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Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. A coroner is an independent judicial office holder. It is recommended that all mine and metallurgical sites where cyanide is present conduct periodic simulation exercises of cyanide exposure events as a means to promote preparedness by testing policies and plans, standard operating procedures, and personnel training. 42. The content of such training to include: what cyanide is used for within the workplace and where it can be found, the method for identifying cyanide within the workplace, personal protective equipment and limitations associated with such equipment, the signs and symptoms of cyanide exposure, first aid / treatment procedures for people potentially exposed to cyanide. When the coroner's jury could not determine a cause of death, an "_" will appear in the verdict category. 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. Ensure that gaps or compliance issues identified during investigations into inmate deaths (including by Correctional Services Oversight and Investigations) are communicated and reinforced to relevant staff and healthcare providers. Develop and deliver training for constables and sergeants on interpersonal skills, emotional intelligence, leadership, and team building. 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. We recommend that a public awareness campaign be developed that highlights the dangers of working in proximity to overhead power lines and provides information on how members of the public can report seemingly unsafe or non-compliant practices. Provide training to workers on the signs and symptoms of heat stress and heat stroke, how to prevent heat-related illness and first aid steps to be taken should a worker believe they or their co-worker are showing signs of such illness. Review the process for obtaining inmates medical history from their next of kin when inmates are identified as potentially suicidal or violent. This would cover end-to-end event response and include all details necessary to transport the victim(s) to regional hospital facilities. Utilize the resources generated by the Ministry of Labour, Immigration, Training and Skills Development and Infrastructure Health & Safety Association to develop a comprehensive safety plan for when a skid steer (owned or operated by Green Star or one of its employees) is in use at a construction site. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. It is essential that services provided by all institutions listed below be reflective of Indigenous cultural needs. Health and safety representatives are selected in a manner that ensures independence. Checklists and plan for ensuring all safety and medical equipment is readily available and in working order. It is recommended that the Chief Prevention Officer of the. Improve public awareness of both policing and non-policing community-based crisis responses to mental health crisis. Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants. Develop further therapeutic activity programming for youth that reflects a wide variety of interests. The Ministry of Labour shall review and consider whether to impose a renewal requirement on Common Core Underground Certification. 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. Assess the feasibility and impact of establishing a mental health advocate role (or enhancing the abilities of social workers) to be the point person helping patients and families coordinate mental health services: this advocate assists with scheduling follow-up sessions after appointments; check-ins, and visits; support after medication changes; recommends community services; collecting collateral information from relevant parties, based on demand and proper funding, this advocate will be required to manage multiple concurrent cases effectively within a framework of flagging and following up with the highest-risk outpatients, consistently offer a family meeting within 48-72 hours of hospital admission, regardless of the patients status in hospital, to collect collateral information, documented offer of a meeting with family members or support team occurs prior to discharge from hospital to ensure a patient with mental health issues has support, provide mental health services 24 hours a day to better assist communities by expanding self-help services to those in need through online, hybrid, or in-person supports, The Ministry of the Solicitor General (ministry) should review the Offender Tracking Information System. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. Coroner's Duties The office of coroner became constitutional with statehood in 1818. Provide Indigenous-led cultural competency and cultural safety training to all officers. That training be delivered to police officers and jailers relating to medical issues that may mimic intoxication, or that may be concurrent with intoxication, and that this be provided both at the Ontario Police College and to serving officers. The funding formula should reflect the population of Thunder Bay and surrounding areas that uses Thunder Bay as a Hub for medical services. 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. 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. All site supervisors are competent and aware of their duties and responsibilities. The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody. Make adjustments to program curriculum and delivery methods according to gaps and opportunities identified. At every employer site at least two physician assistants / medical professionals should be available to perform medical assistance. 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. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. 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:TimminsFrom: December 12To: December 20, 2022By:Dr.David Eden, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Denis Stanley JosephMilletteDate and time of death: June 3, 2015Place of death:Detour Lake MineCause of death:acute cyanide intoxicationBy what means:accident, The verdict was received on December 9, 2022Presiding officer's name:Dr.David Eden(Original signed by presiding officer). Consideration of streaming short video clips or other helpful information via the television screens on each living unit should also be given. The ministry should ensure that Naloxone spray devices deployed in areas accessible to people in custody are positioned in a manner that correctional staff on security rounds may determine that a device has been used or removed. That joint training be scheduled on an on-going basis, allowing first responders to learn more about the roles and responsibilities of other agencies. . Be publicized to enhance public awareness, and become better known among policing partners possibly through All Chiefs bulletins. Consideration should be given to the United Kingdoms Domestic Abuse Commissioner model in developing the mandate of the Commission. Consider including a case study focused on falling ice in excavations in future inspector training material. Safety by Design refers to the concept of incorporating worker safety into the design and planning of large construction projects. If there is no individual evaluation component, the ministry should consider implementing one. In partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, establish multisectoral, multidisciplinary roundtables at local, regional, and provincial levels accessible to community members and service providers to problem-solve regarding service to young people with complex needs. The ministry should advocate for total compensation offered to nurses and healthcare staff be competitive with that in non-correctional settings. Clarify and enhance the use of high-risk committees by: Strengthening provincial guidelines by identifying high-risk cases that should be referred to committee. We, the jury, wish to make the following recommendations: Surname:MacDougallGiven name(s):Quinn EmmersonAge:19. Consider conducting inquests in a timely manner, within 24 months from the incident date. Continue to ensure that all young people in care have reasonable access to cell phones or other technologies they may need to communicate with their family, their First Nation and others important to them. Inquests. . 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. These outcome measures should be supported by key performance indicators (. Develop and implement a new approach to public education campaigns to promote awareness about, Complete a yearly annual review of public attitudes through public opinion research, and revise and strengthen public education material based on these reviews, feedback from communities and experts, international best practices, and recommendations from the Domestic Violence Death Review Committee (, Use and build on existing age-appropriate education programs for primary and secondary schools, and universities and colleges. 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. 08:52, 2 MAR 2023. 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). The ministry should ensure that Indigenous Liaison Officer (, The ministry should create policy and direction that recognizes the role and function of, Spiritual Elders, knowledge keepers and helpers should be provided honoraria or some form of financial compensation for the important work they are conducting as part facilitating their access to their spiritual rights or as part of culturally relevant programing, and that the Ministry should revise both health and. The inquest jury consists of five people selected by the coroner's constable from a list of jurors from the community. This will be referred to as the inquest 'conclusion' or 'verdict.' The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model. Show entries That all police officers be trained that paramedics cannot medically clear any person, and that an assessment by a paramedic does not mean that a patient does not require medical treatment. 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.