A list of the inquests scheduled for hearing in the Oxford Coroner's Court. Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. Continue ongoing quality assessments to drive continuous improvement of standard operating procedures and protocols, documentation, and best practices with mental health services: to review and audit core services within Windsor Regional Hospital annually to ensure compliance to standards are met and keeping pace with community demands proactively. 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. 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. Greater use of court-ordered language ensuring alleged and convicted offenders will not reside in homes that have firearms. The ministry should ensure that all correctional officers are trained regarding recognizing behaviour of Inmates that might pose a risk to the Inmate or others. 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. On the second day of an inquest at Dublin District Coroner's Court today, counsel for Mr Sweeney's family, Roger Murray SC, said the net effect of the patient being discharged from the high . Reinforce the policy requirement for a Part C health care summary to be completed in every patients health care record. 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. Consider providing cognitive behavioural therapy, and/or other evidence-informed clinical interventions, for inmates who may be at risk of suicide. When a worker experiences a medical issue in the workplace, the possibility that the medical event is due to a workplace hazard should always be considered. The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody. Roger and Bradley Stockton, from Crewe, crashed on the second lap of the sidecar race on . Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training. Increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. Provide additional guidance on how to assess the risk of ice on excavation walls. The ministry should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. The ministry should use the Indigenous led study to create and implement a policy on using Indigenous cultural practices as solutions to combating the opioid crisis at. This includes education of workers, availability and maintenance of rescue equipment (. Enhance procedures for increasing communication and service coordination contained within the signed protocol between child welfare services and the services provided by urban Indigenous agencies, including but not limited to: De dwa da dehs nye s (Aboriginal Health Centre), Hamilton Regional Indian Center, Niwasa Kedaaswin Teg, the Native Womens Centre and the Niagara Peninsula Aboriginal Area Management Board (, Continue to prioritize the Child Welfare Sector Commitments to Reconciliation by transparently sharing data (without personal information and in accordance with Part X of the. The. Older verdicts and recommendations, and responses to recommendations are available by request by: You can also access verdicts and recommendations usingWestlaw Canada. Revise the provincial Use of Force Model (2004) as soon as possible. The task force should focus these reviews on the most vulnerable patients, particularly those diagnosed with moderate to severe mental illness, especially schizophrenia and/or schizophrenia-related disorders. how to prevent heat stress and other heat related illnesses that may arise from working in high temperature conditions, and. Try to find out: the date the. Ensure existing policy and guidelines require probation officers to follow through on enforcement of non-compliance by requiring delivery and documentation of clear instructions regarding expectations to supervised offenders in a way that allows for direct and progressive enforcement decisions. 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 direct access to Naloxone spray for people in custody, including within locked cells. In addition, such education should be repeated quarterly. An inquest is not a trial and does not assign blame or liability. In jury inquests, the coroner directs the jury on matters of law and the jury decides the appropriate verdict . Consideration of the remoteness quotient used to calculate funding in other social services, such as education and policing. The ministry should engage with people with lived experience to develop enhanced supports for people in custody who witness a traumatic event. Construction projects should be planned and organized so that no cellular phones or similar cellular devices shall be used on the worksite except in case of an emergency or where use is restricted to occur inside of a designate structure, stationary vehicle, or other designated area away from any area in which construction work is occurring or ongoing. That the use of paper green sheets be discontinued, that the booking process and prisoner management systems be digitized, and that documentation used for charges in court be separated from the documentation used to manage and care for individuals in custody. For a young person in its program, engage with the guardian at the intake stage to set clear lines of responsibility regarding communication of information regarding the youth to those in the youths circle of care, including communication of self-harm attempts and leaving the property without permission. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current andprevious year. Constructors, employers and supervisors shall ensure that workers are not endangered by cell phone use on construction projects. The ministry should retrofit all units within. In addition to posting hazard alerts on the ministrys website, develop and implement a system of communication to distribute hazard alerts so that they are sent directly to constructors and employers. The ministry should consult with and receive expert advice on remedies to improve living conditions and healthcare delivery and implement any potential life saving strategies on an urgent basis. They contact the survivor to inform her of the offenders living situation, any conditions or limitations on his movement or activities, and what she should do in the event of a possible breach by the offender. The ministry should revise both health and, The ministry should consider contracting Elder positions in addition to. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. 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. Ensure that all safety plans are written down and shared with Lynwood staff, the young persons guardian, and other members of a young persons circle of care where appropriate and consistent with privacy legislation and rights. Coroner's court returns verdict of medical misadventure after inquest into death of Linda Connell (41) five days after minor surgery to remove ovarian cyst 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). (Note: this is included in both mining industry and Ministry of Labour section). Misadventure is where someone doing something lawful unintentionally kills another. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. Mandate that all police service officers receive annual implicit bias and cultural competency training to address stereotyping of Black people, and the existing research on anti-Black racism in policing. This includes: familiarity with the act and the regulations that apply to the work, ability to identify and address workplace hazards. Refresher training should be delivered annually. Implement recommendation #35 from the Inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. provide mandatory standardized training bi-annually on de-escalation strategies and empathy for community mental health-related situations. The Windsor Police Service shall ensure ongoing training pertaining to existing and new missing persons directives. Consider adopting Femicide as one of the categories for manner of death. 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. Provide Indigenous-led cultural competency and cultural safety training to all officers. At the end of an inquest, the Coroner will read out a formal verdict to record: the identity of the deceased; how the death happened ; . 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. The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model. That sufficient staff be hired and maintained to allow for constant visual monitoring of the living units and to adequately and immediately intervene in any circumstances of drugs or other contraband being found. 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. Consider adding the following recommendation to, With respect to elevating work platforms not in use: implementing the requirement of actively storing any operational access (, The Ministry of the Solicitor General (the ministry) shall replace Elgin Middlesex Detention Centre (, The ministry shall immediately assess the number of people in custody at. 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. As part of routine staff training, continue to train staff on the rights of children under relevant legislation, including privacy rights. In most cases, no further action is required, and the death can be registered as normal. Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system. It would also provide a primary point of communication for emergency response and medical personnel. This training should be designed and delivered by Indigenous people. The inquest will then be adjourned to be resumed at a later date. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. Continue working with the Ministry's partners to provide public awareness campaigns and educational materials relating to: Highlighting the dangers and risks associated with working in high temperatures, How workers should prepare themselves to safely work in high temperatures. Explore and research the availability and efficacy of additional less-lethal use of force options for officers. 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. The ministry should engage with Indigenous communities, organizations and health care providers in the development of corporate strategies, such as the Correctional Health Care Strategy and the Mental Health and Addictions Strategy for Corrections. Provide annual reports, accessible to the public, on ongoing research findings through the Chief Prevention Officer. The ministry should ensure that people in custody have access to a reliable means of initiating an emergency medical response. Held at: North YorkFrom:July 18To: July 18, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Metti YonanDate and time of death: November 28, 2014 at 12:40 p.m.Place of death:Sunnybrook Hospital, 2075 Bayview Avenue, North YorkCause of death:blunt force crushing injuries to the torso that caused extensive internal hemorrhageBy what means:accident, The verdict was received on July 18, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner). Details of upcoming Openings, Inquest Hearings, Pre-Inquest Reviews, Documentary Inquests and Adjournments. 4.1 It is recommended that employers, constructors, supervisors ensure that any hazard identified in risk assessments be relayed to workers together with the associated level of risk. arrives at St. Pancras Coroner's Court for a hearing into the singer's . 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. The Office of the Chief Coroner should consider conducting inquests within a timely manner, within 24 months from the incident date with the exception of extraordinary circumstances. Crowns should also consider a history of, Study the best approach for permitting disclosure of information about a perpetrators history of, Explore the implementation of electronic monitoring to enable the tracking of those charged or found guilty of an. 17 June 2022 . 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.
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