2020 coroner’s inquests’ verdicts and recommendations

Chronological listing of verdicts and recommendations

The Office of the Chief Coroner (OCC) for Ontario provides death investigations and inquests, when necessary, to ensure that no death is overlooked, concealed or ignored. The OCC use the findings to generate recommendations to help improve public safety and prevent future deaths in similar circumstances. The OCC distributes all verdicts and recommendations to organizations for them to implement, including:

• agencies
• associations
• government ministries
• other identified organizations may be identified in the recommendations

The OCC asks recipients to respond within six months to indicate if the recommendation(s) was implemented, and if not, the rationale for their position.

The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. Older verdicts and recommendations, and responses to recommendations are available by request by:

• e-mail: occ.inquiries@ontario.ca
• Tel: 1-877-991-9959

You can also access verdicts and recommendations using Westlaw Canada.

November

Gutierrez, Eulogio Clavel

Surname: Gutierrez
Given name(s): Eulogio Clavel
Age: 59

Held at: 189 Red River Road, Thunder Bay
From: November 16
To: November 19, 2020
By: Dr. Jennifer Tang
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Eulogio Clavel Gutierrez
Date and time of death: November 27, 2017
Place of death: Williams Mine, Hemlo, District of Thunder Bay
Cause of death: Multiple trauma after being struck by scoop tram mobile equipment
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on November 19, 2020
Coroner's name: Dr. Jennifer Tang
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Eulogio Clavel Gutierrez

Jury recommendations

To Williams Operating Corporation (WOC):

1. WOC to continue its plan for acquisition of new underground mobile equipment with blind spot cameras, with a goal of completion during 2021.
2. WOC​ to continue its plan for implementation of a proximity detection system with a goal of completion during 2021.

To WOC​ and Manroc Development Inc. (Manroc):

3. At the WOC​ mine site, WOC​ and Manroc, to present, at least once annually, in the course of Health and Safety Presentations to their respective employees on policies and proocedures:
   1. on pedestrian and mobile equipment underground traffic management (including blue light policy and procedure)
   2. how the specific policies and procedures, now in place, address the circumstances surrounding the accident involving Mr. Eulogio Gutierrez

To Ministry of Labour, Training and Skills Development (MOLTSD):

4. MOLTSD update its Information Bulletin "Vehicle/Mobile Equipment and Visibility Hazards in Mining Workplaces" (from December 2014).

To Workplace Safety North (WSN):

5. WSN update its publication "Pedestrian/Mobile Equipment and Visibility" (from 2012).

To MOLTSD (for reference to Mining Legislative Review Committee of Ontario):

6. Explore, evaluate, and consider, along with appropriate stakeholders, available research and provide industry best practice guidance as appropriate, regarding the use of mining safety technologies including proximity detector systems and visibility enhancing cameras for use in underground mining.

To WSN and MOLTSD (for reference to Mining Legislative Review Committee of Ontario)

7. Explore, evaluate, and consider, along with appropriate stakeholders, whether there are opportunities to develop coordinated health and safety systems, including training, at multi-employer mining sites.

Fancey, Joseph

Surname: Fancey
Given name(s): Joseph
Age: 32

Held at: 25 Morton Shulman Ave., Toronto
From: November 9
To: December 7, 2020
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Joseph Fancey
Date and time of death:  October 28, 2016 at  2:42 p.m.
Place of death: Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto
Cause of death: Blunt force trauma to the torso
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on December 7, 2020
Coroner's name: Dr. Geoffrey Bond
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Joseph Fancey

Jury recommendations

To Ministry of Labour, Training and Skills Development:

1. Mandate a standardized license to operate a skid-steer loader. The license should be valid for a set number of years, with a possibility of renewal.
2. Trainers must also be licensed to operate the skid-steer loader about which they are providing training.
3. Training for operators of skid-steer loaders should be provided in the primary language of the trainee, when possible.
4. Constructors should own/rent their own equipment as this provides a clear distinction of authority and responsibility over the equipment. Constructors can provide use of the skid-steer loader to any licenced person as per a written agreement.
5. Hazards and alerts related to safety around heavy equipment and/or specific to skid-steer loaders should be circulated to the construction industry. These hazards and alerts should be discussed at safety and toolbox talks.

