coroner's inquest verdicts

This should incorporate recognition of the historical and ongoing traumas faced by Indigenous communities and adequate cultural competency to provide care/services in a manner that recognizes these traumas. A British coroner will hear about the final hours of Amy Winehouse's life at the inquest into the soul diva's death. 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. The jury hears evidence from witnesses under summons (same as a subpoena) in order to determine the facts of a death. However, if a coroner feels the investigation shows existing circumstances pose a risk of further deaths and that actions should be taken, the coroner is under a duty to make a report. This is the only information that can be provided at this time. Coroner's court returns verdict of medical misadventure after inquest into death of Linda Connell (41) five days after minor surgery to remove ovarian cyst Inquest to conclude. 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. 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. These reviews should analyze relevant health care files and assess quality of care. All the latest inquests including openings from Derby Coroners' Court. The incident occurred on the second lap of the race, at Ago's leap. Review the process for obtaining inmates medical history from their next of kin when inmates are identified as potentially suicidal or violent. 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. The inquest will then be adjourned to be resumed at a later date. Immediately institute a provincial implementation committee dedicated to ensuring that the recommendations from this Inquest are comprehensively considered, and any responses are fully reported and published. 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 purpose of an inquest is to establish who the deceased person was, and when, where and how they died. In any new detention centre builds, consideration should be given in the design to allow for timely access for emergency personnel. Establish policies making clear that, absent exceptional circumstances, those assessed as high risk or where the allegations involve strangulation should not qualify for early intervention. 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. 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. In recognition of the fact that law enforcement agencies in the City of Thunder Bay lack the appropriate training, cultural competency, and resources to provide appropriate services to individuals suffering from alcohol/substance use disorder and/or chronic housing insecurity, work to ensure that community-based programs which provide outreach and services to such individuals are maintained and continued, including and not limited to: the Care Bus, operated by NorWest Community Health Centre, the WiiChiiHehWayWin street outreach initiative, operated by Matawa First Nations Management. At every employer site at least two physician assistants / medical professionals should be available to perform medical assistance. 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. There are many ways to contact the Government of Ontario. The Toronto Police Service should improve delivery of relevant information to the inner perimeter where crisis negotiations are taking place without unduly disrupting the negotiation process. 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. Consider how the concept of Safety by Design has been implemented in other jurisdictions and assess whether these concepts can be incorporated into Ontarios health and safety regulations. Use or continue to utilize neutral, descriptive language to describe young people who leave their place of residence without permission. Refer to the mining legislative review committee the consideration of amendments to Ontario Regulation 854, Mines and Mining Plants (the Regulation) that would: Require the following precautions be taken should a worker perform maintenance work in an area in which the work may reasonably be expected to expose the worker to a material containing cyanide at concentrations that may endanger the worker. The ministry should create and implement a policy that requires the use of specific language by correctional officers and healthcare workers at each correctional facility which prioritizes humanizing people in custody by addressing them as patients, persons in custody and/or persons who use drugs. 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. Such programs should include: violence prevention, recognizing healthy and abusive relationships, identifying subtle indicators of coercive control, understanding risk factors (such as stalking, fear caused by, Ensure teachers are trained to deliver the, Develop a roster of resources available to support classroom teachers in the delivery of primary, secondary, and post-secondary programming where local. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. Prioritize continued efforts regarding bed shortages for female inmates. Held at:virtual inquestFrom: September 26To: October 7, 2022By: Murray Segal, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Victor OgundipeDate and time of death: January 26, 2017,10:14 p.m.Place of death:36 Queen Street East, TorontoCause of death:a) Hemoperitoneum, due to b) rupture of liver, due to c) blunt force injury to abdomen.By what means:accident, The verdict was received on October 7, 2022Presiding officer's name:Murray Segal(Original signed by presiding officer), Surname:FreemanGiven name(s):Devon Russell James (Muskaabo)Age:16. II. Revise the use of force report form to require officers to document de-escalation techniques used. 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. 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. 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). In partnership with childrens mental health residential service providers, develop and effectively fund programs that are responsive to the needs of hard-to-serve young people presenting with high-risk behaviors such as aggression or suicidal ideation and other complex needs. This would include training, equipment or work processes and the continued availability of safety data sheets. TT sidecar driver had passenger's dog tag - inquest. It should be clear that it is broadly accessible and not limited to a particular kind of relationship. 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. In order to support fulsome assessment, information sharing within the child welfare system and ensuring a holistic approach to caring for children and young people, develop future amendments to. 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. Conduct a review and consider the role of jailers, the level of supervision given to individuals in custody, and training given to staff in that role, and in particular: Review the level of staffing, and consider a policy that links the number of staff to the number of prisoners, similar to the Ontario Provincial Polices standard of using one guard for seven individuals in custody. It would also provide a primary point of communication for emergency response and medical personnel. Implement regular reviews to ensure the accuracy and reliability of the information in the records management system available to officers. Improved supervision of high-risk perpetrators released on probation, including informed decision-making when applying or seeking to modify conditions that impact the survivors needs and safety. 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. This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools. For the purpose of assisting clinicians in directing patients to receive timely mental health services and promoting accountability of community mental health services, a direction requiring that all hospital and community-based mental health services that receive funding from the Government of Ontario: collect and publish monthly non-identifying data regarding: wait times for treatment (i.e., actual receipt of mental health services by mental health professionals as opposed to waiting times for intake) and patient volumes, days and hours of mental health services provided, provide the resources to allow hospitals and community-based mental health services to provide this data, increase mental health awareness and promotion of initiatives within communities to address the lack of familiarity of services and options available for persons and families dealing with mental health situations. