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. Include in those best practices training requirements or other criteria for achieving competency regarding the assessment of ice on excavation walls as a hazard. 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. In any new detention centre builds, consideration should be given in the design to allow for timely access for emergency personnel. 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. 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. 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 ministry should ensure that correctional officers investigate cell change requests immediately, and grant same immediately, where merited. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. Develop strategies on prescribing and dispensing medications in a manner that would assist with protecting patients from being coerced into diverting the medication to other inmates. Names of the deceased: Rajendiran, Arun Kumar;Tavernier, Darrel; Kelly, StephenHeld at:TorontoFrom:May 30To: June 13, 2022By:Dr.Robert Reddoch, coroner for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:RajendiranGiven name(s):Arun KumarAge:25, Date and time of death: November 12, 2014 at 8:16 p.m.Place of death: Central East Correctional Centre, Lindsay, OntarioCause of death:hangingBy what means:suicide, Surname:TavernierGiven name(s):DarrelAge:42, Date and time of death: January 1, 2018 at 8:37 a.m.Place of death: Ross Memorial Hospital,Lindsay, OntarioCause of death:hangingBy what means:suicide, Surname:KellyGiven name(s):StephenAge:62, Date and time of death: May 18, 2019 at 9:10 a.m.Place of death: Ross Memorial Hospital,Lindsay, OntarioCause of death:hangingBy what means:suicide, The verdict was received on June 13, 2022Coroner's name: Dr.Robert Reddoch(Original signed by coroner), Central East Correctional Centre (CECC) Health Care Review. Roger and Bradley Stockton crashed on the second lap of last year's final sidecar race. Inclusion of and consultation with Indigenous communities/agencies is essential. The ministry should abandon its zero-tolerance policy with respect to both the use of street drugs and the diversion of prescribed drugs, recognizing that this policy stigmatizes and punishes people for behaviours that stem from underlying medical issues. 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. The inspections should focus on assessing whether projects are organized in a manner that ensures safety of all workers. [1] The Toronto Police Service should consider the use of dedicated negotiators. The ministry should provide education opportunities to persons in custody on the following topics: illicit opioid/other drugs available/in circulation, mental and physical health risks of using illicit opioid/other drugs, safe drug-use practices, including never to inject, smoke or ingest drugs alone, the risks of mixing illicit opioid/other drugs with prescription drugs. 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. The following recommendations are made in recognition and acknowledgement of the following principles: Surname:BruneauGiven name(s):OlivierAge:24. The verdict means the jury confirms the death is suspicious, but is unable to reach any other verdicts open to them. Date of inquest. 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. Led by the Chippewas of Georgina Island First Nation, support the development and delivery of a case study training module for childrens aid societies and residential service providers regarding the lessons arising from Devon Freemans life and death and incorporate information from the Narrative document (with the exclusion of personal identifiers or information that may identify individuals or otherwise assign blame). The ministry should investigate how security is assessed concerning spiritual elders, knowledge keepers, and traditional teachers. Workplace incidents are properly investigated and addressed, and the results of those investigations are communicated to the relevant workplace parties. Review the mandate of Probation Services to prioritize: Require that probation officers, in a timely manner, ensure: There is an up-to-date risk assessment in the file. Review existing training for justice system personnel who are within the purview of the provincial government or police services. That the Community Inclusion Coordinator be part of the process for reviewing relevant. Coverage of cellular networks, particularly in remote and rural regions. Held at:HamiltonFrom: September 26To: October 21, 2022By: Jennifer Scott, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Devon Russell James Freeman (Muskaabo)Date and time of death: April 12, 2018 (October 7, 2017 April 12, 2018)Place of death:831 Collinson Rd, FlamboroughCause of death:hanging by ligtureBy what means:suicide, The verdict was received on October 21, 2022Presiding officer's name:Jennifer Scott(Original signed by presiding officer). Ohio, Stark County Coroner's Records, 1890-2002. 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. Consider including conductive energy weapons training as part of the mandatory curriculum for police recruits at the Ontario Police College with a yearly re-certification. Provide support for training and capacity building for childrens aid societies and licensed residential facilities to meet the consultation requirements with bands and First Nation communities under sections 72 and 73 of the. This would both provide a warning and a specific ongoing reminder to any person entering such areas. 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. Nine jurors reached unanimous decisions on all but one of the 14 questions at the inquests into Britain's worst sporting disaster. That all police officers be trained that paramedics cannot medically clear any person, and that an assessment by a paramedic does not mean that a patient does not require medical treatment. Ensure that witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports. 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. 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. That the services collaborate to discuss the practice of wave offs, and develop policies and training for first responders, on how a wave off should not occur. Consider retroactive compensation for the security clearance review period for those candidates that successfully obtain security clearance and sign an employment agreement with the. Constructors, employers and supervisors shall ensure that workers are not endangered by cell phone use on construction projects. It is recommended that all Ontario mines actively using metallurgical cyanide establish clearly demarcated cyanide zones wherever cyanide is used or may be reasonably found at harmful concentrations. 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. 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. 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. A British coroner will hear about the final hours of Amy Winehouse's life at the inquest into the soul diva's death. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. The audit should be independent and should result in an action plan that must be submitted to the. When a community prescription for an opioid medication is discontinued or amended by a. Conduct a review of the safety features designed into the. 