The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. Held at:Ottawa (virtual)From: October 11To: November 10, 2022By:Dr. Geoffrey Bond, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Olivier BruneauDate and time of death: March 23, 2016 at 8:08 a.m.Place of death:Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa, OntarioCause of death:blunt force chest injuryBy what means:accident, The verdict was received on November 10, 2022Presiding officer's name:Dr. Geoffrey Bond(Original signed by presiding officer), Surname:DhindsaGiven name(s):VikramAge:34. 42. The audit should be independent and should result in an action plan that must be submitted to the. 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. Appropriate perpetrator programs and supports needed to accompany electronic monitoring. It is most commonly used when none of the other verdicts are appropriate. In some Coroner's Districts certain inquests can be held based only on documents. 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. Chief Prevention Officer to track effectiveness of the Working at Heights training program through regular evaluations and public-facing reporting to demonstrate the relationship between the Working at Heights training program and falls from heights data generated through the Prevention Division. Prior to commencing work, survey worksites where high temperatures are a concern and ensure that every reasonable precaution is taken to protect workers from heat stress and heat related illnesses. If a police service has a joint mental health-police team, give studied consideration to implementing a police policy that provides, once police officers attending a call identify a potential mental health concern and provided it is safe to do so, that the joint mental health-police team should be engaged. Change its name to one that better reflects its purpose. 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. Coroner Services is an independent and publicly accountable investigation of death agency. Inquests for this area are normally held at Archbishops Palace, Maidstone unless stated otherwise. Coroners' appointments . Visual signage should be placed in the booking area and cell blocks. A physician and/or nurse practitioner should be available to provide in-person health care services on weekends at the, Addictions counselors, discharge planners and social workers should be available to provide in-person services on weekends at the. 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. Consider an appropriate role for community members or organizations as part of the missing person investigation, or in a debrief with the missing person once the investigation is concluded. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers). Mandatory skid steer operation certification and re-certification process. When non-Indigenous service providers are providing care, the First Nation Mental Wellness Continuum Framework should be considered when developing and delivering services to Indigenous children in care. 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. To ensure the safety and ongoing wellness of the children in its care, where a youth has disclosed suicidal behaviours or ideation, make best efforts to bring together all those involved in a youths circle of care to discuss and assess the youths situation and participate in safety planning for the youth (including the youths self-identified support, youths guardian, First Nation if applicable, medical team, supportive community members and family where appropriate). Older verdicts and recommendations, and responses to recommendations are available by request by: You can also access verdicts and recommendations usingWestlaw Canada. Seek and allocate adequate funding and resources to implement the above recommendations. The OCC use the findings to generate recommendations to help improve public safety and prevent future deaths in similar circumstances. There must be special recognition of the unique challenges Black people who also have serious mental health issues face when they come into contact with police. Ensure that survivor-informed risk assessments are incorporated into the decisions and positions taken by Crowns relating to bail, pleas, sentencing, and eligibility for Early Intervention Programs. Advocating for survivors and their families having regard to addressing the systemic concerns of survivors navigating the legal system. All correctional staff and nurses have full access to, All correctional staff and nurses perform a thorough review of. Probation conditions are appropriate for the level of risk of the client and written in a way they can enforce, and, if not, request a variation. As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights. If the cause remains in doubt after a post mortem, an inquest will be held. The Toronto Police Service should continue to build a diverse. 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. The same expert panel as noted above should provide recommendations to define outcome measures which clearly describe the successful progression of Indigenous youth through the welfare system to independence and adulthood. 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. Programs and other initiatives to address drug addiction and abuse should be encouraged, prioritized and promoted in prominent places throughout the facility where they are likely to come to the attention of persons in custody. We recommend that, absent exceptional circumstances, claims should be processed within 30 days of receipt of the documentation from the correctional facility. Background: Annually, there are around 30,000 coroner's inquests held in England and Wales that conclude with a verdict. Names of the deceased: Blumberg, Alexsey; Bondarevs, Aleksandrs; Fayzullo, Fazilov; Korostin, VladimirHeld at:remote inquestFrom:January 31To: February 4, 2022By:Dr.John Carlisle, coroner for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:BlumbergGiven name(s):AlexseyAge:38, Date and time of death: December 24, 2009 at 4:30 p.m.Place of death: 2757 Kipling Avenue, TorontoCause of death:multiple injuries due to a fall from a suspended work platformBy