The death of Daniel Robert NELSON was drug related. Inclusion of and consultation with Indigenous communities/agencies is essential. To Green Star Grading & Sodding Construction Ltd. (Green Star): Surname:SoaresGiven name(s):RicardoAge:32. An inquest is a judicial process and a Coroner's Court is a court of law. 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). Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. The ministry should prioritize the completion of its project to implement electronic health records for patients living in correctional facilities. Please check the website on the day of the hearing. Provide support for training and capacity building for childrens aid societies and licensed residential facilities to meet the consultation requirements with bands and First Nation communities under sections 72 and 73 of the. 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. Review whether one on one supervision needs to be provided to individuals in custody who pose particularly high risk, such as individuals who expressed suicidal ideation. Revise the use of force report form to require officers to document de-escalation techniques used. If it cannot be done immediately, the correctional officers should then bring the Inmate to admit and discharge pending re-assignment to a cell. 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. Said plan should include checking that the back-up alarm on the skid steer is operational. Revise the provincial Use of Force Model (2004) as soon as possible. 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 (. The ministry shall implement a policy requiring the inclusion of a letter describing what is contained in the return of property of an individual that has died in custody. 08:52, 2 MAR 2023. It is recommended that the Chief Prevention Officer of the. That the use of medically fragile flags be considered for the. 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. Ensure that all police officers who interact directly with the public are provided with the four-day mental health training currently provided to incoming police officers in their first year of service. An an inquest is purely a fact-finding hearing; nobody is on trial. Review policies to ensure the timely, reliable, consistent, and accurate dissemination of information, including the use of emergency alerts and media releases, where the police are aware of circumstances that could put the public in danger, and that the focus is on safety when developing policies regarding what information to share with whom and when. Another is David West, the owner of Abracadabra restaurant in London, which . Contact Kent and Medway Coroner. Evidence and release of body What happens when evidence is gathered and when a body can be released Inquests held. A list of the inquests scheduled for hearing in the Oxford Coroner's Court. Hazard alerts should be distributed in a timely manner after a health and safety concern is made evident. 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. This shall include adequate training and resources for all care providers and all staff within MAPs so that individuals with a likelihood of violent behaviour as a result of trauma are still able to receive care and services from the. That the Ministry of Health immediately address patient flow at the Thunder Bay Regional Health Sciences Center emergency department to address police and ambulance off-load delays and code black events. The aim is to get all the facts about the circumstances of a death. . The ministry should ensure that people in custody have access to a reliable means of initiating an emergency medical 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. These supports should account for the social barriers to accessing such supports within a custodial environment. The revisions should require correctional institutions to ensure that: one or more staff member is designated to develop a recovery plan when an inmate is removed from suicide watch, one or more staff member is designated to oversee the plan and ensure it is implemented, placement of inmates in recovery is reviewed with health care staff and this review is documented, The recovery plan is available for health care and operational staff. As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights. 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. It would also provide a primary point of communication for emergency response and medical personnel. 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. These reviews should analyze relevant health care files and assess quality of care. provide mandatory standardized training bi-annually on de-escalation strategies and empathy for community mental health-related situations. Prioritize continued efforts regarding bed shortages for female inmates. The ministry should implement dedicated and centralized real time monitoring of cameras at. That where an individual dies in cells, all officers involved in the arrest or monitoring of the deceased be provided information about the cause of death, and training on symptoms that may be related to this cause of death, as soon as reasonably possible following the death. The Coroner may also hold an Inquest if the death was due to natural causes and is considered by the Coroner to be in the public interest. . The Coroner is expected to open an inquest where there is reasonable suspicion that the deceased has died a violent or unnatural death, where the cause of death is unknown or if the deceased. 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. arrives at St. Pancras Coroner's Court for a hearing into the singer's . Held at: SudburyFrom:June 13To: June 16, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Ronald LepageDate and time of death:April 6, 2017 at 9:12 p.m.Place of death:Health Sciences North, 41 Ramsey Lake RoadCause of death:blunt force/crush injury to abdomen and pelvisBy what means:accident, The verdict was received on June 16, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:BlairGiven name(s):Delilah SophiaAge:30. Consideration for the needs of rural and geographically remote survivors of. how to identify and address the precursors to heat stress, and other heat related illnesses that may arise from working in high temperature conditions. