The coroner’s inquest jury examining Rowan Stringer’s death made 49 recommendations to, among others, the federal government, as well as Ontario’s ministries, school boards and sports organizations.

Some of these recommendations, as outlined, have already been acted upon. Our mandate was to examine the remaining recommendations, and to provide our advice to government on how best to proceed. In order to do that, we established five themes: Surveillance; Prevention; Detection; Management; and Awareness. These align with the Harmonized Approach adopted by the Federal-Provincial/Territorial Working Group on Concussions in Sport. While there is some unavoidable overlap between themes, for the most part we were able to fit each of the coroner’s jury recommendations into one of the five themes, along with our proposed Actions for implementation.

What follows are our Committee’s recommended Actions, theme by theme, on how to prevent, mitigate and create awareness about concussion in amateur sport in Ontario. Taken together, they are a guide to implementing all of the remaining coroner’s jury recommendations.

For each theme, we indicate which of the jury recommendations are addressed. In addition, our Committee has chosen to propose a few additional Actions, the importance of which became clear to us in the course of doing our work. It is our hope that the government will consider these Actions carefully, and implement them all.

It is important to note that, by virtue of our mandate and Terms of Reference, this report and our recommended Actions focus on amateur sport. However, the Committee recognizes that the issues identified, and the potential solutions offered by these Actions, are much broader than amateur sport. It is our hope that these principles and Actions will be applied in a way that encourages the safe participation in all types of physical activity by all Ontarians.

Legislation (Action #1)

(Addresses Coroner recommendations #1, 3, 5, 12, 18, 20, 29, 30, 32, 37, and 48)

In the Verdict Explanation of the Rowan Stringer inquest jury’s recommendations, the presiding coroner, Dr. Louise McNaughton-Filion, explains that while PPM 158 was useful in promoting an awareness of concussions and the importance of having strategies to prevent, identify and manage them, the memorandum did not carry the force of law and did not apply to activities outside of public schools.

She states, "The jury appears to support the idea that a law would bring with it coverage of these areas missing in PPM 158, as well as a consistent approach and enforcement of the approach to concussion across the province.” Our Committee agreed wholeheartedly.

To this end, we are proposing legislation: Rowan’s Law. Since the impact of Rowan’s Law would cross all five themes, we have elected to list it separately, as an overarching recommended Action. Many of the other Actions which follow are enablers of Rowan’s Law — the "how", to be enacted in regulation or policy, that will make Rowan’s Law effective and practical.

Action #1

The Province of Ontario should enact legislation (“Rowan’s Law”) governing all organized amateur sport—public, private, school-based and non-school-based (including those delivered by not-for-profit or for-profit entities where there is a fee charged for participation) — in Ontario. This legislation would include, at a minimum, the following key components:

  1. Mandatory education, at least annually, and prior to the start of the season, for all athletes, parents/guardians of child/ youth athletes, educators/school staff, coaches and officials in concussion prevention, recognition and management.
  2. Mandatory immediate removal from play for assessment of any athlete who is suspected of having sustained a concussion. If the assessment by an appropriately trained individual confirms any signs or symptoms of concussion, the athlete may not return to play.
  3. If an athlete is removed from play for signs or symptoms of suspected concussion, a medical diagnosis by a physician or nurse practitioner must be obtained prior to return to play.
  4. The progressive return to learn and return to play process following concussion is guided by current evidence-based consensus guidelines [the Canadian Guideline on Concussion in Sport, the International Consensus Statement on Concussion in Sport, or equivalent], and overseen by an individual with the appropriate skill and expertise to implement this process.
  5. Codes of Conduct, as set out in Regulation, must be developed and utilized in all organized amateur sport activities in Ontario. These may be tailored to each sport, and to each type of participant (i.e., players, coaches, officials, organizers and parents/ guardians). The Code of Conduct must include a Zero Tolerance policy for dangerous behaviours which are considered high risk for causing concussions or head injuries. The relevant Code of Conduct must be provided to each participant and parent/ guardian, who must all sign the Code of Conduct as a condition of participating in the sport. This demonstration of commitment to a Code of Conduct must be renewed on a regular basis; and at a minimum, annually, prior to the start of the season.
  6. Mandatory collection of data on all incidents of suspected concussion on the field of play and/or removal from play for suspected concussion. These data would be provided as prescribed to the Ministry of Health and Long-Term Care to oversee the analysis and dissemination of this information to the public and to researchers, in order to evaluate the impact of measures taken to improve the safety of amateur sport in Ontario.
  7. Requirement that information about incidents of suspected concussion be shared (i) immediately with parents/ guardians (in the event of athletes under the age of 18), and (ii), with other sport delivery partners relevant to the athlete, with the consent of the athlete or their parent/guardian.
  8. Declaration of an annual “Rowan’s Law Day”, to fall on a consistent weekday between Labour Day and October 31st.