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Show entries Where gaps exist, the ministry should explore and research means to increase actual programing at Detention and Correctional Centres: Analysis of data collection or research of Indigenous core or other programing should include identification of gaps, steps taken to resolve gaps, improvements and best practices; This analysis and research should be reported, maintained and disseminated to Ontario`s correctional Institutions, service providers and for use with consultation with First Nation, Metis and Inuit community; The ministry should consider evaluating and modifying their policies on allowing volunteers into the facility that have a criminal record. The mnistry should ensure that the Toronto South Detention Centre, and any other detention centres organized in the same manner, have an additional copy of the unit notification card kept on the unit for review by correctional officers while an inmate is absent due to court or other external location. Conclusion. Responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth. Consider adopting Femicide as one of the categories for manner of death. To support the well-being of children, continue to ensure that, as part of the intake process, staff acquire and review all relevant information and documents relating to a young person, including any plans of care developed by prior residential facilities and any information relating to suicidal behaviour or ideation. . These roundtables should include representatives of relevant government ministries, including Children, Community and Social Services, Health, Education, and Indigenous Affairs, community-based service providers, societies, Indigenous child well-being agencies, mental health lead agencies, childrens rights experts, educators, youth justice workers, and police as necessary. 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 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. A coroner's inquest is a public court hearing where the coroner determines about how, when and where someone died following a post-mortem. Recognition that, in remote and rural areas, funding cannot be the per-capita equivalent to funding in urban settings as this does not take into account rural realities, including that: economies of scale for urban settings supporting larger numbers of survivors, the need to travel to access and provide services where telephone and internet coverage is not available. 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. As you say modern Coroners' inquests records can be found amongst departmental files at The National Archives including most investigations into air accidents which are open after 30 or so years, however some like the inquest into the 1974 bombing at the Tower of London (MEPO 26/252, which include a transcript of coroner's inquest and statements) is closed for 84 years and others like the . This will be referred to as the inquest 'conclusion' or 'verdict.' This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. An 'investigation' is a new way a Coroner can handle a case that was introduced in reforms of the legislation in July 2013. Possibilities should include, but not be limited to factors such as toxic exposure through skin or inhalation. 4.1 It is recommended that employers, constructors, supervisors ensure that any hazard identified in risk assessments be relayed to workers together with the associated level of risk. This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities. 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. 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. Ensure that all police officers who interact directly with the public are provided with the four-day mental health training currently provided to incoming police officers in their first year of service. The inquest would be held in the district where the death occurred. 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. Risk assessments and risks of lethality are taken into account when making enforcement decisions. The Coroner investigates deaths in order to establish who . The Coroner cannot make any decisions as to civil or criminal liability, but at the end of an inquest hearing a decision will be made on where, when, and how the person has died. 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. Crowns should actively oppose variation requests to have firearms returned for any purpose, such as hunting. The ministry should position equipment necessary for an emergency medical response close to living units. Rename crisis hotline services and create awareness campaigns to educate the public about their existence to make the public aware that these services are available before a person reaches the point of crisis. It is essential that services provided by all institutions listed below be reflective of Indigenous cultural needs. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services. The ministry shall support the National Inquiry into Missing and Murdered Indigenous Women and Girls' Call to Justice 14.6 as it applies to provincial corrections services. It is recommended that the Chief Prevention Officer of the. Which justice participants should have access to the findings made by a civil or family court. The ministry should ensure cooperation between. The following recommendations are made in recognition and acknowledgement of the following principles: Surname:BruneauGiven name(s):OlivierAge:24. The coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . NELSON, Daniel Robert. Prepare an emergency response plan to use if a worker does come into contact with a hazard. If it cannot be done immediately, the correctional officers should then bring the Inmate to admit and discharge pending re-assignment to a cell. 4:33 p.m. - April 28, 2022. Funding for services provided to survivors that allows for the hiring and retention of skilled and experienced staff so that they are not required to rely on volunteers and fundraisers in order to provide services to survivors. The protocol should address: the circumstances in which a missing persons report should be filed, the information to be provided as part of that report, the residential homes responsibilities prior, during, and after filing a report (including conducting a property search where appropriate). For young people in care, engage with any outside service provider at the intake stage to set clear lines of responsibility regarding communication of information regarding the young person to those in the youths circle of care, including communication of self-harm attempts and leaving the property without permission. Research and, if appropriate, develop and integrate additional flags into the records management systems that accurately identify an active, serious threat to officers and the public, including behavioural and mental health flags, and a numerical measurement of risk. 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. Promote and utilize the participation of young people and youth-driven practices in services, tools and programs, such as: the Wise Practices resources and Life Promotions toolkit by Indigenous youth, that are about their own wellness and make space for the young people to put into practice tips and ideas from those services, tools and programs. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. In recognition of the important roles of family and Indigenous communities, offer to involve the family and the Indigenous community of a deceased Indigenous young person in the Pediatric Death Committee Review process where appropriate, having due regard to confidentiality concerns.

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