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented. The audit should be independent and should result in an action plan that must be submitted to the. The protocol should address: the circumstances in which a missing persons report should be filed, the information to be provided as part of that report, the residential homes responsibilities prior, during, and after filing a report (including conducting a property search where appropriate). How employers should prepare their workers and their job sites to ensure safe working conditions during periods of high temperatures. the health care needs of the inmate population, compliance with provincial policies and professional standards, record keeping and communication of health care information, an audit of a meaningful selection of inmate health care files, interviews with health care staff to determine the causes of any deficiencies uncovered in the review. 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). Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training. 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. Require cyanide distribution lines be painted purple for identification and dye be added to cyanide solutions during mixing to make it red/purple in colour. Ensure that police officers can accurately identify their own, Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (. The ministry should take steps to actively promote awareness of information, services and programs available to persons in custody regarding opioid/other substance use. 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. In December a coroner . Prioritize developing and implementing a long-term plan to establish adequate housing for male/female inmates. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. 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). It should be clear that it is broadly accessible and not limited to a particular kind of relationship. 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. Explore developing and providing all police recruits with additional de-escalation training. 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. 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. 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. The ministry should embrace an evidence-based approach to harm reduction in a manner that protects the mental and physical health of persons in custody. That joint training be scheduled on an on-going basis, allowing first responders to learn more about the roles and responsibilities of other agencies. An inquest has heard of the final moments before a father and son died racing together in last year's TT. 2.30pm Andrew Phillips, aged 56, from Altrincham, died 31/05/22 in JRH. 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. The ministry should ensure mental health nurses are available on call 24 hours a day, seven days a week, to see any Inmates waiting for them as soon as possible to allow all assessments to be completed in a timely fashion regardless of whether any given Inmate has temporarily left the institution for court. The arresting officers and jailers must clearly indicate/communicate verbally and with diverse signage the procedures and rights of people in custody. In jury inquests, the coroner directs the jury on matters of law and the jury decides the appropriate verdict . Date of inquest. 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. Consider the creation of a multidisciplinary mental health services team approach, (including a mental health case manager) for children and their families to support continuity of care throughout their childhood and to provide broad and supportive care. Designated funding for transportation for those receiving, Funding to ensure mental health supports for. That officers and jailers continue to be trained on an ongoing basis to seek out and record answers from the arrested person about their medical condition. Study the feasibility of, and implement if feasible, justice sector participants having access to relevant findings made in family and civil law proceedings for use in criminal proceedings, including at bail and sentencing stages. 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. 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. A coroner's inquest . What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. The Solicitor General of Ontario should provide oversight on the mandatory annual training curriculum and number of hours that are provided by local police services e.g. 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. That the Thunder Bay Police Service Board retain an expert consultant for the purposes of providing an independent assessment of the level of staffing required of the Thunder Bay Police Service. The ministry should amend its policies and practices for admissions officer/. Unfortunately, we cannot provide any additional information other than what is on the Court List. 2022 coroners inquests verdicts and recommendations, other identified organizations may be identified in the recommendations. Commission a study to examine the creation and implementation of a province-wide, civilian-led crisis intervention system to respond to persons in crisis, including mental health crisis. Educate any worker who is to work for or on behalf of Green Star at a construction site where a skid steer is in use (including those who operate skid steers) regarding the risks and dangers associated with working on or near a skid steer and ensure that they are familiar with the aforementioned safety plan. Openings. The jury hears evidence from witnesses under summons (same as a subpoena) in order to determine the facts of a death. Clarify the definition of accident in sections 52 and 53 of the, Consider studying the effectiveness of Albertas. When operationally feasible, the ministry should run the scenario-based. Provide frequent training to all workers to familiarize them with the hot weather plan/heat response plan and the dangers of working in high heat environments. Older verdicts and recommendations, and responses to recommendations are available by request by: e-mail: occ.inquiries@ontario.ca. 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..

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