Said plan should include checking that the back-up alarm on the skid steer is operational. This unique intersection of Blackness and lived experience of mental health issues must be specifically addressed in any training on use of force, de-escalation, and police interaction with such persons. 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). Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders. The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. These outcome measures should be supported by key performance indicators (. 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. The inspections should focus on assessing whether projects are organized in a manner that ensures safety of all workers. Immediately institute a provincial implementation committee dedicated to ensuring that the recommendations from this Inquest are comprehensively considered, and any responses are fully reported and published. 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. 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. Date of inquest. If the cause remains in doubt after a post mortem, an inquest will be held. all health care staff will have access to, Develop an action plan to ensure that there is adequate physical space at the, Upgrade the physical infrastructure at the, Increase the physical space available for inmate programming at the. 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. Police services and police services boards shall establish standing or advisory committees on race and impartial policing and on mental health in order to meet with representatives of peer-run organizations and members of affected communities on an ongoing basis to discuss concerns and facilitate solutions. Implement the National Action Plan on Gender-based Violence in a timely manner. The implementation plan should be made public in order to ensure accountability. Explore developing and providing all police officers with additional de-escalation training. Review, in consultation with stakeholders, the discretionary nature of inquests into the deaths of children in care and consider advocating for legislative change requiring said deaths to be the subject of mandatory inquests. However, unlike other court processes, the Coroner's inquest is an inquiry and not a trial. Require all police services to immediately inform the Chief Firearms Officer (, Create a Universal RMS records management system accessible by all police services (including federal, provincial, municipal, military and First Nations) in Ontario, with appropriate read/write access to all. II. Older verdicts and recommendations, and responses to recommendations are available by request by: occ.inquiries@ontario.ca 1-877-991-9959 You can also access verdicts and recommendations using Westlaw Canada. Require emergency response personnel in plants using cyanide to be provided with basic first aid/. It is recommended that the North Bay Police Service and the North Bay Police Services Board consider policy and training amendments that require officers to notify Emergency Medical Services (, It is recommended that the North Bay Police Service and the North Bay Police Services Board consider steps that are required to ensure that, It is recommended that the North Bay Police Service, the North Bay Police Services Board and the Special Investigations Unit, review the process for data extraction from a Conducted Energy Weapon (, Assessthe feasibility of requiring a constructors supervisor (as required by section 14 of, Post in a conspicuous place the name of the current constructors supervisor, Require a written delegation of supervisory authority, Review the supervisor awareness training required by section 2 of. The ministry should ensure that all correctional officers and nurses have full access to medical and mental health records, and previous incarcerations, where permitted by law. Ensure that all safety plans are written down and shared with Lynwood staff, the young persons guardian, and other members of a young persons circle of care where appropriate and consistent with privacy legislation and rights. The ministry should take immediate steps to improve opportunities for persons in custody to access recreation and exercise facilities and programs. 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. In conjunction with recommendation number12, the ministry should abandon the use of the title, Native Inmate Liaison Officer, and move toward the exclusive use of the title, Indigenous Liaison Officer.. Held at:Town of MidlandFrom: October 17To: October 20, 2022By:Dr. Mary Beth Bourne, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Vikram DhindsaDate and time of death: January 18, 2017 at 5:12 a.m.Place of death:Unit 3 A Wing, Cell #16 Central North Correctional Centre 1501 Fuller Avenue, PenetanguisheneCause of death:hangingBy what means:suicide, The verdict was received on October 21, 2022Presiding officer's name:Dr. Mary Beth Bourne(Original signed by presiding officer). That the Thunder Bay Police Service Board consider creating a position of Deputy Chief, Indigenous Relations. 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. The reviewers should work with the local health care team to identify gaps and find solutions. Refresher training should be delivered annually. Conduct a review of the safety features designed into the. Ensure that witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports. The ministry should develop training for correctional officers on strategies to work constructively with Indigenous men in custody, similar to the Biidaaban Kwewok and Biidaaban Niniwok Beginnings for Indigenous Women and Men training. A coroner's inquest . Establish an independent Intimate Partner Violence Commission dedicated to eradicating intimate partner violence (, Driving change towards the goal of eradicating. A coroner is an independent judicial office holder. There is still an open verdict on Berezovsky's death, which could mean the UK is unwilling to get to the truth. 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. 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. . Implement recommendation #6 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities. The educational opportunities should be provided upon intake and at least once a month in a group setting, and the contact information for healthcare workers should be provided to persons in custody if they would like to get more information. The ministry should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. That mandatory training for all first responders and all staff of both services be provided on an ongoing basis that addresses issues around impacts of systemic and structural racism. 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. Contact Kent and Medway Coroner. 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. 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. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. 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. 05/09/2022. Study the feasibility of, and implement if feasible, justice sector participants having access to relevant findings made in family and civil law proceedings for use in criminal proceedings, including at bail and sentencing stages. This should include the provision of adequate space within, The ministry should conduct a review of the barriers to accessing, The ministry should conduct a needs assessment to determine whether patients at. Please check the website on the day of the hearing. arrives at St. Pancras Coroner's Court for a hearing into the singer's . 