The ministry should provide direct access to Naloxone spray for people in custody, including within locked cells. 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. Start grassroots Safe Spaces program that businesses can participate in where survivors can feel safe and ask for information (. 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). 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 Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. 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. . Employers shall ensure that workers are trained on the cell phone policy. The ministry should advocate for total compensation offered to nurses and healthcare staff be competitive with that in non-correctional settings. The inquest into Julie's death finished last week with the Coroner giving a neglect conclusion in respect of the care which North Bristol NHS Trust provide to Julie. 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. That care and services must be provided using a trauma informed approach to ensure that individuals who have suffered complex traumas are not excluded from the services that may assist them. The revised risk assessment factors, as well as search urgency factors, should be evidenced-based and clearly defined. There is still an open verdict on Berezovsky's death, which could mean the UK is unwilling to get to the truth. Explore the possibility of developing and including crisis intervention training as part of the mandatory curriculum for police recruits at the Ontario Police College and the requirement that all officers re-qualify at a determined interval. Provide professional education and training for justice system personnel on. The Office of the Chief Coroner (OCC) for Ontario provides death investigations and inquests, when necessary, to ensure that no death is overlooked, concealed or ignored. 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. 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). Consider renaming the Model to better reflect the range of tools and techniques available to officers. Revise the use of force report form to require officers to document de-escalation techniques used. BBC Radio Sussex. mental health, interpreters etc. Derbyshire Police. Where gaps exist, the ministry should explore and research means to increase actual programing at Detention and Correctional Centres: Analysis of data collection or research of Indigenous core or other programing should include identification of gaps, steps taken to resolve gaps, improvements and best practices; This analysis and research should be reported, maintained and disseminated to Ontario`s correctional Institutions, service providers and for use with consultation with First Nation, Metis and Inuit community; The ministry should consider evaluating and modifying their policies on allowing volunteers into the facility that have a criminal record. The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody. Research and, if appropriate, develop and integrate additional flags into the records management systems that accurately identify an active, serious threat to officers and the public, including behavioural and mental health flags, and a numerical measurement of risk. 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 Toronto Police Service should improve delivery of relevant information to the inner perimeter where crisis negotiations are taking place without unduly disrupting the negotiation process. 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. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. Inquisition and narrative verdict - Catherine Hickman; The ministry should adopt Good Samaritan principles in operational policies and practices to encourage persons in custody to call for help or try to help another person suspected of being in medical distress or come forward with information about drugs within the institution, without being subjected to any institutional misconduct proceedings for possession or use of contraband. Blackburn. When will a death be reported to the Coroner? The Toronto Police Service should provide emergency task force (. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. 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. Verdicts and Coroner's recommendations. While recognising that inquests must be . To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. The ministry should deliver alerts to persons in custody on an urgent basis regarding new and emerging threats from novel street drugs. Inquests. Implement more rigorous and thorough assessment of potential and current employees. When a community prescription for an opioid medication is discontinued or amended by a. 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. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. Prepare an emergency response plan to use if a worker does come into contact with a hazard. The ministry shall consult with an expert in trauma-informed care to review the current care programs to provide specific suggestions for institutional changes to promote trauma informed practices within the detention centre. Section 9: Giving Evidence As a witness you are not on trial, you are there to assist the court The Coroner decides which witnesses should attend, and in what order they are called. Evidence relating to the Five Incidents . why each inmate was held in conditions of segregation (for example: inmates refusal to comply, lack of physical space to accommodate time out of cell, inadequate staffing, measures taken to alter the inmates conditions of confinement so that they no longer constitute segregation. An inquest is not a trial and does not assign blame or liability. . 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. This training should also include periodic or ongoing refresher training. Ensure that adequate staffing is provided at each institution to implement recovery plans. It simply aims to gather information in order to answer these questions. internal audits by a health care manager or designate, external audits by the Corporate Health Care Unit, Ensure that the planned Electronic Medical Record (, be available to all health care staff at the point of care, ensure that health care professionals who provide care remotely have complete access to inmates health care files, include methods of communicating health care orders electronically, Ensure that psychiatrists who provide services at the. Held at: OttawaFrom:April 20To: April 29, 2022By:Dr.Bob Reddochhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Babak SaidiDate and time of death: December 23, 2017 at 11:30 a.m.Place of death:Morrisburg, OntarioCause of death:gunshot wounds to the right shoulder and right side of the back.By what means:homicide, The verdict was received on April 29, 2022Coroner's name:Dr.Bob Reddoch(Original signed by coroner). That an accessible sobering centre with a locally developed model of care appropriate to meet the needs of Thunder Bay and surrounding communities be established. Create emotionally supportive debrief sessions for police officers at the division or platoon level for those involved in critical incidents resulting in serious bodily harm or death, with regard for the Special Investigations Unit investigative process. Ensure that police officers can accurately