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 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. The purpose of an inquest is to establish who the deceased person was, and when, where and how they died. 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. 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:SudburyFrom: August 29To: September 2, 2022By: Dr. David Cameron, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Richard Raymond PigeauDate and time of death: October 20, 2015 at 12:06 p.m.Place of death:3259 Skead Road, Skead, ON, P0M 2Y0 1660 Level, 1660-021 RampCause of death:crush-type blunt force injuries to torsoBy what means:accident, The verdict was received on September 2, 2022Presiding officer's name: Dr. David Cameron(Original signed by presiding officer), Surname: GordonGiven name(s): JacobAge:24. Inclusion of and consultation with Indigenous communities/agencies is essential. Require cyanide distribution lines be painted purple for identification and dye be added to cyanide solutions during mixing to make it red/purple in colour. Reconvene one year following the verdict to discuss the progress in implementing these recommendations. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services. Consideration should be given to two-way information sharing including of case notes, and opportunities to order treatment in institutions for those with existing probation orders who are on remand. To use any such collected information to assess the effectiveness of the deployed alternative responses, to identify the potential for the improvement of future responses and outcomes, and to support any request for additional resources. Review current procedures and processes in respect of police response to persons who have a mental illness. Police services and police services boards shall establish standing or advisory committees on race and impartial policing and on mental health in order to meet with representatives of peer-run organizations and members of affected communities on an ongoing basis to discuss concerns and facilitate solutions. Once the ministry completes the consultations on tear-resistant sheets and blankets, if there are viable options, the ministry endeavor to implement the use of such bedding in all provincial institutions. II. In jury inquests, the coroner directs the jury on matters of law and the jury decides the appropriate verdict . 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. The summary should be placed at the front of each health care record and should list all serious medical diagnoses, including opioid use disorder. The site also provides information on how to request copies of the original files. 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. In addition, such education should be repeated quarterly. 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. Consider conducting an ice management campaign for large construction projects in Eastern Ontario. The verdict means the jury confirms the death is suspicious, but is unable to reach any other verdicts open to them. The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. When a worker experiences a medical issue in the workplace, the possibility that the medical event is due to a workplace hazard should always be considered. Older verdicts and recommendations, and responses to recommendations are available by request by: e-mail: occ.inquiries@ontario.ca. The ministry should embrace an evidence-based approach to harm reduction in a manner that protects the mental and physical health of persons in custody. Did you find what you were looking for? At every employer site at least two physician assistants / medical professionals should be available to perform medical assistance. The Senior Coroner for this area is Patricia Harding. That the Ministry of Health immediately address patient flow at the Thunder Bay Regional Health Sciences Center emergency department to address police and ambulance off-load delays and code black events. Implement recommendation #35 from the Inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Conduct a comprehensive, third-party audit of its health and safety system. These would keep Indigenous youth within their local community and connected to family, culture, and local supports. 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. Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants. The verdict of the coroner's jury will fall into one of the following five categories: accident, natural, suicide, homicide and justifiable homicide. In partnership and in consultation with bands and First Nation communities, and affiliated Indigenous stakeholders, provide direct, sustainable, equitable, and adequate funding accessible to childrens aid societies and residential service providers to access Indigenous-led cultural services, culturally restorative practices, cultural competency, and educational supports and other cultural supports within the child welfare system. Half day. 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. 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). Time of death could not be determined.Place of death: Combermere, OntarioCause of death: upper airway obstructionBy what means: homicide, Surname: KuzykGiven name(s): AnastasiaAge:36, Date and time of death: September 22, 2015. Which justice participants should have access to the findings made by a civil or family court. Implement recommendation #20 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. 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). Details of upcoming Openings, Inquest Hearings, Pre-Inquest Reviews, Documentary Inquests and Adjournments. Implement recommendation #6 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. We, the jury, wish to make the following recommendations: Surname:MacDougallGiven name(s):Quinn EmmersonAge:19. The ministry should consult with the Ministry of the Attorney General to determine a process for obtaining summary information about upcoming court appearances for persons in custody and prospective length of time in custody, and rapidly provide this information to health care and programming staff. We recommend that the frequency of required refresher courses/training for Constructors, Employers, Supervisors, and Workers, who work in proximity to overhead power lines. 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. This unique intersection of Blackness and lived experience of mental health issues must be specifically addressed in any training on use of force, de-escalation, and police interaction with such persons. 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. Seek and allocate adequate funding and resources to implement these recommendations. mechanical devices, such as a pin, that can be inserted into a boom or crane to prevent movement into the prohibited zone. The ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive additional Indigenous cultural safety training. Work with Indigenous communities to support the creation of residential treatment options that are Indigenous-run and Indigenous-informed with Indigenous-specific programming. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. To Green Star Grading & Sodding Construction Ltd. (Green Star): Surname:SoaresGiven name(s):RicardoAge:32. 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. 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. 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. Hearings. 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 funding model and approach to the child welfare service delivery model, including consideration of developing a prevention and reunification process that focuses on family preservation, family reunification, kinship preservation, family contact, assessment of child, youth and parent strengths and needs, parenting skills, home management and routine, infant care, and exploring and developing support networks. The ministry shall treat people in custody on remand as presumed to be innocent. These programs must also consider service coordination when a young person transitions to a new community to avoid the young person being placed on a waiting list to receive assistance. the health care needs of the inmate population, compliance with provincial policies and professional standards, record keeping and communication of health care information, an audit of a meaningful selection of inmate health care files, interviews with health care staff to determine the causes of any deficiencies uncovered in the review. 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. 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. 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. There is still an open verdict on Berezovsky's death, which could mean the UK is unwilling to get to the truth. 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. 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). The verdict was received on December 1, 2021 Coroner's name: Dr. Steven Bodley (Original signed by coroner) We, the jury, wish to make the following recommendations: Inquest into the death of: Mark King Jeffrey Jury recommendations Correctional Services of Canada should: make the Anijaarniq: A Holistic Inuit Strategy publicly available