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. Half day. 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. 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. models in other jurisdictions that identify relevant. 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. Set up satellite offices for police officers to work safely and comfortably to spread police resources more evenly over wide rural areas (, Encourage Crowns to consult with the Regional Designated High-Risk Offender Crown for any case of. Names of the deceased: Frenette, Steven;Foreman, Daniel;Bullen, David;McConnell, Jonathan; Borja, SusanHeld at:virtual, Office of the Chief CoronerFrom:November 14To: December 1, 2022By:Dr.Robert Reddoch, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:FrenetteGiven name(s):StevenAge:35, Date and time of death: September 20, 2018 at 7:38 p.m.Place of death: Ross Memorial Hospital, LindsayCause of death:central nervous system depression due to (or as a consequence of) combined fentanyl toxicity and diazepamBy what means: accident, Surname:ForemanGiven name(s):DanielAge:39, Date and time of death: October 3, 2018 at 9:10 p.m.Place of death: Central East Correctional Centre, LindsayCause of death:fentanyl intoxicationBy what means: accident, Surname:BullenGiven name(s):DavidAge:50, Date and time of death: December 29, 2018 at 7:52 a.m.Place of death: Central East Correctional Centre, LindsayCause of death:acute fentanyl toxicityBy what means: accident, Surname:McConnellGiven name(s):JonathanAge:36, Date and time of death: April 28, 2019 at 8:40 a.m.Place of death: Central East Correctional Centre, LindsayCause of death:carfentanil toxicityBy what means: accident, Surname:BorjaGiven name(s):SusanAge:50, Date and time of death: August 10, 2019 at 6:26 a.m.Place of death: Central East Correctional Centre, LindsayCause of death:toxic effects of oxycodone, methadone, quetiapine and pregabalinBy what means: accident, The verdict was received on December 1, 2022Coroner's name: Dr. Robert Reddoch(Original signed by presiding officer), Surname:CouvretteGiven name(s):Gordon DaleAge:43. If there is any information relating to suicidal behaviour or ideation, it must be flagged so any other society workers are immediately aware of that aspect of a particular young persons history. Expedite the processing, and provision of support (if warranted), to front-life provincial corrections staff claims when they are involved in inmate suicides. 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. 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. Consider renaming the Model to better reflect the range of tools and techniques available to officers. The orientation should include hazards, work processes and medical issues, that may be unique to that work site. 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. 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. The revised risk assessment factors, as well as search urgency factors, should be evidenced-based and clearly defined. Consideration for the needs of rural and geographically remote survivors of. If there is no individual evaluation component, the ministry should consider implementing one. Prepare and distribute a hazard alert about the hazards of cyanide in the workplace. Related Information. Prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. This includes education of workers, availability and maintenance of rescue equipment (. 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. Time of death could not be determined.Place of death: Combermere, OntarioCause of death: upper airway obstructionBy what means: homicide, Surname: KuzykGiven name(s): AnastasiaAge:36, Date and time of death: September 22, 2015. Coroner's Officer. All physician assistants and doctors are trained on all medical equipment available at the worksite. The Coroner's Office can be contacted by email at coroners@cambridgeshire.gov.uk or by telephone on 0345 045 1364. The inspections should focus on assessing whether projects are organized in a manner that ensures safety of all workers. 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 ministry should develop training for correctional officers on strategies to work constructively with Indigenous men in custody, similar to the Biidaaban Kwewok and Biidaaban Niniwok Beginnings for Indigenous Women and Men training. Hazard alerts should be distributed in a timely manner after a health and safety concern is made evident. 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. 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. The reviewers should work with the local health care team to identify gaps and find solutions. Use or continue to utilize neutral, descriptive language to describe young people who leave their place of residence without permission. 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. Funding for services provided to survivors that allows for the hiring and retention of skilled and experienced staff so that they are not required to rely on volunteers and fundraisers in order to provide services to survivors. In most cases, no further action is required, and the death can be registered as normal. The number of jurors generally ranges from 6 to 20. Review and improve training to housing support personnel on cultural competency, anti-Black racism, implicit bias, mental health and its intersectional nature. Recognition that, in remote and rural areas, funding cannot be the per-capita equivalent to funding in urban settings as this does not take into account rural realities, including that: economies of scale for urban settings supporting larger numbers of survivors, the need to travel to access and provide services where telephone and internet coverage is not available. 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). Specifically: increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. Continue to facilitate learning events related to the youth presenting with complex suicide needs and remain an active community participant in the Youth with Complex Suicide Needs (. incorporate the approach of minimizing the risk of hanging in the designing and planning of the bookshelves in all units. . The ministry should review and if necessary consider enhancing the mechanisms for ensuring that all staff receive their suicide awareness training in accordance with the timelines set out in policy. Require all police services to immediately inform the Chief Firearms Officer (, Create a Universal RMS records management system accessible by all police services (including federal, provincial, municipal, military and First Nations) in Ontario, with appropriate read/write access to all. 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. Regular meetings between mine emergency response team and. 