To Infrastructure Health and Safety Association:

6. Manuals and documentation should be provided in the primary language of the workers if they are available from the manufacturer. They should be available by multiple means including hard copies and online.
7. Skid-steer loaders should be retrofitted with the cab door/gate/panel attached if it is available as an option. Moving forward, new skid-steer loaders should be manufactured with a door/gate/panel attached.

To Ministry of Labour, Training and Skills Development and the Infrastructure Health and Safety Association:

8. Explicit permission should be sought and given for every usage of a skid-steer loader.
9. During loading and unloading of trucks, an active spotter is required to aid in the movement of the truck as well as the act of loading and unloading. This can include the driver of the truck acting as a spotter and does not have to be a dedicated individual.
10. Each company should unload and load their own deliveries when using a skid-steer loader.
11. Every use of equipment requires that the user of the equipment must perform a full inspection, regardless of when it was last used by someone else, or when the user last used the equipment. This should be recorded and filed on site, and be a part of the documentation inspected by the ministry.

McLeod, Horatio Liam Christopher

Surname: McLeod
Given name(s): Horatio Liam Christopher
Age: 9

Held at: 3 Dixon Drive, Trenton
From: November 9
To: November 16, 2020
By: Dr. Louise McNaughton-Filion
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Horatio Liam Christopher McLeod
Date and time of death:  September 10th 2017 at 8:08 a.m.
Place of death: Children’s Hospital of Eastern Ontario
Cause of death: Chest and abdominal injuries due to off road vehicle collision
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on November 16, 2020
Coroner's name: Dr. Louise McNaughton-Filion
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Horatio Liam Christopher McLeod

Jury recommendations

To the Ministry of Education

1. The Ministry of Education, in consultation with Parachute Canada, should integrate off-road vehicle (ORV) safety into its current teaching of motor vehicle safety in elementary and secondary schools.

To the Ministry of Transportation, Ontario Federation of All-Terrain Vehicle Clubs, Canadian All-Terrain Vehicle Safety Institute, Canadian Quad Council, Canada Safety Council

2. The Ministry of Transportation, the Ontario Federation of All-Terrain Vehicle Clubs, The Canadian All-Terrain Vehicle Safety Institute, the Canadian Quad Council and the Canada Safety Council should work together to provide a mandatory standardized safety and training course for off-road vehicles which is approved by the provincial and federal governments, as well as the Canadian All-Terrain Safety Institute and the Canadian Quad Council. This course shall consist of both theoretical and practical hands-on learning for all youth and adults and must be completed successfully to receive an Off-Road Vehicle permit/licence/certificate of competency. Consideration should be given to renewing this on a regular basis (for example, every 3 years) and the efficacy of the training program should be reviewed and evaluated regularly to ensure that it is a current and effective training course.