Theme #1 — Surveillance (Actions #2, 3 and 4)

(Addresses Coroner's jury recommendations #2, 11, 33 and 40)

It has been said that you can't manage what you can't measure, and this is as true of concussions as it is with anything else.

It became clear through the Committee’s work that we currently do not have a complete picture of concussion in Ontario. While we have some (likely incomplete) data on people diagnosed with concussion by their family physician or in an emergency department, we have no way of knowing how many suspected concussions occur, and the circumstances of these events.

Only through the proper collection and analysis of data can we assess the extent of the problem we are facing with respect to concussions, the degree to which the policies and programs we put in place are in fact being followed, and, the effectiveness of the measures being implemented.

Action #2

The Ministry of Health and Long-Term Care (MOHLTC) should create and disseminate a publicly-available report on a regular basis, and at least annually, on concussion incidence which includes data from the point of injury, primary care and the hospital sector, as well as self-reporting / survey data from the public. This report would include information about the nature, severity and circumstances of the injuries, such that the effectiveness of injury prevention measures can be assessed over time.

Action #3

All amateur sport delivery partners in Ontario must ensure the collection and reporting of data regarding the incidence of head injuries (including suspected concussion) and highrisk play, including, but not limited to, all incidents where a player was removed from play due to a suspected head injury, and where a player was expelled/suspended for violating the sport’s zero tolerance policy.

Action #4

Until superseded by legislation, the Ministry of Education should continue to evaluate and ensure compliance with PPM 158.

Theme #2 — Prevention (Actions #5 and 6)

(Addresses Coroner's jury recommendations #5, 6, 7, 20, 21, 22, 31, 33, 34)

The simple truth is, as long as people play sports, particularly certain kinds of sports, there are going to be times when they get hit in the head or the body.

There are going be times when they suffer concussions. There is no way to make any sport 100 percent concussion-proof without discouraging people from playing, and we have no intention of doing that. What we want to do is to ensure that reasonable measures are taken, by players and by others involved in the sports being played, to make those sports as safe as possible.

Some concussions can be prevented, through awareness and avoidance of high-risk hits, and by adopting a zero tolerance approach to behaviours which put athletes at risk. They can also be prevented through ensuring that the field of play — whether a rugby pitch, an ice rink, or a gymnasium — is in a safe condition.

Action #5

Codes of Conduct must be developed and utilized in all organized amateur sport activities in Ontario. These may be tailored to each sport, and to each type of participant (i.e., athletes, coaches, officials, organizers and parents/guardians). Each Code of Conduct must include, as a minimum:

  1. A commitment to fair play and respect for all participants and officials
  2. A commitment on the part of all to disclose honestly to coaches/trainers when an athlete is injured (including experiencing signs or symptoms of possible concussion), or when such injury is suspected in another athlete. This would include a commitment to participate in “check-ins” before and after each game and practice, to identify any injuries or concerns about every player’s well-being
  3. The adoption and enforcement of a Zero Tolerance policy by all amateur sport delivery partners in Ontario for prohibited head hits, high tackles and other dangerous behaviours which are considered high risk for causing concussions or head injuries. This should apply equally whether the action was intentional or unintentional.
  4. The organization with jurisdictional responsibility over a particular sport must determine the content of its own Zero Tolerance policy, and how the policy is enforced. However, as a minimum, a participant engaging in prohibited activities shall be expelled for the remainder of the game. If the infraction occurs in the last 25% of regulation playing time, the player should also be suspended for the next scheduled game. Each sport should also impose escalating penalties for repeat offenders.