what means: accident, Surname:BondarevsGiven name(s):AlexsandrsAge:24, Surname:FazilovGiven name(s):FayzulloAge:31, Surname:KorostinGiven name(s):VladimirAge:40, The verdict was received on February 4, 2022Coroner's name: Dr. John Carlisle(Original signed by coroner). Create emotionally supportive debrief sessions for police officers at the division or platoon level for those involved in critical incidents resulting in serious bodily harm or death, with regard for the Special Investigations Unit investigative process. The Ontario Use of Force model shall be redesigned to highlight and emphasize the importance of de-escalation at all points during police interactions. In consultation with residential homes and child and youth mental health facilities like Lynwood, develop a common joint responsibility protocol governing the process, roles and responsibilities when it comes to searching for youth who have left congregate settings without permission. Include in those best practices training requirements or other criteria for achieving competency regarding the assessment of ice on excavation walls as a hazard. 4:33 p.m. - April 28, 2022. how to prevent heat stress and other heat related illnesses that may arise from working in high temperature conditions, and. 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. What is an 'investigation'? development of an integrated Plan of Care focused on the social determinants of health for the family and child that follows them through community services when they are in the community and also when they are in the care of a childrens aid society and incorporate the cultural and spiritual needs of the child; and. 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. Physicians should be encouraged to communicate with a patients community health care providers when discontinuing or amending a prescription for an opioid medication, when consent is provided by the patient. 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. Consideration of the remoteness quotient used to calculate funding in other social services, such as education and policing. Continue to work with bands and First Nation communities, including First Nations and urban Indigenous service providers, and Indigenous child well-being agencies to develop regulations as soon as possible that would support implementation and proclamation of amendments to the, In accordance with subsection 1(2), paragraph 6, of the, Strongly recommend as part of the five-year review of the, mandatory notification to a child or youths band or First Nation community when a child or youth is absent from their residence without permission for more than 24 hours (and upon their return), mandatory notification to a child or youths band or First Nation community when a child who is a resident in a childrens residence dies, and in the event of any other serious occurrence, as listed at subsection 84(1) of the. Call us on 020 7632 4300 or make an enquiry online. The ministry should ensure that healthcare and correctional staff at correctional facilities receive additional training about building rapport and resolving challenging encounters with persons in custody. Constructors, employers and supervisors shall ensure that workers are not endangered by cell phone use on construction projects. 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. The ministry should deliver alerts to persons in custody on an urgent basis regarding new and emerging threats from novel street drugs. Inquest to conclude. This training should also include periodic or ongoing refresher training. The ministry should adopt Good Samaritan principles in operational policies and practices to encourage persons in custody to call for help or try to help another person suspected of being in medical distress or come forward with information about drugs within the institution, without being subjected to any institutional misconduct proceedings for possession or use of contraband. Please check the website on the day of the hearing. To the Ministry of the Solicitor General and Windsor Police Service, Surname:OgundipeGiven name(s):VictorAge:41. 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. 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). This training should be designed and delivered by Indigenous people. While recognising that inquests must be . Establish clear guidelines regarding the flagging of perpetrators or potential, Recognize that the implementation of the recommendations from this Inquest, including the need for adequate and stable funding for all organizations providing, Create an emergency fund, such as the She C.A.N Fund, in honour of Carol Culleton, Anastasia Kuzyk and Nathalie Warmerdam to support women living with. 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 evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. incorporate the approach of minimizing the risk of hanging in the designing and planning of the bookshelves in all units. 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. Explore the capability of the information management systems to accurately capture the number of calls for service which are initially reported and dispatched as another type of call but are later assessed by the responding officers to be a call which has a significant person in crisis component. Amend section 232(1) of the Construction Regulations to: Clarify that the walls of an excavation shall be stripped of ice that may slide, roll or fall upon a worker. Ensure that the employer continues to properly identify and review Potential Chemical Hazards of cyanide at the mine site and modify the training, procedures and medical response as required. Being accessible by clients voluntarily and via referral,and not just through the criminal justice system. Implement the corporate health care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. Measures to improve public awareness should be developed in consultation with content experts and community organizations that represent persons with lived experience. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones. The death of Daniel Robert NELSON was drug related. 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.