To the Ministry of Transportation

3. The Ministry of Transportation should implement changes to the Off-Road Vehicles Act R.S.O. 1990, c. 0.4 and the Highway Traffic Act, R.S.O. 1990, c. H.8 as applicable, (modelled on Sean’s Law in Massachusetts) such that the minimum age to drive an off-road vehicle is 16 and applies to both public and private land. Off-road vehicle drivers should have, at a minimum, an ORV permit/licence/certificate of competency in addition to a G2/M2 driver’s licence. The changes to the legislation should provide for enforcement powers such that, if a child less than 16 is found to be riding an ORV, on public or private land or on a road, the ORV will be seized, and the owner and/or operator of the ORV shall, for a first offence be fined. Consideration should be given to enhanced penalties for repeated violations of these provisions.
4. The Off-Road Vehicles Act R.S.O. 1990, c. 0.4 and the Highway Traffic Act, R.S.O. 1990, c. H.8 should be amended to require that the operator and passenger of an off-road vehicle must wear a government-certified helmet, seatbelts where applicable, eye protection, and protective clothing and footwear at all times, whether they are off road or on road. The changes to the legislation should provide for fines for non-compliance with these provisions. Consideration should be given to enhanced penalties for repeated violations of these provisions.
5. The Off-Road Vehicles Act R.S.O. 1990, c. 0.4 and the Highway Traffic Act, R.S.O. 1990, c. H.8 should be amended to provide that the operator of an ORV must have a zero-percentage blood alcohol concentration, whether driving off-road or on road. Consideration should also be given to enhanced graduated penalties for repeated violations of these provisions.
6. The Off-Road Vehicles Act R.S.O. 1990, c. 0.4 and the Highway Traffic Act, R.S.O. 1990, c. H.8 should be amended to provide that children aged 14 and 15 can only operate an off-road vehicle on a closed course, should such courses become available, provided that:
   1. they are directly supervised by an adult (the adult is within immediate sight of the operator at all times)
   2. both adult and the operator have completed and passed an approved Off-Road Vehicle safety training course
   3. the operators are wearing a government-certified helmet, eye protection, protective clothing and footwear at all times
   4. they are operating an off-road vehicle that is fit for their age, size and capability (i.e. power-restricted and not able to exceed 30 km per hour)
   5. both a trained official and a trained first responder are present
7. The Off-Road Vehicles Act R.S.O. 1990, c. 0.4 and the Highway Traffic Act, R.S.O. 1990, c. H.8 should be amended to:
   1. prohibit operators of ORVs designed for single riders from carrying a passenger, whether off-road or on road, on public or private land.
   2. prohibit children under the age of 12 years from occupying the passenger’s seat of the ORV regardless if on-road or off-road, and regardless if public or private land; and,
   3. provide that no person less than 16 years of age may have a passenger on an ORV while driving on a roadway or off-road, on public or private land, even if the ORV is capable of carrying a passenger (unless that passenger is an adult with an approved permit/licence/certificate of competency).
   These changes to the legislation should provide for fines for non-compliance with these provisions. Consideration should be given to enhanced penalties for repeated violations of these provisions.
8. The Off-Road Vehicles Act R.S.O. 1990, c. 0.4 and the Highway Traffic Act, R.S.O. 1990, c. H.8 should be amended to permit a passenger on an off-road vehicle only in the following conditions:
   1. the operator has completed and passed an approved off-road vehicle safety training course, and has in their possession, a current and approved certificate as evidence of successful completion of this course
   2. the operator must be at least 16 years of age or older
   3. the passenger must wear a government-certified helmet, eye protection, protective clothing, and footwear, (as well as an appropriate seatbelt if a side by side vehicle) at all times.
   These changes to the legislation should provide for fines for non-compliance with these provisions. Consideration should be given to enhanced penalties for repeated violations of these provisions.
9. The Ministry of Transportation should require an off-road vehicle permit/licence/certificate of competency in order to purchase an ORV. This permit/licence/certificate of competence should require off-road vehicle safety training before being obtained. All ORVs should be registered in Ontario with the Ministry of Transportation, regardless of whether their intended use is on private or public land, or on a roadway.
10. Enforcement of safety related regulations should be done by “trail wardens” on the basis of an expansion of the “trail warden system” used in other provinces, such as Quebec. Trail wardens should be trained and given the ability to warn trail users and to issue offence notices in order to promote and maintain safety. Penalties should be graduated and include registered warnings and fines, up to the removal of an ORV permit or seizure of an ORV depending on the offence.
11. Police officers should maintain their authority to issue offence notices for violations of the Off-Road Vehicles Act and the Highway Traffic Act. All provincial and municipal police services should provide off-road vehicle safety training to police officers to aid in the enforcement of off-road vehicle safety legislation.
12. MTO should investigate, maintain statistics and publicly report on the number of instances in which drivers have been issued offence notices for driving under the age of 16, passengers under the age of 12, helmet, seat belt and safety equipment compliance.

