Fund for safe rooms to be installed in survivors homes in high-risk cases. 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. incorporate the approach of minimizing the risk of hanging in the designing and planning of the bookshelves in all units. 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. These solutions should be communicated to relevant staff and stakeholders in a timely manner. Verdicts into the deaths of six people and the Coroner's recommendations. The ministry should investigate how security is assessed concerning spiritual elders, knowledge keepers, and traditional teachers. 4:33 p.m. - April 28, 2022. Inquests. Physicians, psychiatrists, and psychologists should be notified promptly of any issues that have been identified in processing their orders. Amend the Construction Regulations to include a mandatory requirement for training of Health and Safety Representatives who work on construction projects. All physician assistants and doctors ensure that workplace hazards are incorporated into the assessment of any medical emergency. 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. 'Short form' verdicts such as accident or misadventure; natural causes; suicide; and homicide make up the majority of all verdict conclusions. 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. Enhance policies and procedures to support collaborative communication and planning with First Nations communities when providing services to an Indigenous family/child/youth by building upon the work of the specialized Indigenous service team, the Sharing Circles for Indigenous youth in care developed in partnership with Catholic Childrens Aid Society, the Hamilton Regional Indian Center and Niwasa Kedaaswin Teg, and the recommendations from the Societys Child Death Update (Exhibit 24). For a young person in its program, engage with the guardian at the intake stage to set clear lines of responsibility regarding communication of information regarding the youth to those in the youths circle of care, including communication of self-harm attempts and leaving the property without permission. Consider retroactive compensation for the security clearance review period for those candidates that successfully obtain security clearance and sign an employment agreement with the. Held at:TorontoFrom:November 21To: November 24, 2022By:Dr.Jennifer Tanghaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased: Craig BlackettDate and time of death: 17:08 - May 27, 2016Place of death: 3058 Lakeshore Blvd West, Toronto, OntarioCause of death:Multiple blunt force injuriesBy what means:accident, The verdict was received on November 24, 2022Coroner's name: Dr.Jennifer Tang(Original signed by coroner), Surname:DavisGiven name(s):Murray JamesAge:24. 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. Consideration for the needs of rural and geographically remote survivors of. 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. 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. 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. Sources of Evidence and Disclosure . Ensure that health care professionals who provide care remotely have access to relevant information from an inmates health care file. Improve public awareness of mental health issues to counteract stigma and discrimination against persons with mental health issues. 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 The educational opportunities should be provided upon intake and at least once a month in a group setting, and the contact information for healthcare workers should be provided to persons in custody if they would like to get more information. Consideration should be given to disseminating information through alternative methods where cellular service is not consistently available. All physician assistants and doctors are trained on all medical equipment available at the worksite. The ministry should take immediate steps to improve opportunities for persons in custody to access recreation and exercise facilities and programs. Seek and allocate adequate funding and resources to implement the above recommendations. The ministry should review and if necessary consider enhancing the mechanisms for ensuring that all staff receive their suicide awareness training in accordance with the timelines set out in policy. Explore the capability of the information management systems to track the deployment of alternative responses to assist a person in crisis and the outcomes. The provision of medical care including the appropriate dispensing of medications to participants in the program, in recognition that participants may face barriers in accessing medical care and carrying out treatment plans independently. It should be clear that it is broadly accessible and not limited to a particular kind of relationship. 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. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. 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. Consider including a case study focused on falling ice in excavations in future inspector training material. Full Hearing. BBC Radio Sussex. 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. Risk assessments and risks of lethality are taken into account when making enforcement decisions. Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing. 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. EASTWOOD, Claire Louise. 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. Continue working with their partners to provide timely alerts, reminders and warnings to the public about the dangers of working in high temperature conditions on days when the temperatures reach dangerous levels. Ensure that all safety plans are written down and shared with Lynwood staff, the young persons guardian, and other members of a young persons circle of care where appropriate and consistent with privacy legislation and rights. 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. Introduction . IV. Explore, with community mental health partners, the feasibility of extending the availability of Mobile Crisis Rapid Response Team (. The orientation should include hazards, work processes and medical issues, that may be unique to that work site. mental health, interpreters etc. 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. We recommend that, absent exceptional circumstances, claims should be processed within 30 days of receipt of the documentation from the correctional facility. The inquest jury consists of five people selected by the coroner's constable from a list of jurors from the community. 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. 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). This decision is made by the Coroner. If none already exists, explore with community mental health partners, the feasibility of establishing and adequately resourcing joint mental health-police response teams to assist with person in crisis calls for service. 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. 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. within hiring practices to ensure personality and culture fit, situational judgement, role-specific skills, incorporate in regular performance evaluations to ensure that the individuals values remain consistent with expectations. Even in countries where the jury system is strong, the coroner's jury, which originated in medieval England, is a disappearing form. This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities. 