This should be a focus for performance management and quality assurance processes. Held at:North BayFrom: November 21To: November 24, 2022By:Dr.S.C. Bodleyhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Gordon Dale CouvretteDate and time of death: February 22nd 2018 06:21Place of death:North Bay Regional Health Centre, 50 College Dr, North Bay, Ontario, P1B54ACause of death:Sudden death with no anatomical cause associated with acute-on-chronic cocaine and amphetamine abuse/intoxication, forcible struggle and possible Autonomic Hyperactivity SyndromeBy what means:accident, The verdict was received on November 24, 2022Presiding officer's name:Dr.S.C. Bodley(Original signed by presiding officer), Surname: Blackett,Given name(s):CraigAge:41. The ministry should conduct an Indigenous led study that consults with Indigenous community organizations and Indigenous healthcare providers to obtain information regarding Indigenous cultural and spiritual healing practices and use of Indigenous traditions known to assist in prevention of substance use, wellness and a means to address addictions in a culturally sound way. To the Ministry of the Solicitor General and Windsor Police Service, Surname:OgundipeGiven name(s):VictorAge:41. 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. The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody. 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. Specifically, they should consider the length or passage of time since a volunteer had any criminal convictions and the nature of the criminal conviction to determine criteria that would increase Indigenous volunteers participation in Indigenous programing and to provide peer resources in an effective way. Ensure that witnesses or persons injured during an event that leads to a police-involved death are directed to trauma-informed supports. 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). If there is no individual evaluation component, the ministry should consider implementing one. Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system. 2022 coroners inquests verdicts and recommendations, other identified organizations may be identified in the recommendations. What verdicts can a coroner give? - The MDU - Medical Defence Union 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. EASTWOOD, Claire Louise. That a Task Force be developed with a mandate to establish a sobering centre in Thunder Bay. 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) Inquest to conclude. 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. Greater use of court-ordered language ensuring alleged and convicted offenders will not reside in homes that have firearms. 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. NELSON, Daniel Robert. Continue to prioritize the recruitment, hiring, and retention of workers with First Nations identity and from other equity-deserving groups, recognizing skills related to Indigenous knowledge and cultural identity alongside traditional mainstream credentials. Inquest Livestream - Province of British Columbia Another is David West, the owner of Abracadabra restaurant in London, which . Inquests are held at HM Coroner's Court in Woking. Provide adequate and sustainable funding and resources to ensure that a range of placement options and transition services, including independent and semi-independent living arrangements, are available for children and young people receiving services from childrens aid societies and Indigenous well-being agencies. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. how to identify and address the precursors to heat stress, and other heat related illnesses that may arise from working in high temperature conditions. 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. 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. Court listings - Avon Coroner The ministry should explore the use of a scoring metric to determine risk in areas such as mental health and violence, assessed first at Intake and re-evaluated on a continuous basis. Consider re-allocating more time to scenario-based de-escalation training during annual use of force certification at the, Post the verdict and recommendations of this inquest on the. It is recommended that the Ministry of Labour, Training and Skills Development take steps to amend the. Consider the viability of a requirement for dump trucks to be equipped with back-up cameras that provide 360 degree visibility. 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). Advise all workers that they should report health and safety concerns to their health and safety representative, joint health and safety committee, to Fermars Health and Safety Department, or directly to the. To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. PDF Coroner's Inquests - A Guide for Learners within hiring practices to ensure personality and culture fit, situational judgement, role-specific skills, incorporate in regular performance evaluations to ensure that the individuals values remain consistent with expectations. Inquests - Derbyshire Live - Derby Telegraph Programs are funded at a level that anticipates an increased stream of referrals. The Chief Coroner's Annual Reports cover matters that the Chief Coroner wishes to bring to the attention of the Lord Chancellor, and matters that the Lord Chancellor has asked the Chief Coroner to cover. Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a pilot project. Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. Consider conducting an ice management campaign for large construction projects in Eastern Ontario. Deliver training to frontline officers on the purpose of the Crime Abatement Program, the information included in Crime Abatement Program records, and how to access such records. Review existing training for justice system personnel who are within the purview of the provincial government or police services. The ministry should undertake a study to identify the effects of overcrowding, and other living conditions on inmate populations especially those with addictions and/or pre-existing mental illness and to take any appropriate corrective measures. 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. That joint training be scheduled on an on-going basis, allowing first responders to learn more about the roles and responsibilities of other agencies. It is their duty to find out the medical cause of the death if it is not known, and to enquire about the cause of it if it was due to violence or was otherwise unnatural. 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. 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 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. Explore developing and providing all police officers with additional de-escalation training. Seek and allocate adequate funding and resources to implement these recommendations. Hillsborough inquests: Fans unlawfully killed, jury concludes Full Hearing. 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. Employers shall ensure that workers are trained on the cell phone policy. 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. Coroner training overview In conjunction with the Chief Coroner, the Judicial College delivers a varied training programme for all coroners involving induction, continuation and one-day training on specific topics. Recognize that the best practice is to consider Indigenous Dispute Resolution by connecting with the First Nation regarding any challenges faced by a First Nations young person and/or family. Implement more rigorous and thorough assessment of potential and current employees. Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training. The data should be standardized, disaggregated, tabulated and publicly reported. Measures to improve public awareness should be developed in consultation with content experts and community organizations that represent persons with lived experience. 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. List of inquests | Oxfordshire County Council The ministry should ensure that correctional officers investigate cell change requests immediately, and grant same immediately, where merited. All physician assistants and doctors are trained on all medical equipment available at the worksite. Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors. It would also provide a primary point of communication for emergency response and medical personnel. Consideration of the remoteness quotient used to calculate funding in other social services, such as education and policing. Once the ministry completes the consultations on tear-resistant sheets and blankets, if there are viable options, the ministry endeavor to implement the use of such bedding in all provincial institutions. In some Coroner's Districts certain inquests can be held based only on documents. Workplace incidents are properly investigated and addressed, and the results of those investigations are communicated to the relevant workplace parties. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. Share those best practices with construction sector employers and constructors. The inquest would be held in the district where the death occurred. This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools. 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. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. Require emergency response personnel in plants using cyanide to be provided with basic first aid/. Wednesday 15 March Inquest to conclude Formally declare intimate partner violence as an epidemic. The ministry shall consult with the federal government and other provinces and territories to determine if there is bedding that is less susceptible to tearing for use by persons in custody not on suicide watch. IV. Prepare and distribute a hazard alert about the hazards of cyanide in the workplace. When the coroner's jury could not determine a cause of death, an "_" will appear in the verdict category. Prepare an emergency response plan to use if a worker does come into contact with a hazard. 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 child welfare service delivery model, including consideration of the following: continue monitoring the effectiveness of annualized funding announced in July 2020 as part of the Child Welfare Redesign Strategy to provide access to prevention-focused customary care for bands and First Nation communities, support the implementation of models of service to enable children and youth to have meaningful, lifelong connections to their family, community and culture; a sense of belonging; a sense of identity and well-being and physical, cultural and emotional safety; and that plans of care are reflective of the childs physical, mental, emotional, spiritual and cultural identities beginning from the time a case is opened by a society, continue to review the Ontario Eligibility Spectrum, the need for verification, and adopt a needs-based approach (instead of a caregiver deficits approach) to supporting and protecting the well-being of children and youth informed by Indigenous experts. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current andprevious year. The coroner must investigate a death, known as an inquest, if they think that: someone died a violent or unnatural death, the cause of death is unknown, or someone died in prison, police custody or state detention. The ministry should position equipment necessary for an emergency medical response close to living units. 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. The ministry should review the suicide awareness training to ensure that it includes a robust individual evaluation component for comprehension of the course materials. It is recommended that construction associations, including without limitation those listed at subparagraph 2.1, incorporate and promote a best practice for dump truck operators exiting haulage trucks to adhere to the following steps: position wheel chocks in appropriate locations, refrain from placing yourself between tires and/or axles, 2.1 Infrastructure Health and Safety Association. 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. The inquest heard from 278 witnesses and is estimated to have cost the taxpayer more than 6.5m. Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. 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. The ministry should provide direct access to Naloxone spray for people in custody, including within locked cells. Try to find out: the date the. Introduction . Sudden death of woman after routine surgery linked to use of blood The Senior Coroner for this area is Patricia Harding. Misadventure is where someone doing something lawful unintentionally kills another. The ministry should update all forms to remove the term North American Indian in favour of First Nations/Inuit/Mtis on any admission or information forms used with people in custody. Provide direct, sustainable, equitable, and adequate joint funding from the named Ministries and Government of Canada to First Nations, off-reserve Indigenous service providers, and non-Indigenous service providers serving off-reserve First Nations children, youth and families to increase the capacity for collaboration in the provision of child welfare and mental health services. Annual training is also provided for coroners' officers. Held at: OttawaFrom:April 20To: April 29, 2022By:Dr.Bob Reddochhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Babak SaidiDate and time of death: December 23, 2017 at 11:30 a.m.Place of death:Morrisburg, OntarioCause of death:gunshot wounds to the right shoulder and right side of the back.By what means:homicide, The verdict was received on April 29, 2022Coroner's name:Dr.Bob Reddoch(Original signed by coroner). The incident occurred on the second lap of the race, at Ago's leap. Encourage review and participation in all best practices regarding cyanide safety put forth in the international Cyanide Management Code. the cost of transportation for survivors and service providers. The ministry should develop guidance to determine criteria by which. Inquest conclusions - Lancashire County Council Did you find what you were looking for? Provide annual reports, accessible to the public, on ongoing research findings through the Chief Prevention Officer. Consideration for the needs of rural and geographically remote survivors of. Implement recommendation #35 from the Inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Designated funding for transportation for those receiving, Funding to ensure mental health supports for. 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. The Toronto Police Service should consider the use of dedicated negotiators. . The ministry shall consult with an expert in trauma-informed care to review the current care programs to provide specific suggestions for institutional changes to promote trauma informed practices within the detention centre. Held at: TorontoFrom:June 29To: June 29, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Frank FerranteDate and time of death: July 28, 2015 at 8:34 p.m.Place of death:Southlake Regional Health Centre, 596 Davis Drive, NewmarketCause of death:heat strokeBy what means:accident, The verdict was received on June 29, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:YonanGiven name(s):MettiAge:66.
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