Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services. 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. All health and safety representatives are competent and aware of their duties and responsibilities. Try to find out: the date the. 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. TT sidecar driver had passenger's dog tag - inquest. Revise the provincial Use of Force Model (2004) as soon as possible. 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. Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants. Contact Kent and Medway Coroner. 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. Inclusion of and consultation with Indigenous communities/agencies is essential. The coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities. Require employers to develop and implement cyanide awareness training that meets requirements set out in the Regulation for the content of such training and frequency of refresher training. Employers shall ensure that workers are trained on the cell phone policy. Such a program should: operate only upon the consent of each individual participant, be managed in partnership between a sobering centre, managed alcohol facility and community care teams, include a system by which first responders can contact case managers/care team members to: inform them that an individual in their care has been in contact with first responders (emergency medical services (, In recognition of the seriousness of alcohol/substance use disorder (. The ministry should provide educational opportunities to persons in custody and operational staff at correctional facilities about the Good Samaritan principles that it adopts in its operational policies and practices. If it cannot be done immediately, the correctional officers should then bring the Inmate to admit and discharge pending re-assignment to a cell. Health and safety representatives are selected in a manner that ensures independence. The Office of the Chief Coroner should consider conducting inquests within a timely manner, within 24 months from the incident date with the exception of extraordinary circumstances. The ministry should ensure and enforce thorough training that: All correctional staff read the unit notification cards of the inmates in their unit at the start of their work shift (immediately following shift change) and whenever an inmate returns to the unit from court or other external location. 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. The hazard alert should identify cyanide, in all of its forms, as a potential workplace hazards. Seek and allocate adequate funding and resources to implement the above recommendations. IV. Coroners will look to establish the medical cause of death. The ability to respond immediately with risk management services in collaboration with. Names of the deceased: Blumberg, Alexsey; Bondarevs, Aleksandrs; Fayzullo, Fazilov; Korostin, VladimirHeld at:remote inquestFrom:January 31To: February 4, 2022By:Dr.John Carlisle, coroner for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:BlumbergGiven name(s):AlexseyAge:38, Date and time of death: December 24, 2009 at 4:30 p.m.Place of death: 2757 Kipling Avenue, TorontoCause of death:multiple injuries due to a fall from a suspended work platformBy what means: accident, Surname:BondarevsGiven name(s):AlexsandrsAge:24, Surname:FazilovGiven name(s):FayzulloAge:31, Surname:KorostinGiven name(s):VladimirAge:40, The verdict was received on February 4, 2022Coroner's name: Dr. John Carlisle(Original signed by coroner). For a free, no-obligation, initial discussion of how we may be able to help, please contact us today. Unfortunately, we cannot provide any additional information other than what is on the Court List. This may be done through by creating a mailing list of employers, constructors and trade unions, in the construction sector or in consultation with the Infrastructure Health and Safety Association, or such other partners as may assist with the development and implementation of the system. Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission. The 74,160 records in this database were extracted from the Cook County Coroner's Inquest Records. A coroner's inquest . 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. To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. 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. Measures to improve public awareness should be developed in consultation with content experts and community organizations that represent persons with lived experience. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. Revise the provincial policy on recovery plans for inmates who are removed from suicide watch. This training should be designed and delivered by Indigenous people. Related Information. Specifically: increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. It is recommended that training related to the management of change process take place on a regular basis (annual as a minimum) to ensure that all employees are continually informed as to what requires the initiation of the management of change process. The relevant coroners office will contact you if this is the case. Be staffed 24 hours a day and 7 days a week. Coroner Services is an independent and publicly accountable investigation of death agency. In December a coroner . Designated funding for transportation for those receiving, Funding to ensure mental health supports for. The ministry should ensure that healthcare and correctional staff at correctional facilities receive additional training about building rapport and resolving challenging encounters with persons in custody. 