Require primary actors involved in a major incident to conduct a formal de-brief and write a report identifying lessons learned and recommendations for improvement, if appropriate. mechanical devices, such as a pin, that can be inserted into a boom or crane to prevent movement into the prohibited zone. Explore the possibility of developing and including crisis intervention training as part of the mandatory curriculum for police recruits at the Ontario Police College and the requirement that all officers re-qualify at a determined interval. This increase shall: Not come as an alternative to the creation of a sobering centre, in recognition of the fact that these institutions would provide different services. Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. (Note: this is included in both mining industry and Ministry of Labour section). The provision of therapeutic care. Verdicts into the deaths of six people and the Coroner's recommendations. . The ministry should implement dedicated and centralized real time monitoring of cameras at. . Date inquest concluded. These would keep Indigenous youth within their local community and connected to family, culture, and local supports. The Coroner usually conducts the inquest alone but will sometimes sit alongside a jury. provide mandatory standardized training bi-annually on de-escalation strategies and empathy for community mental health-related situations. Regular contact with survivors to receive updates, provide information regarding the offenders residence and locations frequented, and any changes to such circumstances, and seek input from survivors and justice system personnel before making decisions that may impact her safety. 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. 13 January 2022 Following a change in the law in 2013, the coroner now gives a 'determination' on the cause of death. The ministry should investigate how security is assessed concerning spiritual elders, knowledge keepers, and traditional teachers. 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. The inquest would be held in the district where the death occurred. The ministry should explore the benefits and detriments of periodic re-screening for suicidal risk or mental health concerns akin to the admissions screenings to see if an inmates status has changed while in custody. 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. That the Thunder Bay Police Service ensure that the Reconciliation training currently being undertaken by the service is not a one-time training course, but rather provided as continuous training over the course of an officers career and that the police service consult with Indigenous Nations. They will make whatever inquiries are necessary to find out the cause of death, this includes ordering a post-mortem examination, obtaining witness statements and medical records, or holding an inquest. The audit should be independent and should result in an action plan that must be submitted to the. Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders. Consider adopting Femicide as one of the categories for manner of death. These supports should account for the social barriers to accessing such supports within a custodial environment. 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. Sources of Evidence and Disclosure . Held at: TorontoFrom:June 29To: June 29, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Frank FerranteDate and time of death: July 28, 2015 at 8:34 p.m.Place of death:Southlake Regional Health Centre, 596 Davis Drive, NewmarketCause of death:heat strokeBy what means:accident, The verdict was received on June 29, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:YonanGiven name(s):MettiAge:66. 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). Please check the website on the day of the hearing. Consider re-allocating more time to scenario-based de-escalation training during annual use of force certification at the, Post the verdict and recommendations of this inquest on the. Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system. Training should be given to establish who should lead the call when dealing with a potentially violent incident or crisis. All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. 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. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. If none already exists, explore with community mental health partners, the feasibility of establishing and adequately resourcing joint mental health-police response teams to assist with person in crisis calls for service. Held at: Toronto, virtuallyFrom: August 22To: August 26, 2022By: Dr. Bonnie Goldberg, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Alexander PeterWettlauferDate and time of death: March 14, 2016 at 1:21 a.m.Place of death:Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, TorontoCause of death:gunshot wounds to chestBy what means:undetermined, The verdict was received on August 26, 2022Presiding officer's name: Dr. Bonnie Goldberg(Original signed by presiding officer), Surname: PigeauGiven name(s): RichardAge:54. 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 ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive awareness training regarding the causes and nature of substance use disorder to address stigma surrounding addiction. The ministry should ensure that spiritual elders, knowledge keepers, and helpers are provided honoraria or financial compensation for their important work delivering cultural programming and access to their spiritual rights. The ministry should embrace an evidence-based approach to harm reduction in a manner that protects the mental and physical health of persons in custody. Police services and police services boards shall establish permanent data collection and retention systems to record race, mental health issues, and other relevant factors on use of force incidents. The inquest into the Lakanal House fire in the London borough of Southwark on 3 July 2009 began on 14 January and ended on March 28 2013. . Continue working with their partners to provide timely alerts, reminders and warnings to the public about the dangers of working in high temperature conditions on days when the temperatures reach dangerous levels. 17 June 2022 . 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. Within 6 months of the jurys verdict, strike a task force to review, report on, and initiate changes to: funding, accountabilities, and timely access to care for all community-based mental health services that receive funding from the Government of Ontario, available resources and supports for family members and/or caregivers of patients and community services receiving mental health services, how family members and/or caregivers and community services can provide support and/or information about patients when patient consent is not provided, address what information can be shared from family members and other stakeholders, align services and community agencies to better share information about individuals with mental health concerns in the community, Establish further study and review of the criteria and training associated with the, mandatory refresher training for emergency room physicians and psychiatrists in the province of Ontario on when and how to use the Form 1 options associated with mental health, the assessment of Box A and Box B criteria for psychiatric evaluation and involuntary detention, to determine how best to ensure collateral information from family members and relevant community services information can be included as part of the process for determining appropriate treatment options. Coroner's Officer. within hiring practices to ensure personality and culture fit, situational judgement, role-specific skills, incorporate in regular performance evaluations to ensure that the individuals values remain consistent with expectations. It is recommended that the Chief Prevention Officer of the. Consider extending the recommendations 10-22 to include all municipal police forces across Ontario. To support ongoing consultation, communication, and transparency between the Society and the bands and First Nations communities of the children and youth it serves, the Society shall reach out to those bands and First Nation communities and offer to develop a communication protocol and offer to initiate quarterly reviews regarding all children receiving services from the Society. The following recommendations are made in recognition and acknowledgement of the following principles: Surname:BruneauGiven name(s):OlivierAge:24. In some Coroner's Districts certain inquests can be held based only on documents. We recommend that, absent exceptional circumstances, claims should be processed within 30 days of receipt of the documentation from the correctional facility. A-Z of records. 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. System approaches, collaboration and communication. 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. 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. That access to electronic health records be provided to all paramedics in Ontario, and if such access is available, that Superior North. For conductive energy weapons consider high visibility markings (colour) to differentiate them from firearms. While recognising that inquests must be . This includes: familiarity with the act and the regulations that apply to the work, ability to identify and address workplace hazards. 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. An inquest jury examining the cases of two Oji-Cree men has released 35 recommendations after a four-week hearing in Thunder Bay, Ont. The ministry should engage in community consultation on the development of Indigenous core programming with Indigenous leadership including First Nation, Mtis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres. This shall include adequate training and resources for all care providers and all staff within MAPs so that individuals with a likelihood of violent behaviour as a result of trauma are still able to receive care and services from the. Trauma-informed practices, including an understanding of why survivors may recant or may not cooperate with a criminal investigation, best practices for managing this reality, and investigation and prosecution of perpetrators. January There are many ways to contact the Government of Ontario. The reviewers should work with the local health care team to identify gaps and find solutions. Communication between first responders at the scene must be documented. Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants. 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.
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