To the MTO, Transport Canada

13. The Ministry of Transport and Transport Canada should work together, to ensure only licenced, registered off-road vehicles, built to industry standard, can be operated on public or private land. The Off-Road Vehicles Act R.S.O. 1990, c. 0.4 and the Highway Traffic Act, R.S.O. 1990, c. H.8 should be amended to require:
    1. a current safety check in order to register an off-road vehicle
    2. the operator who registers the ORV to have a valid ATV operator permit and either a G2 or M2 driver’s licence
    3. an easily visible tag or sticker showing a current licence/registration on the ORV. The proceeds from the sale of these stickers or tags should be used for regulatory enforcement, to develop safe ATV trails, and to promote driver and passenger safety initiatives
    These changes to the legislation should provide for fines for non-compliance with these provisions. Consideration should be given to enhanced penalties for repeated violations of these provisions.
14. Transport Canada should adopt Canadian Off Highway Vehicle Council (COHV), American National Standards Institute (ANSI), Safety Vehicle Institute of America and the Recreational Off Highway Vehicle Association standards for both all-terrain vehicles and utility-terrain vehicles, whether they are for off-road or on-road use. Only ORVs that meet these standards should be sold in Canada, no matter their size.
15. All advertising or marketing of off-road vehicles that is directed to children under the age of 16 years should be banned.

To COHV, ANSI, and Transport Canada

16. An annual national review of engineering and design standards for off-road vehicles should be conducted to address safety innovations, and to make recommendations for safety improvements in ORVs (for example, safe rollover protection, crush protection, tamper proof speed governors, safer seat designs, warning signals/engine disabler when seatbelts are not engaged in a side by side). Equipping ORVs with event data recorders should be considered to assist police in investigating ORV collisions.

To Ministry of Transport (MTO) and Ontario Federation of ATV Clubs, Parachute

17. The MTO and the Ontario Federation of ATV Clubs and Parachute should continue working together, in a coordinated manner with outreach to riders of all ages, regarding safety and training and to raise awareness that riding ORVs on any road is a high-risk activity and that most roadway crashes do not involve other vehicles.
18. The MTO should create the equivalent of the “Off-Road Vehicle Advisory Committee” to aid in establishing and enforcing regulation and legislation (as done in Massachusetts with ‘Sean’s Law’). Members must include those directly involved in drafting and enforcing legislation, safety organizations and relevant stakeholders, in order to make evidence based informed decisions, such as changes in legislation or enforcement. This committee could use the policy development cycle already in place at the Ministry of Transportation, but must have a legislative advisory arm. It should ensure new evidence informs legislation, training, and other regulation. This committee, in conjunction with the Ministry of Transportation, should measure and report the impact of safety initiatives implemented on off-road vehicle safety, and make these reports public.

To Insurance Board of Canada

19. Insurance companies in Canada should provide an off-road vehicle insurance rebate if the owner has successfully completed ORV safety training. The policy of insurance should require that all operators of the insured vehicle have a valid ORV rider permit and safety training.

To Ministry of Transportation, Canadian Institute for Health Information

20. The Ministry of Transportation and the Canadian Institute for Health Information should develop and promote an accurate and comprehensive tracking system, of both the number of registered off-road vehicles, ORV riders and the injuries and fatalities associated with ORV use, for children and youth, as well as adults. An analysis of risk factors (such as seatbelt use, helmet use, alcohol and drug use) would help to determine the best points of intervention to improve ORV safety and eliminate preventable injury and death from ORV use.

To The Royal College of Physicians and Surgeons of Canada, College of Family Physicians of Canada, all Canadian medical schools, all Canadian nursing schools, Parachute, Canadian Pediatric Society, Canadian Association of Emergency Physicians

21. These organizations should develop teaching tools regarding safe off-road vehicle use for primary care providers and emergency care providers to share with patients and their families, while also determining the best time and approach for providing this information. The information provided by physicians should reflect the needs of community particularly rural, northern or remote settings. These organizations should train future primary care providers and emergency care providers in safe ORV use in order to ensure they have a strong knowledge base for the care and education of their patients.

