Encourage all fixed term Nurse Practitioners at the, Reinstate funding for an embedded Kawartha Lakes Police Service detachment inside the Central East Correctional Centre. If not already provided, the ministry should explore the availability of substance abuse treatment programs for all Ontario detention centres such as Narcotics Anonymous, and if not available, explore alternatives to that. 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. 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 coroner of Inquests, Mrs Jayne Hughes, found that the pair had died by misadventure as they had . Funding to be provided on an annualized basis, with adequacy assessed and considered after the first three years. Investigations and inquests in Mid Kent and Medway In recognition of the seriousness of alcohol/substance use disorder as a medical condition which may mask the appearance of other serious medical conditions, a program should be established in the City of Thunder Bay to provide medical alert bracelets to individuals at high risk for adverse medical outcomes. The Toronto Police Service should review research and studies in regard to use of non-lethal tools to incapacitate a subject in possession of a firearm. If the cause remains in doubt after a post mortem, an inquest will be held. Be publicized to enhance public awareness, and become better known among policing partners possibly through All Chiefs bulletins. Why was the coroner's inquest suspended despite it was open for public and the Russian Investigative Committee was duly represented there? Information on Coroners openings and hearings. We recommend that Occupational Health and Safety be amended to allow Health and Safety representatives and Joint Health and Safety committees authority to keep confidential the name of any workers who report unsafe conditions. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. 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. Conduct a comprehensive, third-party audit of its health and safety system. The Toronto Police Service should provide emergency task force (. Training should be given to establish who should lead the call when dealing with a potentially violent incident or crisis. Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. Section 14.6 states the following: We call upon Correctional Service Canada and provincial and territorial services to provide intensive and comprehensive mental health, addictions, and trauma services for incarcerated Indigenous women, girls, and. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services. 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. 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. If there is any information relating to suicidal behaviour or ideation, it must be flagged so any other society workers are immediately aware of that aspect of a particular young persons history. Explore developing and providing all police officers with additional de-escalation training. Evidence and release of body What happens when evidence is gathered and when a body can be released Inquests held. The study would, in part, inquire into the following: The process to identify relevant findings and for sharing those findings with other justice participants. Programs are funded at a level that anticipates an increased stream of referrals. Construction projects should be planned and organized so that no cellular phones or similar cellular devices shall be used on the worksite except in case of an emergency or where use is restricted to occur inside of a designate structure, stationary vehicle, or other designated area away from any area in which construction work is occurring or ongoing. Coroner training overview - Courts and Tribunals Judiciary 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. Regular contact with survivors to receive updates, provide information regarding the offenders residence and locations frequented, and any changes to such circumstances, and seek input from survivors and justice system personnel before making decisions that may impact her safety. 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. 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. Any requests to obtain and use video or other recordings from the inquest shall be made to the Office of the Chief Coroner for their consideration. The ministry should explore safer alternatives to wooden pencils being provided to Inmates. 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. whether the missing person is an Indigenous youth. Evidence relating to the Five Incidents . To ensure that First Nations children benefit from their legal entitlements under, In the spirit of recommendations made in the past in other settings, including those in the, residential treatment resources for Indigenous communities, service coordination for children with complex trauma and complex needs to ensure safety, continuity of care, and the avoidance of long wait lists. Consideration should be given to the United Kingdoms Domestic Abuse Commissioner model in developing the mandate of the Commission. 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. The training should address: understanding how emotional prejudice impacts decision making, tactics/solutions for mitigating the harmful impact of stereotyping on health and criminal justice outcomes, That both services consult with Indigenous Nations, Provincial Territorial Organizations (. Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. 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). Coroner's verdict in inquest into . Deaths reported to the coroner - Kent County Council 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. 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. 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). Coroner's inquests | ontario.ca This would include training, equipment or work processes and the continued availability of safety data sheets. Implement the Spirit Bear Plan through collaboration with. The ministry should ensure that pending the admissions process and related mental health assessments, Inmates are placed in a temporary housing unit without a cellmate. Missoula coroner's inquest jury returns verdict in fatal officer 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. 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. That sufficient staff be hired and maintained to allow for constant visual monitoring of the living units and to adequately and immediately intervene in any circumstances of drugs or other contraband being found. SUMMARY OF CORONER'S VERDICTS AND FINDINGS (KEEGAN J) I. 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.