The Solicitor General of Ontario should provide oversight on the mandatory annual training curriculum and number of hours that are provided by local police services e.g. 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). emerging technologies, like an electro magnetic sensor to prevent a boom or crane from entering the prohibited zone (disabling controls). Develop health and safety materials and for all workers and train workers, including temporary workers, on health and safety protocols prior to them undertaking any work. Develop and implement a plan to cap the length of time for fixed term employment status, and roll over into full time status (for correctional officers and nursing staff). The study would, in part, inquire into the following: The process to identify relevant findings and for sharing those findings with other justice participants. It simply aims to gather information in order to answer these questions. 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. 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. In any new detention centre builds, consideration should be given in the design to allow for timely access for emergency personnel. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards. Implement the Spirit Bear Plan through collaboration with. 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. Revise the use of force report form to require officers to document de-escalation techniques used. The Senior Coroner for this area is Patricia Harding. These supports should account for the social barriers to accessing such supports within a custodial environment. 'Short form' verdicts such as accident or misadventure; natural causes; suicide; and homicide make up the majority of all verdict conclusions. The jury must deliver a verdict answering the five questions regarding the death: who (identity of the deceased) when (date of death) where (location of death) how (medical cause of death) 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. Related Information. Review current procedures and processes in respect of police response to persons who have a mental illness. That the use of medically fragile flags be considered for the. Mandatory skid steer operation certification and re-certification process. The ministry should position equipment necessary for an emergency medical response close to living units. Study the feasibility of, and implement if feasible, justice sector participants having access to relevant findings made in family and civil law proceedings for use in criminal proceedings, including at bail and sentencing stages. Develop further therapeutic activity programming for youth that reflects a wide variety of interests. 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). Held at:LondonFrom:November 21To:November 30, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Murray James DavisDate and time of death: August 17, 2017 8:00 a.m.Place of death:Elgin Middlesex Detention Centre, 711 Exeter Road, London, ONCause of death:Acute combined fentanyl and hydromorphone toxicityBy what means:accident, The verdict was received on November 30, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:AmaralGiven name(s):JoseAge:49. This should be a focus for performance management and quality assurance processes. 2022 coroners inquests verdicts and recommendations, other identified organizations may be identified in the recommendations. 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 ministry should develop guidance to determine criteria by which. 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. Funding for mobile tracking system alarms and other security supports for survivors of, Funding for services dedicated to perpetrators of, Develop a plan for enhanced second-stage housing for. 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. . Ensure that the emergency medical care providers for the mine site have a thorough orientation of the mine site they are assigned to and are aware of the hazards and the measures adopted at the workplace. Nine jurors reached unanimous decisions on all but one of the 14 questions at the inquests into Britain's worst sporting disaster. While recognising that inquests must be . Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants. Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. Provide professional education and training for justice system personnel on. There are many ways to contact the Government of Ontario. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers). Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training. 08:52, 2 MAR 2023. 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. EASTWOOD, Claire Louise. Held at:Town of MidlandFrom: October 17To: October 20, 2022By:Dr. Mary Beth Bourne, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Vikram DhindsaDate and time of death: January 18, 2017 at 5:12 a.m.Place of death:Unit 3 A Wing, Cell #16 Central North Correctional Centre 1501 Fuller Avenue, PenetanguisheneCause of death:hangingBy what means:suicide, The verdict was received on October 21, 2022Presiding officer's name:Dr. Mary Beth Bourne(Original signed by presiding officer). The ministry should ensure and enforce through training that all correctional staff ensure that any important information, including historical information, is entered into. Deliver training to frontline officers on the purpose of the Crime Abatement Program, the information included in Crime Abatement Program records, and how to access such records. Seek and allocate adequate funding and resources to implement these recommendations. All the latest inquests including openings from Derby Coroners' Court. 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. 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. The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model. Amend the notification requirements in section 7.1 of the Construction Regulations to include a signed and dated attestation that the work platforms will be installed, inspected, tested and maintained in accordance with the applicable regulations, including sections 139 and 139.1. Regularly consult with bands and First Nation communities and Indigenous stakeholders on program implementation and service delivery for new and existing initiatives; and report back within a reasonable period of time. Create guidelines for staff in making decisions regarding whether to issue, review, revoke, or add conditions to. III. Held at:Toronto (virtual)From: December 6To: December 9, 2022By:Mr. Etienne Esquega, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Jose AmaralDate and time of death: November 25, 2015 at 2:40 a.m.Place of death:Musselwhite MineCause of death:blunt force trauma to head and neckBy what means:accident, The verdict was received on December 9, 2022Presiding officer's name:Mr. Etienne Esquega(Original signed by presiding officer), Surname:MilletteGiven name(s):Denis Stanley JosephAge:52. 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. 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. In compliance with its by-laws, the Board will create terms of reference for its governance committee and make the terms of reference public. The ministry should ensure that all correctional officers and nurses have full access to medical and mental health records, and previous incarcerations, where permitted by law. 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. Inform staff of the LivingWorks Start online training on suicide prevention and provide them with information to register. 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. Explore developing and providing all police officers with additional de-escalation training. The ministry should conduct a comprehensive and ongoing process of engagement with patients in its custody in the development of healthcare strategy, policy and delivery. 