coroner's inquest verdicts coroner's inquest verdicts

Held at:WindsorFrom: September 12To: September 23, 2022By: Dr. Daniel L. Ambrosini, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Matthew MahoneyDate and time of death: Pronounced deceased at 9:39 a.m. on March 21st, 2018Place of death:Windsor Regional Hospital (Ouellette Campus)Cause of death:multiple gunshot woundsBy what means:homicide, The verdict was received on September 23, 2022Presiding officer's name: Dr. Daniel L. Ambrosini(Original signed by presiding officer). Include coercive control, as defined in the. 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. Formally declare intimate partner violence as an epidemic. Measures to improve public awareness should be developed in consultation with content experts and community organizations that represent persons with lived experience. Ensure that health care professionals who provide care remotely have access to relevant information from an inmates health care file. The Coroner cannot make any decisions as to civil or criminal liability, but at the end of an inquest hearing a decision will be made on where, when, and how the person has died. As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights. 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. Coroner Current inquests Media and other observers Inquest hearings are held in public and members of the public, including the media, are welcome to attend Court in person to observe. The ministry should ensure cooperation between. 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. A physician and/or nurse practitioner should be available to provide in-person health care services on weekends at the, Addictions counselors, discharge planners and social workers should be available to provide in-person services on weekends at the. The ability to respond immediately with risk management services in collaboration with. The task force would involve representatives from, and meaningful input from: Members of the Thunder Bay community including individuals with lived/living experience, members of the Thunder Bay District Mental Health & Addictions Network, Superior North Emergency Medical Services, Nishnawbe Aski Nation and Anishinabek Nation, other Indigenous and community partners who wish to participate. The Toronto Police Service should continue to explore the feasibility of implementing body-worn cameras for all. We recommend that tailboard documents should be standardized, regulated, and include a section that addresses possible encroachment of overhead powerlines of the minimum distance permitted under Section 188 (2) of Regulation 213/91 for Construction Projects. 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. 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. The ministry should take immediate steps to improve opportunities for persons in custody to access recreation and exercise facilities and programs. Review existing training for justice system personnel who are within the purview of the provincial government or police services. The Coroner may also hold an Inquest if the death was due to natural causes and is considered by the Coroner to be in the public interest. This will require consultation with and inclusion of a diverse group of Indigenous communities/agencies, in recognition of the fact that Indigenous cultures/traditions/ways of being are not monolithic and that Thunder Bay is home to Indigenous peoples from across the North who possess a spectrum of cultural values/languages/ways of being. 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). It should have no impact on Ontario Works or Ontario Disability Support Plan payments. All correctional staff and nurses have full access to, All correctional staff and nurses perform a thorough review of. Show entries However, unlike other court processes, the Coroner's inquest is an inquiry and not a trial. 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 ministry should engage with people with lived experience to develop enhanced supports for people in custody who witness a traumatic event. The verdict was received on December 1, 2021 Coroner's name: Dr. Steven Bodley (Original signed by coroner) We, the jury, wish to make the following recommendations: Inquest into the death of: Mark King Jeffrey Jury recommendations Correctional Services of Canada should: make the Anijaarniq: A Holistic Inuit Strategy publicly available 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. 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. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. 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. The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model. Consider providing cognitive behavioural therapy, and/or other evidence-informed clinical interventions, for inmates who may be at risk of suicide. Communication between first responders at the scene must be documented. Ensure that health care transfer summaries are completed in compliance with provincial policies when inmates are transferred between institutions. Review current procedures and processes in respect of police response to persons who have a mental illness. Increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. This training should also include periodic or ongoing refresher training. Most medical treatment-related Inquest hearings are held in public, usually without a jury, and the Coroner decides the verdict having heard all the necessary evidence. Court listings are held in the Avon Coroner's Court, Old Weston Road, Flax Bourton, Bristol BS48 1UL At this time Jury inquests are being held at Ashton Court Mansion House, Ashton Court Estate, Long Ashton, Bristol, BS41 9JN These listings are subject to change. Work in consultation with residential homes and child and youth mental health facilities like Lynwood to develop a living document for each youth in its care that can be readily shared with police if necessary, in the event that the youth is absent from the residence without permission and a missing persons report is being filed, and in accordance with the requirements under Part X of the. 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 create and implement a policy that requires the use of specific language by correctional officers and healthcare workers at each correctional facility which prioritizes humanizing people in custody by addressing them as patients, persons in custody and/or persons who use drugs. 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. Did you find what you were looking for? The ministry shall treat people in custody on remand as presumed to be innocent. Explore developing and providing all police recruits with additional de-escalation training. Take all reasonable measures to ensure workers are educated, understand and avoid the hazard. Fund for safe rooms to be installed in survivors homes in high-risk cases. That joint training be scheduled on an on-going basis, allowing first responders to learn more about the roles and responsibilities of other agencies. The 74,160 records in this database were extracted from the Cook County Coroner's Inquest Records. An inquest has heard of the final moments before a father and son died racing together in last year's TT. An inquest is a judicial process and a Coroner's Court is a court of law. Educate any worker who is to work for or on behalf of Green Star at a construction site where a skid steer is in use (including those who operate skid steers) regarding the risks and dangers associated with working on or near a skid steer and ensure that they are familiar with the aforementioned safety plan. Ensure that the Central East Correctional Centre (. arrives at St. Pancras Coroner's Court for a hearing into the singer's . Conclusions (verdicts) At the end of the Inquest, the Coroner can give the following Conclusions about the death: Natural causes Accident or misadventure Suicide 2022 coroners inquests verdicts and recommendations, other identified organizations may be identified in the recommendations. 