The ministry should deliver alerts to persons in custody on an urgent basis regarding new and emerging threats from novel street drugs. 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. Encourage all fixed term Nurse Practitioners at the, Reinstate funding for an embedded Kawartha Lakes Police Service detachment inside the Central East Correctional Centre. It should be clear that it is broadly accessible and not limited to a particular kind of relationship. When operationally feasible, the ministry should run the scenario-based. Implement the corporate health care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. 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. 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). We recommend that, absent exceptional circumstances, claims should be processed within 30 days of receipt of the documentation from the correctional facility. Coroner Current inquests Media and other observers Inquest hearings are held in public and members of the public, including the media, are welcome to attend Court in person to observe. 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. Increasing program availability and develop flexible options for, Recognize the specialized knowledge and expertise of, Address barriers and create opportunities and pathways to services for, Improve the coordination of services addressing substance use, mental health, child protection, and, As new services are funded, include aims and outcomes associated with building an underlying network of specialized services to address, Endeavour to minimize destabilizing factors for perpetrators of, Investigate and develop a common framework for risk assessment in. The following are few of the most commonly used inquest verdicts: Natural cause (this includes cases of fatal medical issues) Misadventure and/or accidents Industrial disease (you can get this as coroner's inquest for asbestosis that causes death) Unlawful killing Lawful killing (this includes cases of death by acts of war or self-defense) The inquest would be held in the district where the death occurred. II. Include coercive control, as defined in the. Review current procedures and processes in respect of police response to persons who have a mental illness. This increase shall: Not come as an alternative to the creation of a sobering centre, in recognition of the fact that these institutions would provide different services. The dangers of working in proximity to overhead powerlines, even when no work on overhead power lines is intended. Presiding Coroner: Witness List: Livestream Instructions: Note or copy the passcode BEFORE clicking on the Livestream Link Click on the link above When prompted, enter passcode, your name and email address You will automatically be connected when the Inquest is in session . Introduction . The ability to respond immediately with risk management services in collaboration with. Continue working with partners to provide public awareness campaigns and educational materials in a greater variety of media formats (billboards, bus shelters, Utilizing the resources publicly provided by the. Coroners' appointments . Explore digitized records of over a century of coroner's records from Stark County, Ohio, available online . BBC Radio Sussex. The Solicitor General of Ontario should study the phenomenon of individuals attempting to induce police officers to use lethal force, to improve best police practices across the province. The coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . The Regulation would require that, in such circumstances: impermeable personal protective equipment to be used and there be a process for verifying or confirming the use of the required personal protective equipment before work is performed in the area, the flushing of cyanide-containing material from lines, titrations to ensure cyanide content in any debris or materials in the area is below a set threshold (, lock out and tag out procedures are to be developed and implemented, workers required or assigned to work in the area have received cyanide awareness training and proper removal of. 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. The difference can be explained as accident reflecting death following an event over which there is no human control where as misadventure is an intended act but with unintended consequence. Employers shall ensure that workers are trained on the cell phone policy. In conjunction with recommendation number12, the ministry should abandon the use of the title, Native Inmate Liaison Officer, and move toward the exclusive use of the title, Indigenous Liaison Officer.. Coverage of cellular networks, particularly in remote and rural regions. 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. 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. Fund for safe rooms to be installed in survivors homes in high-risk cases. 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. We, the jury, wish to make the following recommendations: Surname:MacDougallGiven name(s):Quinn EmmersonAge:19. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. Once the data is gathered and analyzed, in partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, seek authority and any necessary funding to implement and act upon the data recommendations to support better outcomes for children and youth, including seeking the necessary authority to make any legislative and regulatory changes to support changes for better outcomes. Ensure that police officers responding to a mental health crisis are aware that police have responded previously to incidents involving the same parties, and facilitate access for responding officers to significant information regarding previous calls. The Office of the Chief Coroner should consider conducting inquests within a timely manner, within 24 months from the incident date with the exception of extraordinary circumstances. mechanical devices, such as a pin, that can be inserted into a boom or crane to prevent movement into the prohibited zone. That care and services must be provided using a trauma informed approach to ensure that individuals who have suffered complex traumas are not excluded from the services that may assist them. Include in those best practices training requirements or other criteria for achieving competency regarding the assessment of ice on excavation walls as a hazard. 