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. Misadventure is where someone doing something lawful unintentionally kills another. When the coroner's jury could not determine a cause of death, an "_" will appear in the verdict category. Explore the capability of the information management systems to track the deployment of alternative responses to assist a person in crisis and the outcomes. When non-Indigenous service providers are providing care, the First Nation Mental Wellness Continuum Framework should be considered when developing and delivering services to Indigenous children in care. Explore digitized records of over a century of coroner's records from Stark County, Ohio, available online . The circumstances in which judges can lead inquests and details of notable inquests overseen by a judge. An approach that is not one-size-fits-all. Review and improve training to housing support personnel on cultural competency, anti-Black racism, implicit bias, mental health and its intersectional nature. Increasing program availability and develop flexible options for, Recognize the specialized knowledge and expertise of, Address barriers and create opportunities and pathways to services for, Improve the coordination of services addressing substance use, mental health, child protection, and, As new services are funded, include aims and outcomes associated with building an underlying network of specialized services to address, Endeavour to minimize destabilizing factors for perpetrators of, Investigate and develop a common framework for risk assessment in. The OCC distributes all verdicts and recommendations to organizations for them to implement, including: The OCC asks recipients to respond within six months to indicate if the recommendation(s) was implemented, and if not, the rationale for their position. Review current procedures and processes in respect of police response to persons who have a mental illness. Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. There are no fees attached to this service. Re-evaluate the capacity of Community Outreach and Support and Mobile Crisis Rapid Response teams to meet the growing need for these services in the Region of Peel. To support ongoing consultation, communication, and transparency between the Society and the bands and First Nations communities of the children and youth it serves, the Society shall reach out to those bands and First Nation communities and offer to develop a communication protocol and offer to initiate quarterly reviews regarding all children receiving services from the Society. 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 content of such training to include: what cyanide is used for within the workplace and where it can be found, the method for identifying cyanide within the workplace, personal protective equipment and limitations associated with such equipment, the signs and symptoms of cyanide exposure, first aid / treatment procedures for people potentially exposed to cyanide. The task force should focus these reviews on the most vulnerable patients, particularly those diagnosed with moderate to severe mental illness, especially schizophrenia and/or schizophrenia-related disorders. Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. An inquest is not a trial and does not assign blame or liability. 4:33 p.m. - April 28, 2022. Within 6 months of the jurys verdict, strike a task force to review, report on, and initiate changes to: funding, accountabilities, and timely access to care for all community-based mental health services that receive funding from the Government of Ontario, available resources and supports for family members and/or caregivers of patients and community services receiving mental health services, how family members and/or caregivers and community services can provide support and/or information about patients when patient consent is not provided, address what information can be shared from family members and other stakeholders, align services and community agencies to better share information about individuals with mental health concerns in the community, Establish further study and review of the criteria and training associated with the, mandatory refresher training for emergency room physicians and psychiatrists in the province of Ontario on when and how to use the Form 1 options associated with mental health, the assessment of Box A and Box B criteria for psychiatric evaluation and involuntary detention, to determine how best to ensure collateral information from family members and relevant community services information can be included as part of the process for determining appropriate treatment options. Which justice participants should have access to the findings made by a civil or family court. 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. Fund for safe rooms to be installed in survivors homes in high-risk cases. The Ministry of Labour shall review and consider whether to impose a renewal requirement on Common Core Underground Certification. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. Funding to be provided on an annualized basis, with adequacy assessed and considered after the first three years. Consideration of the remoteness quotient used to calculate funding in other social services, such as education and policing. This would both provide a warning and a specific ongoing reminder to any person entering such areas. 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. . The inquest into the Lakanal House fire in the London borough of Southwark on 3 July 2009 began on 14 January and ended on March 28 2013. . how to prevent heat stress and other heat related illnesses that may arise from working in high temperature conditions, and. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. 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. 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. 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. That the Thunder Bay Police Service review its jailer academic programming and, if not already included, incorporate an educational component on the Human Rights Code and training on cultural sensitivity. Conclusion. We recommend that where a construction project involves work in proximity to overhead power lines and equipment that has the potential to contact overhead power lines such as a boom or a crane is being operated, the. 