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. 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 the case of high risk and dangerous subjects, consider the application of Situation Mission Execution Administration Command & Communication (, Where there is an existing threat assessment on file, provide contact information so that. Seek and allocate adequate funding and resources to implement the above recommendations. whether the missing person is an Indigenous youth. Medical Inquests | Coroners Inquests | Leigh Day Funding to be provided on an annualized basis, with adequacy assessed and considered after the first three years. Inclusion of and consultation with Indigenous communities/agencies is essential. 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. What verdicts can the inquest return? - Saunders Law 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 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. Consider including conductive energy weapons training as part of the mandatory curriculum for police recruits at the Ontario Police College with a yearly re-certification. On the second day of an inquest at Dublin District Coroner's Court today, counsel for Mr Sweeney's family, Roger Murray SC, said the net effect of the patient being discharged from the high . Shoreham air crash: Pilot seeks judicial review of inquest verdict 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). Annual training is also provided for coroners' officers. 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. 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. That officers and jailers continue to be trained on an ongoing basis to seek out and record answers from the arrested person about their medical condition. The ministry should analyze the data they collect to determine where there are gaps in service delivery of programs at particular institutions. Coroner Services is an independent and publicly accountable investigation of death agency. 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 ministry should explore implementation of harm reduction strategies similar to those used at supervised consumption sites. [1] 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. how to identify and address the precursors to heat stress, and other heat related illnesses that may arise from working in high temperature conditions. After 11 years, Diana the verdict: killed by a combination of Henri The data should include age, gender, perceived race, and officer perception of whether the individual has any mental health issues; The results of the data collected on use of force incidents must be taught to all frontline police officers. The coroner Sir John Goldring said he would accept a. Inquest Livestream - Province of British Columbia 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. 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. Ensure that all health care staff are trained in suicide prevention policies and documentation. This decision is made by the Coroner. The Toronto Police Service should improve delivery of relevant information to the inner perimeter where crisis negotiations are taking place without unduly disrupting the negotiation process. Ensure that Probation Services reviews and, if necessary, develops standardized protocols and policies for probation officers with respect to intake of. 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. These outcome measures should be supported by key performance indicators (. Assess the feasibility and impact of establishing a mental health advocate role (or enhancing the abilities of social workers) to be the point person helping patients and families coordinate mental health services: this advocate assists with scheduling follow-up sessions after appointments; check-ins, and visits; support after medication changes; recommends community services; collecting collateral information from relevant parties, based on demand and proper funding, this advocate will be required to manage multiple concurrent cases effectively within a framework of flagging and following up with the highest-risk outpatients, consistently offer a family meeting within 48-72 hours of hospital admission, regardless of the patients status in hospital, to collect collateral information, documented offer of a meeting with family members or support team occurs prior to discharge from hospital to ensure a patient with mental health issues has support, provide mental health services 24 hours a day to better assist communities by expanding self-help services to those in need through online, hybrid, or in-person supports, The Ministry of the Solicitor General (ministry) should review the Offender Tracking Information System. An inquest is a judicial process and a Coroner's Court is a court of law. Consider using specialized care units for inmates who have been removed from suicide watch. The ministry should prioritize the completion of its project to implement electronic health records for patients living in correctional facilities. The ministry should ensure that Indigenous Liaison Officer (, The ministry should create policy and direction that recognizes the role and function of, Spiritual Elders, knowledge keepers and helpers should be provided honoraria or some form of financial compensation for the important work they are conducting as part facilitating their access to their spiritual rights or as part of culturally relevant programing, and that the Ministry should revise both health and. 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. Provide training to workers on the signs and symptoms of heat stress and heat stroke, how to prevent heat-related illness and first aid steps to be taken should a worker believe they or their co-worker are showing signs of such illness. 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. Continue working with the Ministry's partners to provide public awareness campaigns and educational materials relating to: Highlighting the dangers and risks associated with working in high temperatures, How workers should prepare themselves to safely work in high temperatures. 