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. The ministry should explore implementation of harm reduction strategies similar to those used at supervised consumption sites. Held at:25 Morton Schulman Avenue, Toronto (virtually)From:February 28To:March 11, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Quinn EmmersonMacDougallDate and time of death: April 3, 2018 at 4:23 p.m.Place of death:Hamilton General Hospital, 237 Barton Street East, Hamilton, OntarioCause of death:gunshot wound of the torso (right chest)By what means:homicide, The verdict was received on March 11, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:SantosGiven name(s):FernandoAge:59. It is recommended that the Ministry of Labour, Training & Skills Development take steps to amend the. Include in those best practices training requirements or other criteria for achieving competency regarding the assessment of ice on excavation walls as a hazard. 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. 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. 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. This can be: accident/misadventure unlawful killing natural causes. 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. Consider the circumstances of all police-related inquests as training scenarios. It would also provide a primary point of communication for emergency response and medical personnel. Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system. Identify all ongoing construction projects involving Claridge Homes group of companies in Ontario and conduct proactive inspections of those sites. (Note: this is included in both mining industry and Ministry of Labour section). Improved supervision of high-risk perpetrators released on probation, including informed decision-making when applying or seeking to modify conditions that impact the survivors needs and safety. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. Consideration should be given to the United Kingdoms Domestic Abuse Commissioner model in developing the mandate of the Commission. The reviewers should work with the local health care team to identify gaps and find solutions. Ensure that all health care staff are trained in suicide prevention policies and documentation. Date of inquest. Inquests are held at HM Coroner's Court in Woking. Tailboard meetings/forms must be completed. 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. Chief Prevention Officer to track effectiveness of the Working at Heights training program through regular evaluations and public-facing reporting to demonstrate the relationship between the Working at Heights training program and falls from heights data generated through the Prevention Division. Programs are funded at a level that anticipates an increased stream of referrals. The ministry should amend its policies and practices for admissions officer/. As inquest concludes seven years after incident, coroner says pilot should have abandoned a manoeuvre he was undertaking Caroline Davies and agency Tue 20 Dec 2022 11.47 EST Last modified on Wed . 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. Consideration of streaming short video clips or other helpful information via the television screens on each living unit should also be given. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. 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. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards. Information on Coroners openings and hearings. Consider an appropriate role for community members or organizations as part of the missing person investigation, or in a debrief with the missing person once the investigation is concluded. A coroner is an independent judicial office holder. 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. Ensure that police officers can accurately identify their own, Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (. These outcome measures should be supported by key performance indicators (. 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. The jury must deliver a verdict answering the five questions regarding the death: who (identity of the deceased) when (date of death) where (location of death) how (medical cause of death) The implementation plan should be made public in order to ensure accountability. 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. That the use of medically fragile flags be considered for the. Blackburn. 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. This should incorporate recognition of the historical and ongoing traumas faced by Indigenous communities and adequate cultural competency to provide care/services in a manner that recognizes these traumas. 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. That the services collaborate to discuss the practice of wave offs, and develop policies and training for first responders, on how a wave off should not occur. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care. The verdict means the jury confirms the death is suspicious, but is unable to reach any other verdicts open to them. 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. Improve public awareness of both policing and non-policing community-based crisis responses to mental health crisis. 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. Develop further therapeutic activity programming for youth that reflects a wide variety of interests. 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. Consider adopting Femicide as one of the categories for manner of death. They contact the survivor to inform her of the offenders living situation, any conditions or limitations on his movement or activities, and what she should do in the event of a possible breach by the offender. When will a death be reported to the Coroner? Foster and support the co-development of life promotion programs such as Promote Life Together between Indigenous and non-Indigenous stakeholders to establish and develop meaningful programs and services, with an emphasis on the inclusion and engagement of Indigenous stakeholders from inception. 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. 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. The inquest jury consists of five people selected by the coroner's constable from a list of jurors from the community. 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. Explore developing and providing all police officers with additional de-escalation training. Derbyshire Police. Review whether the policy for the care and handling of individuals in custody needs to be clarified, particularly in relation to which individuals in custody should be considered high risk. Explore digitized records of over a century of coroner's records from Stark County, Ohio, available online . Inform staff and affected personnel that resources are available to support them with respect to work related stress. Ensure that all police officers who interact directly with the public are provided with the four-day mental health training currently provided to incoming police officers in their first year of service. Funding to be provided on an annualized basis, with adequacy assessed and considered after the first three years. The ministry should consult with the Ministry of the Attorney General to determine a process for obtaining summary information about upcoming court appearances for persons in custody and prospective length of time in custody, and rapidly provide this information to health care and programming staff. It would also provide a primary point of communication for emergency response and medical personnel. The Coroner can hold an inquest even if the death happened abroad. Review whether one on one supervision needs to be provided to individuals in custody who pose particularly high risk, such as individuals who expressed suicidal ideation. It is recommended that the chief coroner take steps to expedite the hearing of coroners inquests, if feasible that they be held within three years. Coroner's Officers are police officers who work under the direction of the coroner and liaise with bereaved families, the emergency services, government agencies, doctors, hospitals and funeral directors. 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). The ministry shall consult with the federal government and other provinces and territories to determine if there is bedding that is less susceptible to tearing for use by persons in custody not on suicide watch.