identify their own, Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (. Increase sustainable and equitable funding for community-based childrens mental health services, including residential placement options and family support, that are responsive to recruitment and retention needs of service providers to employ multidisciplinary staff and professionals and programs that are flexible, responsive, and facilitate the right services at the right time for children and young people with complex needs. Specifically: increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. The following recommendations are made in recognition and acknowledgement of the following principles: Surname:BruneauGiven name(s):OlivierAge:24. The dangers of working in proximity to overhead powerlines, even when no work on overhead power lines is intended. Implement the corporate health care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. Distribute current contact information for ORNGE, air ambulance to all remote workplaces including but not limited to the mining, forestry, and construction industries. The ministry should ensure that all correctional officers are trained regarding recognizing behaviour of Inmates that might pose a risk to the Inmate or others. An 'investigation' is a new way a Coroner can handle a case that was introduced in reforms of the legislation in July 2013. 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 ministry should explore safer alternatives to wooden pencils being provided to Inmates. Half day. 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. For the purpose of assisting clinicians in directing patients to receive timely mental health services and promoting accountability of community mental health services, a direction requiring that all hospital and community-based mental health services that receive funding from the Government of Ontario: collect and publish monthly non-identifying data regarding: wait times for treatment (i.e., actual receipt of mental health services by mental health professionals as opposed to waiting times for intake) and patient volumes, days and hours of mental health services provided, provide the resources to allow hospitals and community-based mental health services to provide this data, increase mental health awareness and promotion of initiatives within communities to address the lack of familiarity of services and options available for persons and families dealing with mental health situations. The ministry should ensure cooperation between. The Ministry of Labour shall review and consider whether to impose a renewal requirement on Common Core Underground Certification. We recommend that locates in the vicinity of power lines should include underground, on grade, and above grade utilities or hazards, as well as current, voltage and distance from grade to the high-power line. That access to electronic health records be provided to all paramedics in Ontario, and if such access is available, that Superior North. What verdicts can a coroner give? How is it different from an inquest? When first addressing an employee in medical distress, a full body assessment (head to toe) must be completed. The training should address: understanding how emotional prejudice impacts decision making, tactics/solutions for mitigating the harmful impact of stereotyping on health and criminal justice outcomes, That both services consult with Indigenous Nations, Provincial Territorial Organizations (. Ensure that security patrols are completed during shift changeovers. The ministry should engage in community consultation on the development of Indigenous core programming with Indigenous leadership including First Nation, Mtis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres. The Coroner is expected to open an inquest where there is reasonable suspicion that the deceased has died a violent or unnatural death, where the cause of death is unknown or if the deceased. 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. A list of the inquests scheduled for hearing in the Oxford Coroner's Court. The plan should include adequate staffing and infrastructure to avoid triple bunking and to accommodate intermittent inmates and inmates in need of specialized care or stabilization. The inquest would be held in the district where the death occurred. 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. Inform staff and affected personnel that resources are available to support them with respect to work related stress. 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. Review and improve training to housing support personnel on cultural competency, anti-Black racism, implicit bias, mental health and its intersectional nature. Amend the Construction Regulations to include a mandatory requirement for training of Health and Safety Representatives who work on construction projects. This would both provide a warning and a specific ongoing reminder to any person entering such areas. The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. Ensure that gaps or compliance issues identified during investigations into inmate deaths (including by Correctional Services Oversight and Investigations) are communicated and reinforced to relevant staff and healthcare providers. 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. 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. Review existing training for justice system personnel who are within the purview of the provincial government or police services. Programs and other initiatives to address drug addiction and abuse should be encouraged, prioritized and promoted in prominent places throughout the facility where they are likely to come to the attention of persons in custody. Institute a policy to mandate regular debriefs with officers involved with incidents that engage the Special Investigations Unit to ensure that supports are in place and the incident to be used as a learning tool so that future incidents can be prevented. The open verdict is an option open to a coroner's jury at an inquest in the legal system of England and Wales. II. In the case of high risk and dangerous subjects, consider the application of Situation Mission Execution Administration Command & Communication (, Where there is an existing threat assessment on file, provide contact information so that. 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. 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. 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. 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. 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 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. 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. Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission. Tailboard meetings/forms must be completed. Promote and utilize the participation of young people and youth-driven practices in services, tools and programs, such as: the Wise Practices resources and Life Promotions toolkit by Indigenous youth, that are about their own wellness and make space for the young people to put into practice tips and ideas from those services, tools and programs. 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. 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.
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