To the Ministry of Transportation, Transport Canada

22. The amendments to The Off-Road Vehicles Act R.S.O. 1990, c. 0.4 and the Highway Traffic Act, R.S.O. 1990, c. H.8, and any other legislative changes arising from the recommendations of the inquest into the death of Horatio McLeod shall be referred to as “Horatio’s Law” in memory of the tragic passing of Horatio McLeod.

To Canadian Off Highway Vehicle Council, American National Standards Institute, and Transport Canada

23. Until safety innovations and off-road vehicle standards demonstrate a reduction in off-road vehicle injuries/fatalities in adults due to their implementation, child and youth models of ORVs should not be sold.

To Transport Canada, all provincial and territorial Ministries of Transportation (or equivalent)

24. All provinces and territories should harmonize and pass effective off-road legislation, starting with the basic rule that only those age 16 or older may drive/ride an off-road vehicle, either on road or on public or private land. In communities where the ORV is the only mode of transportation, or is required for farming or other industry and those under the age of 16, due to this need, are required to use them for these tasks, there should be local training in ORV safety, and only those age 16 or older should drive/ride an ORV when it is for recreational use.

Nabico, Rui-Filipe

Surname: Nabico
Given name(s): Rui-Filipe
Age: 31

Held at: 25 Morton Shulman Avenue, Toronto
From: October 26
To: November 4, 2020
By: Dr. Bob Reddoch
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Rui-Filipe Nabico
Date and time of death:  November 4, 2016 at 12:59 p.m.
Place of death: St. Joseph's Health Centre, Toronto
Cause of death: Sudden arrhythmic death following deployment of an electronic control device in a man with cardiomyopathy and cocaine toxicity
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on November 4, 2020
Coroner's name: Dr. Bob Reddoch
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Rui-Filipe Nabico

Jury Recommendations

To the Ministry of the Solicitor General (the ministry):

1. The ministry should revise and renew the provincial Use of Force Model (2004) as soon as possible. In particular, the model should explicitly include an emphasis on de-escalation as a foundational principle.
2. The ministry should consider revising the provincial Use of Force Model (2004) to include conducted energy weapons (CEWs) and new technologies or equipment as they are implemented.
3. The ministry should consider revising the provincial Use of Force Model (2004) to include the category of "less lethal" to distinguish between the intermediate and lethal weapons.
4. The ministry should include non-police experts and professionals in the review and renewal of the provincial Use of Force Model.
5. The ministry should consider renaming the Use of Force Model in order to communicate that its purpose is to respond to critical situations without resort to the use of force.
6. The ministry should consider regularly mandated reviews of the Use of Force Model based on current research and statistical information to evaluate the model’s effectiveness.
7. The ministry should consider establishing a provincial database of use of force incidents and make the database available to police services and relevant non-policing experts and professionals and allow a means by which they could provide input.
8. The ministry should consider enhancing the provincial use of force reporting form to ensure that police officers record their efforts at de-escalation prior to the use of force, or their reasons for not engaging in de-escalation.
9. The ministry should consider regularly reviewing the minimum standards of training in the use of CEWs and enhanced emphasis on "judgement."
10. The ministry should expedite the implementation of body-worn cameras (BWCs) for police services which have purchased and arranged funding for BWC assets, including data storage, by funding deployment, training, and implementation for all front-line officers in Ontario in order to ensure the time required to equip officers with BWCs is not inhibited by daily operational needs.

To the Ministry of the Solicitor General and the Toronto Police Service (TPS):

11. The ministry and the TPS should advocate for additional research on the issue of whether persons in crisis or those who are intoxicated by stimulants, experiencing "excited delirium," or are obese are at increased risk of death arising from the deployment of CEWs.
12. The ministry and the TPS should incorporate the findings of the research-based evidence when training on the use of CEWs.

