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. Encourage review and participation in all best practices regarding cyanide safety put forth in the international Cyanide Management Code. That bystander training be provided to police officers so that officers feel more comfortable addressing inappropriate behavior by colleagues. Implement recommendation #20 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Where possible and financially feasible, connect young people with external resources that could provide additional opportunities, including but not limited to sport, land-based learning, culture, art, and other pursuits that will assist in developing a forward pathway. Specifically, the the ministry should: ensure that all Native Inmate Liaison Officer/Indigenous Liaison Officer (, benefits, that include access to an employee assistance program, opportunities for support following traumatic incidents, create policy and direction that recognizes the role and function of. An inquest is not a trial and does not assign blame or liability. 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. Held at: TorontoFrom:May 16To: June 3, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Marc Diza EkambaDate and time of death:March 20, 2015 at 10:53 p.m.Place of death:3070 Queen Frederica Drive, Mississauga, OntarioCause of death:multiple gunshot woundsBy what means:homicide, The verdict was received on June 3, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:VeilletteGiven name(s):Jean HervAge:48. Consider the circumstances of all police-related inquests as training scenarios. The ministry should create and implement a policy that requires the use of specific language by correctional officers and healthcare workers at each correctional facility which prioritizes humanizing people in custody by addressing them as patients, persons in custody and/or persons who use drugs. 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. This can be: accident/misadventure unlawful killing natural causes. However, the Coroner may decide to hold an inquest to establish the facts. The ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive additional Indigenous cultural safety training. This training should also include periodic or ongoing refresher training. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. . . How is it different from an inquest? 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. whether the missing person is an Indigenous youth. 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. Storage rules and protocols for tracking data. Take all reasonable measures to ensure workers are educated, understand and avoid the hazard. 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. The ministry should provide educational opportunities to persons in custody and operational staff at correctional facilities about the Good Samaritan principles that it adopts in its operational policies and practices. There are no 'parties' and the Coroner does not make . Continue to follow the international Cyanide Management Code. 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. Section 9: Giving Evidence As a witness you are not on trial, you are there to assist the court The Coroner decides which witnesses should attend, and in what order they are called. The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. The Coroners' Courts Support Service (CCVS) is an independent voluntary organisation whose trained volunteers offer emotional support and practical help to bereaved families, witnesses and others. The ministry should take steps to actively promote awareness of information, services and programs available to persons in custody regarding opioid/other substance use. It would also provide a primary point of communication for emergency response and medical personnel. Explore digitized records of over a century of coroner's records from Stark County, Ohio, available online . Health and safety representatives are selected in a manner that ensures independence. Ensure that all health care staff are trained in suicide prevention policies and documentation. Ensure that housing support personnel communicate the options for both the policing and community-based options to address mental health crisis to affected tenants. Coroner's Officer. This would both provide a warning and a specific ongoing reminder to any person entering such areas. And people detained in hospital under the Mental Health Act. Develop, establish, and provide regular training to, circumstances in which the policy is applicable, including when an individual would be considered potentially dangerous, involving a supervising officer in the planning of the arrest, when possible, completing an arrest decision tool, which may include a checklist of criteria, how to identify possible factors that could complicate an arrest, such as possible mental health issues, unpredictability, past incidents with police, and violent history, In support of the planning process, develop and provide guidance and training on circumstances where it may be appropriate to contact a subject to ask them to attend a police detachment for the purpose of effecting an arrest. risk assessment training with the most up-to-date research on tools and risk factors. 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. Foster and support the co-development of life promotion programs such as Promote Life Together between Indigenous and non-Indigenous stakeholders to establish and develop meaningful programs and services, with an emphasis on the inclusion and engagement of Indigenous stakeholders from inception. These would keep Indigenous youth within their local community and connected to family, culture, and local supports. internal audits by a health care manager or designate, external audits by the Corporate Health Care Unit, Ensure that the planned Electronic Medical Record (, be available to all health care staff at the point of care, ensure that health care professionals who provide care remotely have complete access to inmates health care files, include methods of communicating health care orders electronically, Ensure that psychiatrists who provide services at the. Held at:WindsorFrom: September 12To: September 23, 2022By: Dr. Daniel L. Ambrosini, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Matthew MahoneyDate and time of death: Pronounced deceased at 9:39 a.m. on March 21st, 2018Place of death:Windsor Regional Hospital (Ouellette Campus)Cause of death:multiple gunshot woundsBy what means:homicide, The verdict was received on September 23, 2022Presiding officer's name: Dr. Daniel L. Ambrosini(Original signed by presiding officer). Whether the tool exacerbates risk factors and contributes to recidivism. 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. 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. 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. 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. Misadventure is where someone doing something lawful unintentionally kills another. The inquest into father and son Roger and Bradley Stockton, who died in a sidecar crash June 10 2022, closed this afternoon. Prepare an emergency response plan to use if a worker does come into contact with a hazard. The ministry should implement dedicated and centralized real time monitoring of cameras at. Consider adopting Femicide as one of the categories for manner of death. The ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive awareness training regarding the causes and nature of substance use disorder to address stigma surrounding addiction. 4:33 p.m. - April 28, 2022. The Government of Ontario should enhance supports for families of persons who die in a police encounter, and ensure that those services are delivered in a timely and trauma-informed manner. It simply aims to gather information in order to answer these questions. The arresting officers and jailers must clearly indicate/communicate verbally and with diverse signage the procedures and rights of people in custody. Be staffed 24 hours a day and 7 days a week. consider the need for Navigators, in addition to resource persons, adult ally and circle of supportive persons to assist First Nations youth, as both a prevention and protection resource and for youth both on and off reserve, in navigating various systems such as child welfare and protection, mental health and criminal justice. Regularly consult with bands and First Nation communities and Indigenous stakeholders on program implementation and service delivery for new and existing initiatives; and report back within a reasonable period of time. Explore the capability of the information management systems to track the deployment of alternative responses to assist a person in crisis and the outcomes. 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. Designated funding for transportation for those receiving, Funding to ensure mental health supports for. 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. Implement recommendation #5 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones. Evidence relating to the Five Incidents . The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. The hazard alert should identify cyanide, in all of its forms, as a potential workplace hazards. Regular meetings between mine emergency response team and. Consider conducting an ice management campaign for large construction projects in Eastern Ontario. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. Related Information. 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. 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. To the extent that this training is not already provided, that educational institutions such as colleges and universities provide training for first responders on the history of colonization; residential schools; trauma informed approaches; anti-Indigenous racism; cultural safety, and unconscious bias. EASTWOOD, Claire Louise. A British coroner will hear about the final hours of Amy Winehouse's life at the inquest into the soul diva's death. SUMMARY OF CORONER'S VERDICTS AND FINDINGS (KEEGAN J) I. To Green Star Grading & Sodding Construction Ltd. (Green Star): Surname:SoaresGiven name(s):RicardoAge:32. Consider finding alternate means for survivors to attend and testify in court, such as by video conferencing. To ensure the safety of children in care, train staff to ensure that, to the extent a youths file is transferred from one staff member to another, all information relating to a young persons suicidal behaviour and ideation is clearly flagged in transfer discussions or communications between staff.