If you are thinking about challenging a coroner's decision, it is important that you seek specialist advice as soon as possible. Service providers provide one annual report for all funders across government to account for the funds received, articulate results and highlight key challenges, learnings, and accomplishments. They must be treated as such, including refraining from using the term offender. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. The implementation plan should be made public in order to ensure accountability. An inquest has heard of the final moments before a father and son died racing together in last year's TT. 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. Presiding Coroner: Witness List: Livestream Instructions: Note or copy the passcode BEFORE clicking on the Livestream Link Click on the link above When prompted, enter passcode, your name and email address You will automatically be connected when the Inquest is in session The ministry should retrofit all units within. The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Implement the corporate health care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. The arresting officers and jailers must clearly indicate/communicate verbally and with diverse signage the procedures and rights of people in custody. Efforts to improve public awareness of these options should be developed in consultation with content experts and community organizations that represent persons with lived experience. Just before 4.30pm on the 94th day of the inquest, the jury forewoman told the coroner Lord. All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. Explore developing and providing all police officers with additional de-escalation training. A variety of group-based interventions augmented with individual counseling and case management sessions to assess and manage risk and to supplement services, as needed, to address individual needs. 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. We recommend that significant and automatic fines should be levied against any company/constructor that fails to ensure that a dedicated Signaller be assigned to Hydro-vac crews and/or any crane operation when working in the vicinity of overhead powerlines. IV. Establish a Royal Commission to review and recommend changes to the Criminal Justice system to make it more victim-centric, more responsive to root causes of crime and more adaptable as society evolves. 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. 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. 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 analyze the data they collect to determine where there are gaps in service delivery of programs at particular institutions. 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. Evidence relating to the Five Incidents . Consider adding the following recommendation to, With respect to elevating work platforms not in use: implementing the requirement of actively storing any operational access (, The Ministry of the Solicitor General (the ministry) shall replace Elgin Middlesex Detention Centre (, The ministry shall immediately assess the number of people in custody at. The action plan should be completed in consultation with the. Held at: SudburyFrom:June 13To: June 16, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Ronald LepageDate and time of death:April 6, 2017 at 9:12 p.m.Place of death:Health Sciences North, 41 Ramsey Lake RoadCause of death:blunt force/crush injury to abdomen and pelvisBy what means:accident, The verdict was received on June 16, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:BlairGiven name(s):Delilah SophiaAge:30. It would also provide a primary point of communication for emergency response and medical personnel. 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. The ability to respond immediately with risk management services in collaboration with. 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). 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. Unfortunately, we cannot provide any additional information other than what is on the Court List. Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing. The ministry should prioritize the completion of its project to implement electronic health records for patients living in correctional facilities. These would keep Indigenous youth within their local community and connected to family, culture, and local supports. The Ministry of the Solicitor General is committed to overall public safety and ensuring Ontarios communities are supported and protected by effective and accountable law enforcement, correctional services, death investigations, forensic science services, emergency management operations and animal welfare services. 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. In any new detention centre builds, consideration should be given in the design to allow for timely access for emergency personnel. Annual training is also provided for coroners' officers. Enhance procedures for increasing communication and service coordination contained within the signed protocol between child welfare services and the services provided by urban Indigenous agencies, including but not limited to: De dwa da dehs nye s (Aboriginal Health Centre), Hamilton Regional Indian Center, Niwasa Kedaaswin Teg, the Native Womens Centre and the Niagara Peninsula Aboriginal Area Management Board (, Continue to prioritize the Child Welfare Sector Commitments to Reconciliation by transparently sharing data (without personal information and in accordance with Part X of the. responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth. 