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. Inquisition and narrative verdict - Catherine Hickman; Explore and research the availability and efficacy of additional less-lethal use of force options for officers. Names of the deceased: Culleton, Carol; Kuzyk, Anastasia; Warmerdam, NathalieHeld at:1 International Drive, PembrokeFrom:June 6To: June 28, 2022By:Leslie Reaume, Presiding officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname: CulletonGiven name(s): CarolAge:66, Date and time of death: September 22, 2015. Said plan should include checking that the back-up alarm on the skid steer is operational. 42. The Ministry of the Solicitor General is committed to overall public safety and ensuring Ontarios communities are supported and protected by effective and accountable law enforcement, correctional services, death investigations, forensic science services, emergency management operations and animal welfare services. 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. Continue to facilitate learning events related to the youth presenting with complex suicide needs and remain an active community participant in the Youth with Complex Suicide Needs (. Consider conducting inquests in a timely manner, within 24 months from the incident date. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Continue to train staff to identify and address suicidal ideations and risk factors (acute and chronic) associated with suicide. Also in this section 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. 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. The funding formula should reflect the population of Thunder Bay and surrounding areas that uses Thunder Bay as a Hub for medical services. The ministry should explore safer alternatives to wooden pencils being provided to Inmates. Coverage of cellular networks, particularly in remote and rural regions. 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. 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. 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. The Ministry of Labour shall review and consider whether to amend. 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. 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. Implement the corporate health care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. Coroner's Officers are police officers who work under the direction of the coroner and liaise with bereaved families, the emergency services, government agencies, doctors, hospitals and funeral directors. Ensure that adequate staffing is provided at each institution to implement recovery plans. Crowns should actively oppose variation requests to have firearms returned for any purpose, such as hunting. The ministry shall treat people in custody on remand as presumed to be innocent. The ministry should advocate for total compensation offered to nurses and healthcare staff be competitive with that in non-correctional settings. 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. Advise all workers that they should report health and safety concerns to their health and safety representative, joint health and safety committee, to Fermars Health and Safety Department, or directly to the. A list of the inquests scheduled for hearing in the Oxford Coroner's Court. 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. 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 should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. 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. Programs are funded at a level that anticipates an increased stream of referrals. We recommend that tailboard documents should be standardized, regulated, and include a section that addresses possible encroachment of overhead powerlines of the minimum distance permitted under Section 188 (2) of Regulation 213/91 for Construction Projects. Commission a study to examine the creation and implementation of a province-wide, civilian-led crisis intervention system to respond to persons in crisis, including mental health crisis. To support and promote cultural safety for First Nations children and young people, the, To address the mental health needs of children and young people, the. The task force should focus these reviews on the most vulnerable patients, particularly those diagnosed with moderate to severe mental illness, especially schizophrenia and/or schizophrenia-related disorders. Tailboard meetings/forms must be completed. Consider adopting Femicide as one of the categories for manner of death. 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. 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. Training for new officers should be amended so that the question of the suspects mental health be as prominent in their considerations as the criminal activity they have committed. 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. Older verdicts and recommendations, and responses to recommendations are available by request by: You can also access verdicts and recommendations usingWestlaw Canada. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. The availability and use of weapons prohibition orders in. Make adjustments to program curriculum and delivery methods according to gaps and opportunities identified. 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. Regular refresher training on mental health issues should be provided to all police officers who interact with the public. The Coroner investigates deaths in order to establish who . Visual signage should be placed in the booking area and cell blocks. The task force would involve representatives from, and meaningful input from: Members of the Thunder Bay community including individuals with lived/living experience, members of the Thunder Bay District Mental Health & Addictions Network, Superior North Emergency Medical Services, Nishnawbe Aski Nation and Anishinabek Nation, other Indigenous and community partners who wish to participate. 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). The summary should be placed at the front of each health care record and should list all serious medical diagnoses, including opioid use disorder. Implement the Spirit Bear Plan through collaboration with. 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. The Internal Responsibility System, with an emphasis on the importance of promoting a no-blame workplace safety culture that encourages an open relationship to discuss workplace safety. Develop, establish, and provide regular training to, circumstances in which the policy is applicable, including when an individual would be considered potentially dangerous, involving a supervising officer in the planning of the arrest, when possible, completing an arrest decision tool, which may include a checklist of criteria, how to identify possible factors that could complicate an arrest, such as possible mental health issues, unpredictability, past incidents with police, and violent history, In support of the planning process, develop and provide guidance and training on circumstances where it may be appropriate to contact a subject to ask them to attend a police detachment for the purpose of effecting an arrest. And people detained in hospital under the Mental Health Act. Held at:25 Morton Schulman Avenue, Toronto (virtually)From:February 28To:March 11, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Quinn EmmersonMacDougallDate and time of death: April 3, 2018 at 4:23 p.m.Place of death:Hamilton General Hospital, 237 Barton Street East, Hamilton, OntarioCause of death:gunshot wound of the torso (right chest)By what means:homicide, The verdict was received on March 11, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:SantosGiven name(s):FernandoAge:59. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. The ministry should engage in community consultation on the development of Indigenous core programing with Indigenous leadership including First Nation, Metis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres. new melleray abbey mass times,
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