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. These reviews should analyze relevant health care files and assess quality of care. Conduct scans of other jurisdictions use of emerging technologies and partnerships in the proactive reduction of workplace injuries and fatalities. Provide additional guidance on how to assess the risk of ice on excavation walls. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. System approaches, collaboration and communication. 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. Older verdicts and recommendations, and responses to recommendations are available by request by: You can also access verdicts and recommendations usingWestlaw Canada. 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 . 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. 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. Encourage all fixed term Nurse Practitioners at the, Reinstate funding for an embedded Kawartha Lakes Police Service detachment inside the Central East Correctional Centre. An inquest is a judicial process and a Coroner's Court is a court of law. Verdicts and Coroner's recommendations. Improve mental health awareness of housing support personnel, and in particular, concerning the recognition of mental health crisis. The Ontario Use of Force model shall be redesigned to highlight and emphasize the importance of de-escalation at all points during police interactions. A requirement that all skid steer operators regularly clean and clear debris from the windows of the skid steer to ensure maximum visibility. 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. In compliance with its by-laws, the Board will create terms of reference for its governance committee and make the terms of reference public. It is their duty to find out the medical cause of the death if it is not known, and to enquire about the cause of it if it was due to violence or was otherwise unnatural. 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. 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. The ministry should collaborate with the London Middlesex Medical Officer of Health in developing its harm reduction strategies. 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. 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. These solutions should be communicated to relevant staff and stakeholders in a timely manner. consider the need for Navigators, in addition to resource persons, adult ally and circle of supportive persons to assist First Nations youth, as both a prevention and protection resource and for youth both on and off reserve, in navigating various systems such as child welfare and protection, mental health and criminal justice. Storage rules and protocols for tracking data. Commission a study to examine the creation and implementation of a province-wide, civilian-led crisis intervention system to respond to persons in crisis, including mental health crisis. Another is David West, the owner of Abracadabra restaurant in London, which . Seek and allocate adequate funding and resources to implement these recommendations. Inquests for this area are normally held at Archbishops Palace, Maidstone unless stated otherwise. The coroner's inquest verdicts must not be framed in a way that might determine any question of civil or criminal liability on the part of a named person. III. Funding for mobile tracking system alarms and other security supports for survivors of, Funding for services dedicated to perpetrators of, Develop a plan for enhanced second-stage housing for. The ability to respond immediately with risk management services in collaboration with. The coroner Sir John Goldring said he would accept a. 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). Coverage of cellular networks, particularly in remote and rural regions. The ministry should ensure that people in custody have access to a reliable means of initiating an emergency medical response. Conclusion. It would also provide a primary point of communication for emergency response and medical personnel. This training should also include periodic or ongoing refresher training. 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. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. 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. The Coroner usually conducts the inquest alone but will sometimes sit alongside a jury. 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. Where possible and financially feasible, connect young people with external resources that could provide additional opportunities, including but not limited to sport, land-based learning, culture, art, and other pursuits that will assist in developing a forward pathway. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. The Toronto Police Service should provide emergency task force (. It is recommended that the Ministry of Labour, Training & Skills Development take steps to amend the. development of an integrated Plan of Care focused on the social determinants of health for the family and child that follows them through community services when they are in the community and also when they are in the care of a childrens aid society and incorporate the cultural and spiritual needs of the child; and. That the use of paper green sheets be discontinued, that the booking process and prisoner management systems be digitized, and that documentation used for charges in court be separated from the documentation used to manage and care for individuals in custody. Continue to train staff to identify and address suicidal ideations and risk factors (acute and chronic) associated with suicide. The ministry should seek funding to implement these recommendations. For young people in care, engage with any outside service provider at the intake stage to set clear lines of responsibility regarding communication of information regarding the young person to those in the youths circle of care, including communication of self-harm attempts and leaving the property without permission. Health and safety representatives are selected in a manner that ensures independence. These supports should account for the social barriers to accessing such supports within a custodial environment. Consideration should be given to disseminating information through alternative methods where cellular service is not consistently available. 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. This will be referred to as the inquest 'conclusion' or 'verdict.' Explore adding the term Femicide and its definition to the, Consider amendments to the Dangerous Offender provisions of the, Undertake an analysis of the application of s. 264 of the. What verdict can a coroner give? The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. All the latest inquests including openings from Derby Coroners' Court. Develop health and safety materials and for all workers and train workers, including temporary workers, on health and safety protocols prior to them undertaking any work. Specifically: ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the, Conduct a comprehensive post audit to determine the correctional staffing levels needed at the, Analyze the causes of correctional staff absenteeism at the, Complete an action plan based on the results of the post audit and staff absenteeism analysis. Derbyshire Police. Clear communication of the transfer of supervision; Clear communication of the scope of supervision; and. Regular meetings between mine emergency response team and. In recognition of the important roles of family and Indigenous communities, offer to involve the family and the Indigenous community of a deceased Indigenous young person in the Pediatric Death Committee Review process where appropriate, having due regard to confidentiality concerns.
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