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). Nine jurors reached unanimous decisions on all but one of the 14 questions at the inquests into Britain's worst sporting disaster. That the Thunder Bay Police Service review its jailer academic programming and, if not already included, incorporate an educational component on the Human Rights Code and training on cultural sensitivity. 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). The inquest heard from 278 witnesses and is estimated to have cost the taxpayer more than 6.5m. To Green Star Grading & Sodding Construction Ltd. (Green Star): Surname:SoaresGiven name(s):RicardoAge:32. To ensure open and full communication, data collection, knowledge, and relationship-building regarding the children, youth, and families transferred to ongoing service, consider implementing a one care team per family system with consideration to the file loads of workers. 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. Work towards creating (including if necessary by making a request to the, developing a strategic plan; including review and potential amendments to missing persons investigations (, use of civilian support workers, civilians in duties not required for a sworn officer related to, maintenance and development of community partnerships and, in particular, the Indigenous community, partnerships with youth institutions and, in particular, child and youth mental health facilities, Review and revise the risk assessment process and policies that govern whether a missing person is classified as Level 1 or Level 2, as well as whether an urgent search is required. The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. 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. Improve public awareness of both policing and non-policing community-based crisis responses to mental health crisis. [22] In this inquest the Coroner has examined the approach to be adopted in historical investigations of this nature. Expand cell service and high-speed internet in rural and remote areas of Ontario to improve safety and access to services. 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. Older verdicts and recommendations, and responses to recommendations are available by request by: You can also access verdicts and recommendations usingWestlaw Canada. 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. Establish the frequency of review, for currency, accuracy, and protectiveness, of cyanide-related procedures. incorporate the approach of minimizing the risk of hanging in the designing and planning of the bookshelves in all units. Explore the capability of the information management systems to track the deployment of alternative responses to assist a person in crisis and the outcomes. risk assessment training with the most up-to-date research on tools and risk factors. That joint training be scheduled on an on-going basis, allowing first responders to learn more about the roles and responsibilities of other agencies. This includes: familiarity with the act and the regulations that apply to the work, ability to identify and address workplace hazards. The foundation of training should include, but not be limited to, the history of colonization and the impact on Indigenous peoples; residential schools; trauma informed approaches; anti-Indigenous racism; unconscious bias; and Indigenous cultural safety training. 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. 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. Coroner's verdict in inquest into . If there is no individual evaluation component, the ministry should consider implementing one. 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. Specifically: increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. This can be: accident/misadventure unlawful killing natural causes. Prioritize developing and implementing a long-term plan to establish adequate housing for male/female inmates. Implement recommendation #35 from the Inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Continue to follow the international Cyanide Management Code. The Boards Governance Committee will consider creating an implementation plan that includes but is not limited to: a timeline for implementation of all recommendations received through various reports, inquests and inquiries; a plan for how the recommendation will be implemented; and how consultation and follow-up with Indigenous community will take place. 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 funding formula should reflect the population of Thunder Bay and surrounding areas that uses Thunder Bay as a Hub for medical services. We recommend that where a construction project involves work in proximity to overhead power lines and equipment that has the potential to contact overhead power lines such as a boom or a crane is being operated, the. The open verdict is an option open to a coroner's jury at an inquest in the legal system of England and Wales. The ministry should analyze the data they collect to determine where there are gaps in service delivery of programs at particular institutions. 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. A variety of group-based interventions augmented with individual counseling and case management sessions to assess and manage risk and to supplement services, as needed, to address individual needs. You can also access verdicts and recommendations using Westlaw Canada. 