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. The ministry should undertake a study to identify the effects of overcrowding, and other living conditions on inmate populations especially those with addictions and/or pre-existing mental illness and to take any appropriate corrective measures. The Solicitor General of Ontario should provide oversight on the mandatory annual training curriculum and number of hours that are provided by local police services e.g. The 74,160 records in this database were extracted from the Cook County Coroner's Inquest Records. Said education and instruction should occur prior to the commencement of work on any site where a skid steer is anticipated to be in operation. To the extent that this training is not already provided, that educational institutions such as colleges and universities provide training for first responders on the history of colonization; residential schools; trauma informed approaches; anti-Indigenous racism; cultural safety, and unconscious bias. Revise the provincial Use of Force Model (2004) as soon as possible. In consultation with residential homes and child and youth mental health facilities like Lynwood, develop a common joint responsibility protocol governing the process, roles and responsibilities when it comes to searching for youth who have left congregate settings without permission. Consideration should be given to the United Kingdoms Domestic Abuse Commissioner model in developing the mandate of the Commission. Ensure existing policy and guidelines require probation officers to follow through on enforcement of non-compliance by requiring delivery and documentation of clear instructions regarding expectations to supervised offenders in a way that allows for direct and progressive enforcement decisions. Consider using specialized care units for inmates who have been removed from suicide watch. 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: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. 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. The ministry should ensure and enforce through training that all correctional staff ensure that any important information, including historical information, is entered into. Hearings. It is most commonly used when none of the other verdicts are appropriate. Improve knowledge and awareness for police communicators, call takers, and dispatchers of the signs of mental health crisis, and ensure that communicators are trained to ask questions directed at determining whether a call involves a mental health crisis. When designing new correctional facilities, the ministry shall: minimize the construction of indirect supervision units, consider needs-based housing for women and woman-identifying mental health clients. Conduct a review and consider the role of jailers, the level of supervision given to individuals in custody, and training given to staff in that role, and in particular: Review the level of staffing, and consider a policy that links the number of staff to the number of prisoners, similar to the Ontario Provincial Polices standard of using one guard for seven individuals in custody. Responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth. Explore and research the availability and efficacy of additional less-lethal use of force options for officers. The appropriateness of essential services being provided by private, for-profit partners. This training should also include periodic or ongoing refresher training. Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a pilot project. A jury has returned a not guilty plea in the coroner's inquest into the fatal officer-involved shooting of Johnny Lee Perry II on August 29, 2021. 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. It is essential that services provided by all institutions listed below be reflective of Indigenous cultural needs. Construction projects should be planned and organized so that no cellular phones or similar cellular devices shall be used on the worksite except in case of an emergency or where use is restricted to occur inside of a designate structure, stationary vehicle, or other designated area away from any area in which construction work is occurring or ongoing. Possibilities should include, but not be limited to factors such as toxic exposure through skin or inhalation. Verdicts into the deaths of six people and the Coroner's recommendations. 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. Half day. Consider adopting Femicide as one of the categories for manner of death. If it cannot be done immediately, the correctional officers should then bring the Inmate to admit and discharge pending re-assignment to a cell. It simply aims to gather information in order to answer these questions. To improve outcomes for First Nations children and youth, continue to work through the Child Welfare Redesign Strategy on potential further changes to the funding allocation and the funding model and approach to the child welfare service delivery model, including consideration of developing a prevention and reunification process that focuses on family preservation, family reunification, kinship preservation, family contact, assessment of child, youth and parent strengths and needs, parenting skills, home management and routine, infant care, and exploring and developing support networks. Include the development of strategic partnerships between the sobering centre, managed alcohol programming, medical providers, all subsidized housing providers and community care teams to provide and facilitate appropriate discharge planning for individuals who are to be released from the centre. That bystander training be provided to police officers so that officers feel more comfortable addressing inappropriate behavior by colleagues. In some Coroner's Districts certain inquests can be held based only on documents. The. To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. In December a coroner . The Ontario Use of Force model shall be redesigned to highlight and emphasize the importance of de-escalation at all points during police interactions. Time of death could not be determined.Place of death: Wilno, OntarioCause of death: shotgun wound of the chest and neckBy what means: homicide, Surname: WarmerdamGiven name(s): NathalieAge: 48, Date and time of death: September 22, 2015. The verdict means the jury confirms the death is suspicious, but is unable to reach any other verdicts open to them. Be staffed 24 hours a day and 7 days a week. When first addressing an employee in medical distress, a full body assessment (head to toe) must be completed. 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. Prepare and distribute a hazard alert about the hazards of cyanide in the workplace. This should include funding for more dedicated officers who can conduct drug investigations and share information with appropriate. Compensation should include: cost of medicines or supplies required to facilitate service. That the sobering center meet the criteria for the designation of an alternate level of care by the Ministry of Health to permit paramedics to transport patients to the sobering center rather than an emergency room. Verdicts and Coroner's recommendations. The Toronto Police Service should continue to explore the feasibility of implementing body-worn cameras for all. Specifically: increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. 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.