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. Improve knowledge and awareness for police communicators, call takers, and dispatchers of the signs of mental health crisis, and ensure that communicators are trained to ask questions directed at determining whether a call involves a mental health crisis. Implement regular reviews to ensure the accuracy and reliability of the information in the records management system available to officers. Consider conducting inquests in a timely manner, within 24 months from the incident date. Explore the capability of the information management systems to track the deployment of alternative responses to assist a person in crisis and the outcomes. Consider an appropriate role for community members or organizations as part of the missing person investigation, or in a debrief with the missing person once the investigation is concluded. Implement recommendation #5 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Specifically: increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. Appropriate perpetrator programs and supports needed to accompany electronic monitoring. 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. 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. 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. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. Review policies to ensure the timely, reliable, consistent, and accurate dissemination of information, including the use of emergency alerts and media releases, where the police are aware of circumstances that could put the public in danger, and that the focus is on safety when developing policies regarding what information to share with whom and when. Start grassroots Safe Spaces program that businesses can participate in where survivors can feel safe and ask for information (. Unfortunately, we cannot provide any additional information other than what is on the Court List. 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. It is recommended that the chief coroner take steps to expedite the hearing of coroners inquests, if feasible that they be held within three years. The number of jurors generally ranges from 6 to 20. 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. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care. Introduction . Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. Task analysis safety card form to be reviewed and signed off by supervisor prior to the work commencing, to ensure it has been properly and thoroughly completed. Inclusion of and consultation with Indigenous communities/agencies is essential. Regular refresher training on mental health issues should be provided to all police officers who interact with the public. Information on Coroners openings and hearings. Understanding any impacts after an order for such technology expires. Storage rules and protocols for tracking data. The ministry should prioritize the completion of its project to implement electronic health records for patients living in correctional facilities. 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 74,160 records in this database were extracted from the Cook County Coroner's Inquest Records. The reviewers should work with the local health care team to identify gaps and find solutions. That bystander training be provided to police officers so that officers feel more comfortable addressing inappropriate behavior by colleagues. The ability to respond immediately with risk management services in collaboration with. The. When operationally feasible, the ministry should run the scenario-based. The Ministry of Labour shall review and consider whether to impose a renewal requirement on Common Core Underground Certification. What verdicts can a coroner give? Ensure that any arrest planning course delivered by the, Develop a mandatory training course for sergeants delivered by the, Provide dedicated mandatory mental health training as part of the annual block training delivered to officers through the, Ensure, where there are no legal impediments to doing so, that debriefs are held for involved officers after every major arrest, event, or unique policing scenario to gain insight on lessons learned, and that such lessons are shared with other. The ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive awareness training regarding the causes and nature of substance use disorder to address stigma surrounding addiction. Police services and police services boards shall consult with third-parties, including individuals from the Black community, Black advocacy community organizations, persons with lived experiences from peer-run organizations, and appropriate content experts, and: develop an objective methodology to measure and evaluate police service performance on use of force, take corrective action to address systemic discrimination, provide clear and transparent information to the public on biased and discriminatory use of force. 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. 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. This training should also include periodic or ongoing refresher training. Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors. Inquest to conclude. Inform staff and affected personnel that resources are available to support them with respect to work related stress. Once a risk assessment has been completed, ensure that all missing person cases are triaged to determine the appropriate response to a persons disappearance, including whether that response should involve a combination of the police and/or other community organizations and/or a multi-disciplinary response. The verdict of the coroner's jury will fall into one of the following five categories: accident, natural, suicide, homicide and justifiable homicide. At the end of an inquest, the Coroner will read out a formal verdict to record: the identity of the deceased; how the death happened ; . 13 January 2022 Following a change in the law in 2013, the coroner now gives a 'determination' on the cause of death. Develop workable practices to improve contact and connection of individual young people with safe adults in their circle of care, to reduce circumstances where children are absent and their whereabouts are unknown. Health and safety representatives are selected in a manner that ensures independence. Review, in consultation with stakeholders, the discretionary nature of inquests into the deaths of children in care and consider advocating for legislative change requiring said deaths to be the subject of mandatory inquests. January 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. The ministry shall ensure that wherever a serious mental illness is suspected or identified through mental health screening, that the person in custody will not be placed in conditions of segregation. That access to electronic health records be provided to all paramedics in Ontario, and if such access is available, that Superior North. What verdict can a coroner give? Held at: Toronto, virtuallyFrom: August 22To: August 26, 2022By: Dr. Bonnie Goldberg, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Alexander PeterWettlauferDate and time of death: March 14, 2016 at 1:21 a.m.Place of death:Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, TorontoCause of death:gunshot wounds to chestBy what means:undetermined, The verdict was received on August 26, 2022Presiding officer's name: Dr. Bonnie Goldberg(Original signed by presiding officer), Surname: PigeauGiven name(s): RichardAge:54. 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. To Green Star Grading & Sodding Construction Ltd. (Green Star): Surname:SoaresGiven name(s):RicardoAge:32. Provide adequate and sustainable funding and resources to ensure that a range of placement options and transition services, including independent and semi-independent living arrangements, are available for children and young people receiving services from childrens aid societies and Indigenous well-being agencies. Require primary actors involved in a major incident to conduct a formal de-brief and write a report identifying lessons learned and recommendations for improvement, if appropriate. Fund for safe rooms to be installed in survivors homes in high-risk cases. Inject a significant one-time investment into, Realign the approach to public funding provided to. Prepare an emergency response plan to use if a worker does come into contact with a hazard. Held at: WindsorFrom:June 20To: June 30, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Delilah SophiaBlairDate and time of death: May 21, 2017 at 8:58 p.m.Place of death:Windsor Regional Hospital Ouellette CampusCause of death:hangingBy what means:suicide, The verdict was received on June 30, 2022Coroner's name:Dr.David Eden(Original signed by coroner), The term SWDC/ministry means SWDC and the ministry, Surname:FerranteGiven name(s):FrankAge:44.
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