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. These supports should account for the social barriers to accessing such supports within a custodial environment. Provide direct, sustainable, equitable, and adequate joint funding from the named Ministries and Government of Canada to First Nations, off-reserve Indigenous service providers, and non-Indigenous service providers serving off-reserve First Nations children, youth and families to increase the capacity for collaboration in the provision of child welfare and mental health services. Ensure that the Central East Correctional Centre (. Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing. Held at:25 Morton Schulman Avenue, TorontoFrom:April 4To:April 7, 2022By:Dr.Robert Boykohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Fernando SantosDate and time of death: January 23, 2018 at 3:38 p.m.Place of death:1575 Lakeshore Road West, MississaugaCause of death:blunt force trauma of the torsoBy what means:accident, The verdict was received on April 7, 2022Coroner's name:Dr.Robert Boyko(Original signed by coroner), Surname:SaidiGiven name(s):BabakAge:43. 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. Please note inquests can be changed at the last minute, please check before attending. Explore and research the availability and efficacy of additional less-lethal use of force options for officers. Review the current Use of Force Model (2004) and related regulations, and consider incorporating the concept of de-escalation expressly (both in terminology and visual representation) into the Model as a response option and/or goal. The ministry should explore the use of a scoring metric to determine risk in areas such as mental health and violence, assessed first at Intake and re-evaluated on a continuous basis. Communication between first responders at the scene must be documented. The mnistry should ensure that the Toronto South Detention Centre, and any other detention centres organized in the same manner, have an additional copy of the unit notification card kept on the unit for review by correctional officers while an inmate is absent due to court or other external location. 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. The ministry should also consider what, if any, supports or agencies that are local to the bereaved can be referred, or assist the family, in receiving the news. Crowns should actively oppose variation requests to have firearms returned for any purpose, such as hunting. The Toronto Police Service should continue to explore the feasibility of implementing body-worn cameras for all. Also in this section 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. Understanding any impacts after an order for such technology expires. Mandate that all police service officers receive annual implicit bias and cultural competency training to address stereotyping of Black people, and the existing research on anti-Black racism in policing. Ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the. The same expert panel as noted above should provide recommendations to define outcome measures which clearly describe the successful progression of Indigenous youth through the welfare system to independence and adulthood. Ensure that health care transfer summaries are completed in compliance with provincial policies when inmates are transferred between institutions. The ministry should implement dedicated and centralized real time monitoring of cameras at. 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. The orientation should include hazards, work processes and medical issues, that may be unique to that work site. Implement the National Action Plan on Gender-based Violence in a timely manner. Appropriate perpetrator programs and supports needed to accompany electronic monitoring. Establish policies making clear that, absent exceptional circumstances, those assessed as high risk or where the allegations involve strangulation should not qualify for early intervention. Once the data is gathered and analyzed, in partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, seek authority and any necessary funding to implement and act upon the data recommendations to support better outcomes for children and youth, including seeking the necessary authority to make any legislative and regulatory changes to support changes for better outcomes. The coroner Sir John Goldring said he would accept a. Older verdicts and recommendations, and responses to recommendations are available by request by: e-mail: [email protected]. 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 ministry should revise both health and, The ministry should consider contracting Elder positions in addition to. Coroners' appointments . Seek and allocate adequate funding and resources to implement these recommendations. 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. All physician assistants and doctors are trained on all medical equipment available at the worksite. 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 Toronto Police Service should explore the ability to use audio/visual capabilities to have short notice assistance from external professionals e.g. Follow a study to determine the scale and volume of increase that is necessary to address the shortage of beds in Thunder Bay for all communities that access Thunder Bay for services. 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. The ministry should analyze the data they collect to determine where there are gaps in service delivery of programs at particular institutions. Continue to train staff to identify and address suicidal ideations and risk factors (acute and chronic) associated with suicide. 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).