To the Toronto Police Service:

13. The TPS should implement the use of BWCs by front line police officers as soon as possible. Training on the use of BWCs should include instruction on the importance of such cameras for ensuring accountability and transparency, as well as improving public confidence in policing.
14. The TPS should continue to explore and consider enhancing the in-car camera system (ICCS) by adding side cameras on police vehicles.
15. The TPS should enhance instruction on alternatives to the traditional police challenge, to facilitate more effective communication with persons experiencing crisis.
16. The TPS should continue and enhance cross-training of officers by experts in the community (e.g., Indigenous peoples, marginalized and vulnerable populations, etc.).
17. The TPS should consider expanding physical control in the Use of Force Model and enhancing training of officers to include alternative tactics and distractions.
18. The TPS should include formal orientation to the neighbourhoods within their division for front line officers.
19. The TPS should enhance instruction on ICCS operation to explicitly include positioning of police vehicles to capture the best footage of a scene.
20. The TPS should consider including an accountability process to increase transparency with respect to use/misuse of the BWCs and ICCS.
21. The TPS should consider expanding the number of Mobile Crisis Intervention Team (MCIT) units and recruitment of persons with mental health training into and within police services.
22. The TPS should consider requiring front line officers to satisfy regular psychological evaluations.
23. The TPS should consider delivering real time dispatch information to the in-car computer screen to avoid having to "refresh" for updates.

October

Knox, Kyle

Surname: Knox
Given name(s): Kyle
Age: 24

Held at: 25 Morton Shulman Avenue, Toronto
From: October 26
To: October 29, 2020
By: Dr. Jennifer Tang
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Kyle Knox
Date and time of death:  October 11, 2011
Place of death: 4700 Keele Street, Toronto
Cause of death: Positional asphyxia
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on October 29, 2020
Coroner's name: Dr. Jennifer Tang
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Kyle Knox

Jury recommendations

To the Ministry of Labour:

1. Continue the process of consultation with all relevant stakeholders on equipment new to Ontario.

To the Ministry of Labour and Government of Ontario:

2. Hire additional inspectors to continue enforcing the Occupational Health and Safety Legislation.

Dumanski, Joshua

Surname: Dumanski
Given name(s): Joshua
Age: 30

Held at: Water Tower Inn, Sault Ste. Marie

From: October 19
To: October 22, 2020
By: Dr. D. Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Joshua Dumanski
Date and time of death:  July 16, 2018 at 8:45 a.m.
Place of death: Sault Area Hospital
Cause of death: Mixed toxicity of fentanyl and cocaine
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on October 22, 2020
Coroner's name: Dr. D. Eden
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Joshua Dumanski

Jury recommendations

To the Ministry of the Solicitor General:

We encourage the Algoma Treatment and Remand Center (ATRC) and the Ministry of Community Safety and Correctional Services to explore opportunities to prevent future inmate drug toxicity deaths by strategies including but not limited to:

Staff training

1. generate standardized checklist, specific to the ATRC, for cell checks to ensure all areas are being searched properly, guaranteeing consistency with all correctional officers
2. implement scenario based cell check training at ATRC
3. issue mandatory training for signs of intoxication and potential overdose to be refreshed annually and signed off for proof of training
4. provide continuous training of interpreting body scans with regular updates to incorporate new trends and techniques
5. re-evaluate training within the facility using formalized training development structure

Inmate education

6. offer training for inmates about safe drug use inside and outside of the facility, including but not limited to:
   1. buddy systems
   2. when to alert staff
   3. signs of overdose
   4. drug interactions
7. follow up with naloxone training if initially refused during intake

Inmate programs

8. health care case managers assigned directly to inmate to provide continuity of care
9. develop acute intervention programs to be readily available on the remand side of ATRC
10. more access to social workers on the remand side of ATRC
11. investigate ways to remove barriers that are preventing community social workers to collaborate with social workers inside ATRC for continuity of care

Night rounds

12. recommend changing some of the night rounds to an hour long “proof of life” check
    1. utilize flashlights to check for chest rises as required
    2. Consider entering cells when visibility is low or unable to properly verify “proof of life”
13. explore lighting options to ensure better visibility of inmates during night rounds to avoid night lights being covered
    1. investigate alternative lighting methods for night lights such as red lights

Drug sniffing dogs searches

14. implement more frequent drug sniffing dogs searches with minimal staff aware of search
15. search all areas of the facility, including staff areas
16. ninistry level coordination between policing services with Ministry of Community Safety and Correctional Services to ensure availability of drug sniffing dogs for searches