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. Within 6 months of the jurys verdict, strike a task force to review, report on, and initiate changes to: funding, accountabilities, and timely access to care for all community-based mental health services that receive funding from the Government of Ontario, available resources and supports for family members and/or caregivers of patients and community services receiving mental health services, how family members and/or caregivers and community services can provide support and/or information about patients when patient consent is not provided, address what information can be shared from family members and other stakeholders, align services and community agencies to better share information about individuals with mental health concerns in the community, Establish further study and review of the criteria and training associated with the, mandatory refresher training for emergency room physicians and psychiatrists in the province of Ontario on when and how to use the Form 1 options associated with mental health, the assessment of Box A and Box B criteria for psychiatric evaluation and involuntary detention, to determine how best to ensure collateral information from family members and relevant community services information can be included as part of the process for determining appropriate treatment options. In some Coroner's Districts certain inquests can be held based only on documents. Health and safety representatives are selected in a manner that ensures independence. Office opening hours are Monday to Thursday, 8am to 4pm, and . Refresher training should be delivered annually. 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. 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. Date inquest concluded. support for the development of programs that are flexible and able to respond to a range of needs including chronic and acute needs in a range of health and well-being domains. The jury hears evidence from witnesses under summons (same as a subpoena) in order to determine the facts of a death. In determining whether an, any history of suicidal behaviours (ideations or attempts), whether the person is in an out-of-home placement at a mental health facility for children and youth. Openings. The ministry should ensure cooperation between. crisis resolution and suicide prevention. We recommend that the frequency of required refresher courses/training for Constructors, Employers, Supervisors, and Workers, who work in proximity to overhead power lines. Use or continue to utilize neutral, descriptive language to describe young people who leave their place of residence without permission. Compensation should include: cost of medicines or supplies required to facilitate service. It is recommended that the Ministry of Labour, Training and Skills Development take steps to amend the. 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. Peer support and appropriate circles of support. 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. This training should also include periodic or ongoing refresher training. 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. The Coroner's Office can be contacted by email at coroners@cambridgeshire.gov.uk or by telephone on 0345 045 1364. 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. Require all police services to immediately inform the Chief Firearms Officer (, Create a Universal RMS records management system accessible by all police services (including federal, provincial, municipal, military and First Nations) in Ontario, with appropriate read/write access to all. 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 circumstances in which judges can lead inquests and details of notable inquests overseen by a judge. 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. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards. The range of verdicts that can be declared by the Coroner or jury include: Accidental death Misadventure Suicide Natural causes Unlawful killing Open verdict An 'open' verdict means that the evidence does not fully or clearly explain the cause and circumstances of death. Such a program should: operate only upon the consent of each individual participant, be managed in partnership between a sobering centre, managed alcohol facility and community care teams, include a system by which first responders can contact case managers/care team members to: inform them that an individual in their care has been in contact with first responders (emergency medical services (, In recognition of the seriousness of alcohol/substance use disorder (. Ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the. Provide professional education and training for justice system personnel on. That the Board create a process for regular review of board policy to determine which policies need to be updated or created. It's different to a trial in a criminal court; no-one is convicted at an inquest. Identify all ongoing construction projects involving Claridge Homes group of companies in Ontario and conduct proactive inspections of those sites. emerging technologies, like an electro magnetic sensor to prevent a boom or crane from entering the prohibited zone (disabling controls). The Ministry of Labour shall review and consider whether to amend. How employers should prepare their workers and their job sites to ensure safe working conditions during periods of high temperatures. 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. Implement the National Action Plan on Gender-based Violence in a timely manner. The reviewers should work with the local health care team to identify gaps and find solutions. Provide additional guidance on how to assess the risk of ice on excavation walls. A health care manager and/or physician should be notified when an inmate brings a suspected opioid or prescription medication into the institution or when an inmate appears to be intoxicated while in custody.

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