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. 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. 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. 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. Inform staff and affected personnel that resources are available to support them with respect to work related stress. The ministry should ensure that each institution: develops Indigenous specific programming which reflect the local Indigenous communities and agencies surrounding the institution; provides Indigenous persons in custody with access to Indigenous healing practices including Knowledge Keepers and Elders. Coroner's Duties The office of coroner became constitutional with statehood in 1818. These solutions should be communicated to relevant staff and stakeholders in a timely manner. Implement the Spirit Bear Plan through collaboration with. Health and safety representatives are selected in a manner that ensures independence. 12/09/2022. Provide additional guidance on how to assess the risk of ice on excavation walls. Just before 4.30pm on the 94th day of the inquest, the jury forewoman told the coroner Lord. 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 ministry should explore implementation of harm reduction strategies similar to those used at supervised consumption sites. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. Coroner's inquests are held in cases of sudden, unexplained or suspicious deaths. Court listings are held in the Avon Coroner's Court, Old Weston Road, Flax Bourton, Bristol BS48 1UL At this time Jury inquests are being held at Ashton Court Mansion House, Ashton Court Estate, Long Ashton, Bristol, BS41 9JN These listings are subject to change. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. 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 cost of transportation for survivors and service providers. On the second day of an inquest at Dublin District Coroner's Court today, counsel for Mr Sweeney's family, Roger Murray SC, said the net effect of the patient being discharged from the high . Time of death could not be determined.Place of death: Foymount, OntarioCause of death: shotgun wound of the chest and neckBy what means: homicide, The verdict was received on June 28, 2022Presiding officers name: Leslie Reaume(Original signed by presiding officer). 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). 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. Designate an employee to manage this plan, monitor the weather, ensure compliance with the plan and maintain records. While recognising that inquests must be . Develop an expert panel including Indigenous leaders, researchers, as well as leaders from other provincial child welfare ministries, such as British Columbias Ministry of Children and Family Development who can provide expertise on best practices to revise the child welfare funding formula to address the needs of Indigenous youth. It simply aims to gather information in order to answer these questions. Also in this section 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. The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. To the Ministry of the Solicitor General and Windsor Police Service, Surname:OgundipeGiven name(s):VictorAge:41. Implement recommendation #20 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. 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. Work with the Infrastructure Health and Safety Association to develop guidance material for employers and constructors on how to address the hazard of falling ice. 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. Coroners' appointments . The ministry should ensure that people in custody have access to a reliable means of initiating an emergency medical response. The ministry should advocate for total compensation offered to nurses and healthcare staff be competitive with that in non-correctional settings. That officers and jailers continue to be trained on an ongoing basis to seek out and record answers from the arrested person about their medical condition. . Unfortunately, we cannot provide any additional information other than what is on the Court List. We recommend that significant and automatic fines should be levied against any company/constructor that fails to ensure that a dedicated Signaller be assigned to Hydro-vac crews and/or any crane operation when working in the vicinity of overhead powerlines. The Board will consider yearly public reports setting out the initiatives taken by the Board, the progress of those initiatives and an expected timeline for completion of the initiatives. 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. Held at: Thunder BayFrom:June 13To: June 13, 2022By:Dr.Steven Bodleyhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Gabriel McKayDate and time of death:November 6, 2017 at 11:20 p.m.Place of death:St. Josephs Care Group, 35 Algoma Street North, Thunder Bay, OntarioCause of death:complications related to a severe brain injury sustained as the result of a workplace fall suffered September 14, 2016By what means:accident, The verdict was received on June 13, 2022Coroner's name:Dr.Steven Bodley(Original signed by coroner), Surname:LepageGiven name(s):RonaldAge:59. Inquest Openings from 9:00am on Wednesday 1 March 2023 at Warrington Coroners Court, West Annexe, Town Hall, Sankey Street, Warrington, WA1 1UH : Salim Mahmud Khan Kevin Vincent Flanagan Carl. Develop and implement a pilot project to explore the feasibility of dispatching crisis support workers to mental health service calls that do not require police involvement, similar to Peel Regional Police Mental Health Strategies. 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. Prepare an emergency response plan to use if a worker does come into contact with a hazard. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care. Inquests should be completed within 24 months from the incident date unless the circumstances warrant additional time. Consider conducting an ice management campaign for large construction projects in Eastern Ontario. These would keep Indigenous youth within their local community and connected to family, culture, and local supports. 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). The ministry should position equipment necessary for an emergency medical response close to living units. As inquest concludes seven years after incident, coroner says pilot should have abandoned a manoeuvre he was undertaking Caroline Davies and agency Tue 20 Dec 2022 11.47 EST Last modified on Wed . Fund for safe rooms to be installed in survivors homes in high-risk cases. Coroners are independent judicial officers who investigate deaths reported to them. 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 (. Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing. The ministry should amend its policies and practices for admissions officer/. arrives at St. Pancras Coroner's Court for a hearing into the singer's . The coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . Review current procedures and processes in respect of police response to persons who have a mental illness. 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. 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).
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