Body scans

17. mandatory and periodic training in the interpretation of body scans
18. recommend the ministry to develop a process for the collection of new trends and techniques inmates are using to bring contraband into the facility
    1. develop a process to disseminate the information to all facilities
19. the ministry should continuously monitor opportunities to purchase updated scanning equipment
20. ministry to establish central review hub to review all uncertainties in scans

Naloxone

21. ensure that all staff who directly interact with inmates are equipped with naloxone spray while on duty, including correction officers while conducting rounds

Cell searches

22. mandatory follow up with police services after drugs are found and confiscated
    1. knowledge of laced drugs
23. consider technology which can detect substances in small concentrations

Eid, Gilbert

Surname: Eid
Given name(s): Gilbert
Age: 44

Held at: 25 Morton Shulman Avenue, Toronto
From: October 19
To: October 22, 2020
By: Dr. Mara Goldstein
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Gilbert Eid
Date and time of death:  October 31, 2016  at 9:17 a.m.
Place of death: St. Michael's Hospital, Toronto
Cause of death: Compression asphyxia
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on October 22, 2020
Coroner's name: Dr. Mara Goldstein
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Gilbert Eid

Jury recommendations

To SMID Construction:

1. Provide, to all its supervisors, trenching and excavation training that is offered by or approved of  by the Infrastructue Health and Safety Association. Training to include division of responsibilty between construction company employees and engineers, in accordance with the Occupational Health and Safety Act, R.S.O. 1990, Part III - EXCAVATIONS.
2. A review of the company's health and safety procedures, by all members of the organization including employees and management, should take place and be documented on an annual basis, at minimum.
3. The use of Infrastructue Health and Safety Association Supervisor Log Book (RF008) be incorporated into site procedures, and be embedded into the company health and safety protocol.

Sury, Tomasz

Surname: Sury
Given name(s): Tomasz
Age: 35

Held at: 25 Morton Shulman Avenue, Toronto
From: October 13
To: October 21, 2020
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Tomasz Sury
Date and time of death:  December 30th, 2017, 1:51 a.m.
Place of death: St. Michael's Hospital, 30 Bond Street, Toronto
Cause of death: Gunshot wound to the chest
By what means: Homicide

(Original signed by: Foreperson)

The verdict was received on October 21, 2020
Coroner's name: Dr. Geoffrey Bond
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Tomasz Sury

Jury Recommendations

To the Ministry of the Solicitor General (SOLGEN):

1. The current use of force model taught at Ontario Police College (OPC) needs to have explicit emphasis placed on de-escalation techniques embedded within the model. This new model should be introduced as soon as practicable.
2. Consider the use of civilian experts on a more regular basis in OPC Basic Constable Training on the topics of de-escalation and communication.
3. Consider periodic mandated review of the use of force model based on current research and statistical information to evaluate the model's relevance and efficacy.
4. Consider the establishment of a province-wide use of force database for statistical analysis and evaluation of the use of force model.
5. Consider renaming the 'use of force model' to better reflect the range of tools and techniques available to officers at any given time.
6. Consider a mandated OPC refresher course for use of force instructors every two years.
7. Consider a review of individual police services' new officer training across Ontario to ensure consistent standards in application of the use of force model.
8. Consider incorporating the SMEAC (Situation/Mission/Execution/Administration/Communication) concept into Basic Constable Training.

To SOLGEN and the Peel Regional Police Service (PRPS):

9. Consider the circumstances of all police related inquests as training scenarios.

To the Peel Regional Police Service:

10. Consider incorporating the circumstances of the death of Tomasz Sury into a training scenario for a joint Peel Police Canine Unit and Tactical and Rescue Unit in-house training exercise, with feedback from instructors through debriefing following the exercise.
11. Consider regularly scheduled mandated training between PRPS Canine Unit and Tactical and Rescue Unit.
12. Train officers on communication and planning where inter-operational teams are deployed to search and apprehend a suspect, where the circumstances allow for it. Such planning/briefing should include a discussion on communication strategies if a suspect is located.
13. Standard operating procedures for search operations should include a pre-search briefing as time allows. This should include designation of a team lead and a communications lead.
14. Consider debriefing every event that requires a Special Investigations Unit (SIU) investigation when all matters have been formally concluded. This should include all parties involved in the incident and their supervisors.
15. Consider re-allocating more time to scenario-based training and de-escalation, during annual use of force certification.
16. Consider semi-annual training for all officers on de-escalation and communication.
17. Consider the general use of body cameras.

