Coroner (OCC) for Ontario provides death investigations and inquests, when necessary, to ensure that no death is overlooked, concealed or ignored.
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