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. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. It is most commonly used when none of the other verdicts are appropriate. In jury inquests, the coroner directs the jury on matters of law and the jury decides the appropriate verdict . 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. Continue ongoing quality assessments to drive continuous improvement of standard operating procedures and protocols, documentation, and best practices with mental health services: to review and audit core services within Windsor Regional Hospital annually to ensure compliance to standards are met and keeping pace with community demands proactively. The ministry should explore safer alternatives to wooden pencils being provided to Inmates. Shoreham airshow victims were unlawfully killed, coroner rules Amend the notification requirements in section 7.1 of the Construction Regulations to include a signed and dated attestation that the work platforms will be installed, inspected, tested and maintained in accordance with the applicable regulations, including sections 139 and 139.1. 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. Names of the deceased: Rajendiran, Arun Kumar;Tavernier, Darrel; Kelly, StephenHeld at:TorontoFrom:May 30To: June 13, 2022By:Dr.Robert Reddoch, coroner for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:RajendiranGiven name(s):Arun KumarAge:25, Date and time of death: November 12, 2014 at 8:16 p.m.Place of death: Central East Correctional Centre, Lindsay, OntarioCause of death:hangingBy what means:suicide, Surname:TavernierGiven name(s):DarrelAge:42, Date and time of death: January 1, 2018 at 8:37 a.m.Place of death: Ross Memorial Hospital,Lindsay, OntarioCause of death:hangingBy what means:suicide, Surname:KellyGiven name(s):StephenAge:62, Date and time of death: May 18, 2019 at 9:10 a.m.Place of death: Ross Memorial Hospital,Lindsay, OntarioCause of death:hangingBy what means:suicide, The verdict was received on June 13, 2022Coroner's name: Dr.Robert Reddoch(Original signed by coroner), Central East Correctional Centre (CECC) Health Care Review. Inject a significant one-time investment into, Realign the approach to public funding provided to. 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). Held at:LondonFrom:November 21To:November 30, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Murray James DavisDate and time of death: August 17, 2017 8:00 a.m.Place of death:Elgin Middlesex Detention Centre, 711 Exeter Road, London, ONCause of death:Acute combined fentanyl and hydromorphone toxicityBy what means:accident, The verdict was received on November 30, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:AmaralGiven name(s):JoseAge:49. 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. Coroner's inquests - how they work and what it will involve Openings. 4.1 It is recommended that employers, constructors, supervisors ensure that any hazard identified in risk assessments be relayed to workers together with the associated level of risk. In addition, such education should be repeated quarterly. Coroners - gwynedd.llyw.cymru The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current andprevious year. All correctional staff and nurses have full access to, All correctional staff and nurses perform a thorough review of. 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. Start grassroots Safe Spaces program that businesses can participate in where survivors can feel safe and ask for information (. Increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. The ministry should ensure that pending the admissions process and related mental health assessments, Inmates are placed in a temporary housing unit without a cellmate. Inform staff of the LivingWorks Start online training on suicide prevention and provide them with information to register. 2.30pm Andrew Phillips, aged 56, from Altrincham, died 31/05/22 in JRH. Upcoming inquests - Brighton & Hove City Council Held at:SudburyFrom: August 29To: September 2, 2022By: Dr. David Cameron, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Richard Raymond PigeauDate and time of death: October 20, 2015 at 12:06 p.m.Place of death:3259 Skead Road, Skead, ON, P0M 2Y0 1660 Level, 1660-021 RampCause of death:crush-type blunt force injuries to torsoBy what means:accident, The verdict was received on September 2, 2022Presiding officer's name: Dr. David Cameron(Original signed by presiding officer), Surname: GordonGiven name(s): JacobAge:24. Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. 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 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. 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). . An inquest jury examining the cases of two Oji-Cree men has released 35 recommendations after a four-week hearing in Thunder Bay, Ont. 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. III. Firearm risks, including the links between firearm ownership and, Opportunities for communities, friends, and families to play a role in the prevention and reporting of, Provide specialized and enhanced training of police officers with a goal of developing an, Establish a province-wide 24/7 hotline for men who need support to prevent them from engaging in, Provide services aimed at addressing perpetrators of. State detention includes people in immigration detention centres. That care and services must be provided using a trauma informed approach to ensure that individuals who have suffered complex traumas are not excluded from the services that may assist them. 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 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. 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 . Consider renaming the Model to better reflect the range of tools and techniques available to officers. 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. Evidence and release of body What happens when evidence is gathered and when a body can be released Inquests held. 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.