Action #6

To ensure that the field of play is appropriate for safe play or practice:

  • Each sport should set standards regarding the condition of the playing surface, and make these standards publicly available
  • Venue owners must be accountable for ensuring that the field of play meets the established standards
  • Match officials and coaches must not allow play to occur if these standards are not met

Theme #3 — Detection (Actions #7 and 8)

(Addresses Coroner's jury recommendations #35, 36, 38 and 39)

One of the biggest challenges in dealing with concussions is identification – how do we know when a player is concussed?

Clearly, we need to have people on the sidelines, who know what they're looking for and know what to do if they see it, paying close attention to the athletes on the field of play.

Action # 7

All higher-risk sportsfootnote 2 teams should ideally have both a coach and an assistant coach, as well as an athletic trainer/therapist, present at all games and practices, and ideally there should be an assistant referee at all games.

At a minimum, for all higher-risk sportsfootnote 2, there must be at least one person present at all games and practices, in addition to the coach(es), who has specific training in First Aid, and in concussion identification and management [such as the Making Head Way course or equivalent, as determined by the organization responsible for the delivery of the sport] and who is responsible for observing participants for potential head injury and removing them from play. Ideally, this should be a neutral party.

Action #8

At a minimum, all coaches must complete annual training in concussion identification and management [such as the Making Head Way course or equivalent, as determined by the organization responsible for the delivery of the sport].

Theme #4 — Management (Actions #9, 10 and 11)

(Addresses Coroner's jury recommendations #8, 9, 16, 23, 24, 30, 37 and 41)

As previously noted, it is extremely important that we have data available to track the number of concussions that are occurring, and assess the manner in which we are responding.

This requires buy-in from athletes and their parents, who need to tell us, in effect, what happened and what they did.

Equally important, we need to ensure that when an athlete sustains a head injury in one sport or on one team (or even from a fall or motor vehicle collision), that this information is shared appropriately with those responsible for all sports in which the athlete is participating, so that their return to play can be coordinated. While this can be done in a manual way, this creates challenges in terms of the collection, sharing and reporting of accurate and timely data. Newer electronic solutions, such as apps and web-based products, may assist with this.

We also need to recognize that the requirement of a medical assessment after a potential concussion can represent an additional burden on health care providers; namely, physicians and nurse practitioners, who are the only medical professionals in Ontario permitted to diagnose or rule out a concussion. Ensuring that these professionals are appropriately compensated for the time necessary to complete and document such assessments, and to help guide the return to learn and return to play activities of athletes who sustain a concussion, is one way to support this best practice.

To support the communication between coaches, health professionals and educators, we need to use consistent tools and processes which ensure that the right information is captured, reported and shared.

Action #9

The Government of Ontario should invest in adapting, creating or acquiring an electronic solution, made available to all amateur athletes in Ontario, that supports:

  1. The acquisition of data regarding
    1. head injuries at the field of play; and
    2. concussion diagnosis and a return to learn/return to play plan
  2. Sharing of data with parents/guardians
  3. Sharing of data with other sport delivery partners relevant to the athlete, with the consent of the athlete or parent/guardian
  4. Reporting of anonymized data to the Ministry of Health and Long-Term Care for surveillance and reporting purposes

Such a solution should be provided at no cost to the end users, and be implemented consistently across the province to facilitate information sharing within one solution in all locations.

In the interim, until such an electronic solution exists, the Government of Ontario should implement a paper-based passport system aimed at achieving these key goals in a manual way to address existing gaps in terms of information capture and sharing. At the present time, it remains the responsibility of the athlete or their parent/guardian to communicate information about suspected or confirmed concussion to all sport delivery partners with which the athlete is involved.

