The ministry should require all forms related to the admissions of inmates to be completed in full, including review and signature by a sergeant (or their designate). 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. Inquests for this area are normally held at Archbishops Palace, Maidstone unless stated otherwise. 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. 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. In recognition of the shortage of beds in detox/treatment (rehabilitation) facilities in the City of Thunder Bay, the number of beds in such programs should be increased to adequately meet the needs of the community. Risk assessments and risks of lethality are taken into account when making enforcement decisions. Try to find out: the date the. In compliance with its by-laws, the Board will create terms of reference for its governance committee and make the terms of reference public. 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. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers). models in other jurisdictions that identify relevant. Legal Framework . The ministry should seek funding to implement these recommendations. 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. Annual training is also provided for coroners' officers. how to identify and address the precursors to heat stress, and other heat related illnesses that may arise from working in high temperature conditions. The Government of Ontario should offer and arrange enhanced legal and mental health support for families of persons who die in a police encounter and ensure that those services are delivered in a timely and trauma-informed manner. The ministry should develop guidance to determine criteria by which. Training should be given to establish who should lead the call when dealing with a potentially violent incident or crisis. The ministry should explore implementation of harm reduction strategies similar to those used at supervised consumption sites. The ministry should use the Indigenous led study to create and implement a policy on using Indigenous cultural practices as solutions to combating the opioid crisis at. The Chief Firearms Officer should work with appropriate decision-makers to: The Information and Privacy Commissioner of Ontario should: Surname:McKayGiven name(s):GabrielAge:36. 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. In some Coroner's Districts certain inquests can be held based only on documents. The Ontario Use of Force model should be renamed to accurately capture the intent and purpose of the model, which is a guide to police engagement with the public rather than to suggest that force is inherent in police interactions. The Toronto Police Service should provide emergency task force (. 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. 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. These solutions should be communicated to relevant staff and stakeholders in a timely manner. The ministry shall ensure that wherever a serious mental illness is suspected or identified through mental health screening, that the person in custody will not be placed in conditions of segregation. . Set up satellite offices for police officers to work safely and comfortably to spread police resources more evenly over wide rural areas (, Encourage Crowns to consult with the Regional Designated High-Risk Offender Crown for any case of. The ability to respond immediately with risk management services in collaboration with. Require emergency response personnel in plants using cyanide to be provided with basic first aid/. Review the process and criteria for issuing a media release to ensure that, where appropriate, timely media releases are issued in missing person investigations, and that due consideration to issuing a media release occurs within set time periods during an investigation. Consideration should be given to disseminating information through alternative methods where cellular service is not consistently available. Coroner's Duties The office of coroner became constitutional with statehood in 1818. Name of deceased. 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 employer properly identifies and reviews all potential chemical hazards at the mine site including, but not limited to, the dangers of cyanide. It would also provide a primary point of communication for emergency response and medical personnel. Consider how the concept of Safety by Design has been implemented in other jurisdictions and assess whether these concepts can be incorporated into Ontarios health and safety regulations. To improve outcomes for First Nations children and youth, empower and seek to fund bands and First Nation communities and affiliated stakeholders (such as the Association of Native Child and Family Services Agencies of Ontario) to collect data and analyze data to determine whether, and to what extent, child welfare interventions and services are improving outcomes for children and youth. 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. Provide annual reports, accessible to the public, on ongoing research findings through the Chief Prevention Officer. What is an 'investigation'? The Ministry of Labour shall review and consider whether to impose a renewal requirement on Common Core Underground Certification. The ministry should revise both health and, The ministry should consider contracting Elder positions in addition to. The coroner has a degree of discretion to call a jury in any case that is in the public interest, but a jury must be called if the death occurred in prison; in police custody; by accident, poisoning or any disease that requires other government departments to be notified; or when circumstances exist that might affect the health and safety of the This should include funding for more dedicated officers who can conduct drug investigations and share information with appropriate. If the cause remains in doubt after a post mortem, an inquest will be held. The coroner will open the inquest in order to issue a burial order or cremation certificate (if not already issued immediately after the post-mortem examination) as well as hearing evidence confirming the identity of the deceased. 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. We recommend that an industry wide Hazard Alert be published, alerting end-users, and manufacturers of remote-control devices for booms and cranes, to the risk of inadvertent boom or crane movement associated to the OMNEX T300 Wireless Remote Control, or any similarly designed remote control used for boom or crane operation. The pilot whose plane crashed at the Shoreham Airshow in 2015, killing 11 men, has asked for permission to judicially review the inquest into their deaths. 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. 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 ministry should ensure that correctional officers investigate cell change requests immediately, and grant same immediately, where merited. In addition to posting hazard alerts on the ministrys website, develop and implement a system of communication to distribute hazard alerts so that they are sent directly to constructors and employers. Section 14.6 states the following: We call upon Correctional Service Canada and provincial and territorial services to provide intensive and comprehensive mental health, addictions, and trauma services for incarcerated Indigenous women, girls, and. Specifically, the the ministry should: ensure that all Native Inmate Liaison Officer/Indigenous Liaison Officer (, benefits, that include access to an employee assistance program, opportunities for support following traumatic incidents, create policy and direction that recognizes the role and function of. Work towards creating (including if necessary by making a request to the, developing a strategic plan; including review and potential amendments to missing persons investigations (, use of civilian support workers, civilians in duties not required for a sworn officer related to, maintenance and development of community partnerships and, in particular, the Indigenous community, partnerships with youth institutions and, in particular, child and youth mental health facilities, Review and revise the risk assessment process and policies that govern whether a missing person is classified as Level 1 or Level 2, as well as whether an urgent search is required. 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 data should be standardized, disaggregated, tabulated and publicly reported. Coroner's inquests are held in cases of sudden, unexplained or suspicious deaths. All physician assistants and doctors are trained on all medical equipment available at the worksite. 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 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. In partnership and in consultation with First Nations, provide direct, sustainable, equitable, and adequate funding to First Nations for prevention services, cultural services, and Band Representative Services to service and support both on- and off-reserve First Nations children, youth and families involved in child welfare and in support of children and youth in need of mental health supports pursuant to a needs-based approach that meets substantive equality. 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. To ensure the safety of the children in its care, Lynwoods psychiatric nurse practitioner shall meet with staff upon admission of each new client regarding any diagnosis and/or mental health needs. 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. Possible outcomes include: natural causes; accident; suicide; unlawful or lawful killing; industrial disease and open verdicts (where there is insufficient evidence for any other verdict). The ministry should ensure that all staff be trained regarding crisis and incident response and management. emerging technologies, like an electro magnetic sensor to prevent a boom or crane from entering the prohibited zone (disabling controls). The Coroners' Courts Support Service (CCVS) is an independent voluntary organisation whose trained volunteers offer emotional support and practical help to bereaved families, witnesses and others. In addition, such education should be repeated quarterly. The ministry should ensure mental health nurses are available on call 24 hours a day, seven days a week, to see any Inmates waiting for them as soon as possible to allow all assessments to be completed in a timely fashion regardless of whether any given Inmate has temporarily left the institution for court. 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. The ministry should engage with Indigenous communities, organizations and health care providers in the development of corporate strategies, such as the Correctional Health Care Strategy and the Mental Health and Addictions Strategy for Corrections. 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. Reinforce the policy requirement for a Part C health care summary to be completed in every patients health care record. 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 modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. Did you find what you were looking for? At the end of an inquest, the Coroner will read out a formal verdict to record: the identity of the deceased; how the death happened ; . 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. Explore developing and providing all police recruits 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.