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. Take all reasonable measures to ensure workers are educated, understand and avoid the hazard. All site supervisors are competent and aware of their duties and responsibilities. To support and promote cultural safety for First Nations children and young people, the, To address the mental health needs of children and young people, the. Held at:SudburyFrom: August 29To: September 2, 2022By: Dr. David Cameron, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Richard Raymond PigeauDate and time of death: October 20, 2015 at 12:06 p.m.Place of death:3259 Skead Road, Skead, ON, P0M 2Y0 1660 Level, 1660-021 RampCause of death:crush-type blunt force injuries to torsoBy what means:accident, The verdict was received on September 2, 2022Presiding officer's name: Dr. David Cameron(Original signed by presiding officer), Surname: GordonGiven name(s): JacobAge:24. Verdicts and Coroner's recommendations. 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. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. The study would, in part, inquire into the following: The process to identify relevant findings and for sharing those findings with other justice participants. In any new detention centre builds, consideration should be given in the design to allow for timely access for emergency personnel. These would keep Indigenous youth within their local community and connected to family, culture, and local supports. Funding to be provided on an annualized basis, with adequacy assessed and considered after the first three years. Implement regular reviews to ensure the accuracy and reliability of the information in the records management system available to officers. Where gaps exist, the ministry should explore and research means to increase actual programing at Detention and Correctional Centres: Analysis of data collection or research of Indigenous core or other programing should include identification of gaps, steps taken to resolve gaps, improvements and best practices; This analysis and research should be reported, maintained and disseminated to Ontario`s correctional Institutions, service providers and for use with consultation with First Nation, Metis and Inuit community; The ministry should consider evaluating and modifying their policies on allowing volunteers into the facility that have a criminal record. A list of the inquests scheduled for hearing in the Oxford Coroner's Court. 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. If the cause remains in doubt after a post mortem, an inquest will be held. coroner's jury, a group summoned from a district to assist a coroner in determining the cause of a person's death. 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. Ensure all health care providers, including nurses, physicians, psychiatrists, and psychologists, are trained on the revised Recovery Plan policy. Continue to follow the international Cyanide Management Code. Implement recommendation #35 from the Inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Consider engaging the private sector to assist in developing recruitment and retention strategies and provide current labour market data and analysis. That the sobering center meet the criteria for the designation of an alternate level of care by the Ministry of Health to permit paramedics to transport patients to the sobering center rather than an emergency room. Consider including conductive energy weapons training as part of the mandatory curriculum for police recruits at the Ontario Police College with a yearly re-certification. Follow a study to determine the scale and volume of increase that is necessary to address the shortage of beds in Thunder Bay for all communities that access Thunder Bay for services. Inquests are held at HM Coroner's Court in Woking. In consultation with civil society child rights experts and Indigenous rights experts, undertake a Child Rights Impact Assessment with respect to all proposed regulations made under and amendments to the. Enhance information and supports available to families of persons experiencing mental health crisis with respect to community-based options to support their loved ones. 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. Prohibiting the use of skid steers in reverse unless it is operationally necessary. 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. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. That the Thunder Bay Police Service Board consider creating a position of Deputy Chief, Indigenous Relations. Amend the Construction Regulations to include a mandatory requirement for training of Health and Safety Representatives who work on construction projects. . 42. This unique intersection of Blackness and lived experience of mental health issues must be specifically addressed in any training on use of force, de-escalation, and police interaction with such persons. Ensure that persons with lived experience from peer-run organizations are directly involved in the development and delivery of both mental health crisis and de-escalation training. Develop further therapeutic activity programming for youth that reflects a wide variety of interests. 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. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards. Inquests. 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. 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. Mandatory use of a signaller when operating a skid steer. Strengthen annual education for Crowns regarding applications for Dangerous and Long-term Offender designations in high-risk, Commission a comprehensive, independent, and evidence-based review of the mandatory charging framework employed in Ontario, with a view to assessing its effect on, Review and amend, where appropriate, standard language templates for bail and probation conditions in, plan for removal or surrender of firearms and the Possession and Acquisition License (, possibility of a "firearm free home" condition, past disregard for conditions as a risk factor, When evaluating the suitability of a prospective surety in. 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 funding model and approach to the child welfare service delivery model, including consideration of developing a prevention and reunification process that focuses on family preservation, family reunification, kinship preservation, family contact, assessment of child, youth and parent strengths and needs, parenting skills, home management and routine, infant care, and exploring and developing support networks. Improved supervision of high-risk perpetrators released on probation, including informed decision-making when applying or seeking to modify conditions that impact the survivors needs and safety. Indigenous people must be able to access spiritual rights as well as programs with regularity and without unreasonable delay. Consideration of the remoteness quotient used to calculate funding in other social services, such as education and policing. The Senior Coroner for this area is Patricia Harding. Ensure that health care transfer summaries are completed in compliance with provincial policies when inmates are transferred between institutions. Provide Indigenous-led cultural competency and cultural safety training to all officers.
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