Action #10

The Ministry of Health and Long-Term Care should introduce appropriate fee codes in the OHIP Schedule of Benefits for the initial assessment and ongoing management of patients with suspected and proven concussions. These codes should include the completion of all necessary documentation on return to play/return to learn, such that there is no charge to patients or their families for completion of these forms.

Action #11

The Ministry of Tourism, Culture and Sport should task the Coaches Association of Ontario with creating and regularly updating a “Coach’s Toolkit” with relevant tools and materials to support the use of consistent concussion protocols across all sport settings, aligned with the Canadian Guideline on Concussion in Sport.

This Toolkit should be based on the relevant components of the Ophea Ontario Physical Education Safety Guidelines, and be made available free of charge to all coaches in all sport settings in Ontario. The toolkit should be maintained in electronic format, to ensure that the most current information is readily available to coaches at all times.

The Ministry of Tourism, Culture and Sport should require the use of these materials in all amateur sport settings in Ontario (both school-based and non-school-based).

Theme #5 — Awareness (Actions #12 to 18)

(Addresses Coroner's jury recommendations #3, 14, 15, 18, 25, 26, 27, 29, 32, 42, 43, 44, 45, 47 and 48)

If we are to be successful in bringing about any kind of culture change when it comes to concussion in amateur sport, it will be through increasing awareness about, and increasing the level of knowledge around, head injuries and concussions.

Key to this will be a multi-faceted public awareness campaign aimed at ensuring that all Ontarians know about concussions, and what to do if they suspect that they, a friend, a child, or a teammate may have one. It is only through this approach that we will change—or, in some cases, start— the conversation about concussion in Ontario.

The proposed Rowan’s Law legislation will make it mandatory for any amateur athlete suspected of having a concussion to be assessed by a physician or nurse practitioner, who will either confirm or rule out the diagnosis, before they return to learn and play. If the diagnosis of concussion is made, the physician or nurse practitioner will play a role in the return to learn and return to play process. However, nurse practitioners and physicians in primary care, emergency, pediatrics and other specialities may not have the most up to date knowledge necessary to perform this function. Our Actions include ways to increase the capacity for such assessment and management to occur in the health sector.

Our Committee also recognized that there are other regulated health professionals (including physiotherapists, chiropractors, and even dentists) who may assess and treat athletes after they have sustained a concussion. These providers need to know how to recognize the signs of a possible concussion, so that they consider this possibility and refer appropriately to physicians and nurse practitioners to confirm or rule out the diagnosis.

In the same way, all of our educators, coaches and school staff need to have an awareness and knowledge of concussion, so that everyone is on the same page when educating and supervising our children.

Action #12

The Government of Ontario, as part of all teachers’ education training, should include exposure to basic coaching principles for all teacher candidates, as well as awareness about concussion prevention, detection and management.

Action #13

The Government of Ontario should re-brand the current Concussion Portal on the Ontario.ca website under the name “Rowan’s Law”. In doing so, the Government should engage expertise in branding and marketing to improve the public awareness and use of this site, and protect the integrity of the Rowan’s Law brand.

This site would be a repository for all tools, resources and links related to concussion awareness, prevention, detection, management, and surveillance, as well as personal stories such as Rowan’s. The Rowan’s Law resources can be created by multiple partners, who would be recognized for their work. In curating this site, the Government would be responsible for ensuring that the content is current, evidence-based, and available to all Ontarians. Ongoing efforts should be directed towards increasing awareness of this site among the general public, athletes and their families, coaches and educators.

Action #14

The Government of Ontario should commit to a net new investment in a sustained, multichannel, integrated marketing campaign to increase public awareness of concussion, and the Rowan’s Law brand, by people of all ages. Such a campaign should consider:

  • Messaging to encourage participation in sport and physical activity
  • Role models that resonate with different age groups
  • Catch phrases/messaging
  • Engagement of a diverse target audience (gender, culture, etc.)
  • Exploration of corporate partnerships
  • Use of personal stories (including Rowan’s)
  • Use of the Rowan’s Law logo on school athletic clothing and equipment

Action #15

Concussion education modules should be developed and/or adapted for primary, junior, intermediate and senior school students, and be branded under Rowan’s Law. These should be delivered annually, starting immediately, on or around Rowan’s Law Day.

