coroner's inquest verdicts

Older verdicts and recommendations, and responses to recommendations are available by request by: e-mail: occ.inquiries@ontario.ca. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. Consider the circumstances of all police-related inquests as training scenarios. 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. The ministry should prioritize the completion of its project to implement electronic health records for patients living in correctional facilities. That the Thunder Bay Police Service Board retain an expert consultant for the purposes of providing an independent assessment of the level of staffing required of the Thunder Bay Police Service. In consultation with organizations like Hamilton Childrens Aid Society and other agencies servicing high-risk youth, develop a joint process whereby, Establish the role of an Indigenous Liaison within the. In partnership with the urban Indigenous community, continue active membership on the Indigenous Child Welfare Collaboration Committee established in January 2018 to strengthen relationships, develop pathways and strategies for a coordinated approach to services and wraparound support for First Nations Inuit and Mtis children and families involved in child welfare services in Hamilton. 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. 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. This includes: familiarity with the act and the regulations that apply to the work, ability to identify and address workplace hazards. Explore options for privacy screens or barriers around toilets in cells to avoid the need for inmates to fashion their own privacy sheets. 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). It simply aims to gather information in order to answer these questions. 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. These reviews should analyze relevant health care files and assess quality of care. A coroner's inquest is a public court hearing where the coroner determines about how, when and where someone died following a post-mortem. 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 child welfare service delivery model, including consideration of the following: continue monitoring the effectiveness of annualized funding announced in July 2020 as part of the Child Welfare Redesign Strategy to provide access to prevention-focused customary care for bands and First Nation communities, support the implementation of models of service to enable children and youth to have meaningful, lifelong connections to their family, community and culture; a sense of belonging; a sense of identity and well-being and physical, cultural and emotional safety; and that plans of care are reflective of the childs physical, mental, emotional, spiritual and cultural identities beginning from the time a case is opened by a society, continue to review the Ontario Eligibility Spectrum, the need for verification, and adopt a needs-based approach (instead of a caregiver deficits approach) to supporting and protecting the well-being of children and youth informed by Indigenous experts. The ministry should install monitoring equipment of good quality at, The Ministry should ensure that Opioid Agonist Treatment (, Corporate health care with the ministry should continuously monitor wait times for the availability of. 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. Inform staff of the LivingWorks Start online training on suicide prevention and provide them with information to register. Consider engaging the private sector to assist in developing recruitment and retention strategies and provide current labour market data and analysis. Review and improve training to housing support personnel on cultural competency, anti-Black racism, implicit bias, mental health and its intersectional nature. Ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the. 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. The Regulation would require that, in such circumstances: impermeable personal protective equipment to be used and there be a process for verifying or confirming the use of the required personal protective equipment before work is performed in the area, the flushing of cyanide-containing material from lines, titrations to ensure cyanide content in any debris or materials in the area is below a set threshold (, lock out and tag out procedures are to be developed and implemented, workers required or assigned to work in the area have received cyanide awareness training and proper removal of. January Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission. 12/09/2022. Inform staff and affected personnel that resources are available to support them with respect to work related stress. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. Establish clear guidelines regarding the flagging of perpetrators or potential, Recognize that the implementation of the recommendations from this Inquest, including the need for adequate and stable funding for all organizations providing, Create an emergency fund, such as the She C.A.N Fund, in honour of Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam to support women living with. This training should also include periodic or ongoing refresher training. 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 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. Consider applying other ministry resources to support health care staff recruitment at the, Monitor how often inmates on suicide watch at the, Ensure that if any inmates on suicide watch at the, Provide an anonymized public report on the number of inmates on suicide watch at 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. 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. Explore developing and providing all police recruits with additional de-escalation training. If a police service has a joint mental health-police team, give studied consideration to implementing a police policy that provides, once police officers attending a call identify a potential mental health concern and provided it is safe to do so, that the joint mental health-police team should be engaged. We recommend that all construction projects that utilize booms or cranes in proximity to overhead power lines, be required to make a written request to the owner of the power lines, to facilitate compliance with sections 187 and 188 of Regulation 213/91 for Construction Projects. Compensation should include: cost of medicines or supplies required to facilitate service. II. 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. Coroners' Inquests Inquests are formal court proceedings, with a five- to seven-person jury, held to publicly review the circumstances of a death. The ministry should position equipment necessary for an emergency medical response close to living units. 2.30pm Andrew Phillips, aged 56, from Altrincham, died 31/05/22 in JRH. The Coroner's officer will usually inform interested parties to the Inquest who is to give evidence at the hearing. 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 enhanced police training in addressing mental health-related situations and crises, including awareness education in recognizing and identifying situations where mental illness may play a role. This will be referred to as the inquest 'conclusion' or 'verdict.' Signaller be equipped with a remote e-stop. The ministry should explore implementation of harm reduction strategies similar to those used at supervised consumption sites. The ministry should amend its policies and practices for admissions officer/. The Coroner investigates deaths in order to establish who . Any requests to obtain and use video or other recordings from the inquest shall be made to the Office of the Chief Coroner for their consideration. Implement recommendation #6 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Held at:North BayFrom: November 21To: November 24, 2022By:Dr.S.C. Bodleyhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Gordon Dale CouvretteDate and time of death: February 22nd 2018 06:21Place of death:North Bay Regional Health Centre, 50 College Dr, North Bay, Ontario, P1B54ACause of death:Sudden death with no anatomical cause associated with acute-on-chronic cocaine and amphetamine abuse/intoxication, forcible struggle and possible Autonomic Hyperactivity SyndromeBy what means:accident, The verdict was received on November 24, 2022Presiding officer's name:Dr.S.C. Bodley(Original signed by presiding officer), Surname: Blackett,Given name(s):CraigAge:41.

Juliet Huddy Father, Doug Jackson Sv Seeker Wife, Articles C