Action #16

School boards should implement an annual concussion awareness learning education event for all Ontario school students, starting immediately, on or around Rowan’s Law Day.

Action #17

The Ministry of Education should work with Ophea to develop an e-learning module to review safety guidelines at the start of each school year. This would be a mandatory requirement for all teachers and administrators (similar to the Workplace Hazardous Materials Information System (WHMIS) and Offence Declaration currently).

Action #18

To enhance the level of knowledge regarding concussion detection, diagnosis and management by health care professionals:

  1. The Association of Faculties of Medicine of Canada (AFMC) should incorporate concussion awareness, diagnosis and management (as reflected in the Canadian Guideline on Concussion in Sport and the International Consensus Statement on Concussion in Sport, as updated from time to time) into the mandatory curriculum in all medical schools.
  2. The College of Family Physicians of Canada should incorporate concussion awareness, diagnosis and management (as reflected in the Canadian Guideline on Concussion in Sport and the International Consensus Statement on Concussion in Sport, as updated from time to time) into the mandatory curriculum for all Family Medicine residencies (with further emphasis as part of the curriculum for CCFP-EM and Sports Medicine programs).
  3. The Royal College of Physicians and Surgeons of Canada should incorporate concussion awareness, diagnosis and management (as reflected in the Canadian Guideline on Concussion in Sport and the International Consensus Statement on Concussion in Sport, as updated from time to time) into the mandatory curriculum for the following residency programs:
    • Emergency Medicine
    • Pediatrics
    • Pediatric Emergency Medicine Fellowship
    • Neurology
    • Neurosurgery
    • Physical Medicine and Rehabilitation
  4. The College of Family Physicians of Canada should develop accredited educational programs/modules on concussion awareness, diagnosis and management (as reflected in the Canadian Guideline on Concussion in Sport and the International Consensus Statement on Concussion in Sport, as updated from time to time).
  5. The nurse practitioner education programs in Ontario, in collaboration with the College of Nurses of Ontario, should incorporate concussion awareness, diagnosis and management (as reflected in the Canadian Guideline on Concussion in Sport and the International Consensus Statement on Concussion in Sport, as updated from time to time) into the mandatory curriculum for all nurse practitioners.
  6. For all other Regulated Health Professions, concussion awareness, detection and management (as reflected in the Canadian Guideline on Concussion in Sport and the International Consensus Statement on Concussion in Sport, as updated from time to time, including indications for referral for assessment by a physician or nurse practitioner) should be incorporated into all education curricula.

Additional actions

The Committee identified three additional overarching proposals aimed at promoting excellence in concussion awareness, prevention, detection, management and surveillance, for all amateur athletes in Ontario and across Canada.

Action #19

(Addresses Coroner’s jury recommendation #49)

The Committee is supportive of the work underway at the Federal/Provincial/ Territorial level towards achieving a national harmonized approach to concussion. It is recommended that the Federal government should play a leadership role in this area for sports that occur in both school and nonschool environments.

Action #20

The Committee recommends that the Governments of both Ontario and Canada work with First Nations leaders and stakeholders to strongly encourage and support the dissemination and implementation of these or similar Actions to achieve the goals of increased safe participation in amateur sport, and excellence in concussion awareness, prevention, detection, management and surveillance in all First Nations communities.

Action #21

The Government of Ontario should create a Rowan’s Law Concussion Partners Committee, comprised of key stakeholders from the sport, education, health, injury prevention and government sectors, to ensure that the momentum which began with the creation of the Rowan’s Law Advisory Committee is sustained. This Committee would ensure coordination, support implementation, and provide oversight to the maintenance of these initiatives. At least annually, the Committee would also meet with the Ministers responsible for Sport, Health and Education.

Footnotes

  • footnote[2] Back to paragraph "Higher-risk sports" in this context refers to those sports which have a greater potential for concussions to occur among participants, by virtue of person-to-person or person-to-equipment contact, and/or speed of action.