Pahulak, Miroslaw

Surname: Pahulak
Given name(s): Miroslaw
Age: 55

Held at: 25 Morton Shulman Avenue, Toronto
From: October 6
To: October 7, 2020
By: Dr. Mary Elizabeth Bourne
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Miroslaw Pahulak
Date and time of death:  March 15, 2018
Place of death: 279 Blackburn Blvd., Vaughan
Cause of death: Blunt force craniocerebral trauma due to fall
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on October 7, 2020
Coroner's name: Dr. Mary Elizabeth Bourne
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Miroslaw Pahulak

Jury recommendations

To the Ministry of Labour:

1. We recommend legislating mandatory risk assessment by the contractor/employee on a daily basis during the work project, with a focus on small work projects.
2. We recommend updating the General Hazard Awareness Training, to include an evaluation or test at the end of the training, and the training completion be tracked/recorded.
3. We recommend the Ministry of Labour continue to provide and enhance free safety courses.
4. We recommend after the Notice of Project is received, the Ministry of Labour provides a list of possible courses or certifications recommended for the workers.
5. We recommend the Ministry of Labour continues to educate constructors about the importance of ensuring workers have the necessary safety certifications for the work they are expected to do.

To the Ministry of Labour and Ministry of Municipal Affairs and Housing:

1. We recommend review of fines for failing to file notice of project/work permits to ensure they are updated to 2020 amounts, with a recommended minimum of $5,000.

To the Infrastructure Health and Safety Association:

1. Encourage a wide-spread, work-place safety marketing campaign with an added focus on veteran and smaller contractors.

DesGrosseilliers, Timothy

Surname: DesGrosseilliers
Given name(s): Timothy
Age: 52

Held at: 25 Morton Shulman Ave, Toronto
From: October 5
To: October 8, 2020
By: Dr. Robert Boyko
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Timothy DesGrosseilliers
Date and time of death:  September 8, 2017, 10:38 a.m.
Place of death: 55 St. George Street, Toronto
Cause of death: Blunt impact head trauma with hemoaspiration
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on October 8, 2020
Coroner's name: Dr. Robert Boyko​
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Timothy DesGrosseilliers​

Jury recommendations

To the Canadian Standards Association and the Ontario Ministry of Labour, Training and Skills Development:

1. Study the possibility of installing tower cranes with cameras so that the crane operator has access to video feed in order to see any workers or swampers when there is a blind spot.
2. Consider implementing a regulation which stipulates that all tower cranes must have an on-duty professionally sanctioned rigger who oversees and participates in every lift that occurs using that crane, and that this role must be said rigger's primary role on the job site.

To the Technical Standards and Safety Authority:

3. That as a component of continuing education, all EDM-A Elevator Mechanics receive refresher training in the rigging and hoisting of materials and that such refresher training potentially cover similar topics to the Infrastructure Health and Safety Association Hoisting and Rigging – Basic Safety Training and that further, an element of the refresher include a hands-on component.
4. With regards to the aforementioned training, that said training occur annually, with an emphasis on new industry trends and technologies.
5. Create a bulletin regarding the structural and safety requirements related to Machine Room-Less elevating devices and their installation.

To the Ontario College of Trades:

6. That the Elevating Devices Mechanic Apprenticeship Curriculum Standard reflect the necessary theoretical and hands-on training to ensure elevating devices mechanics are competent to engage in rigging and hoisting.
7. That the Elevating Devices Mechanic Apprentices Curriculum Standard be reviewed on a regular basis to ensure it is up to date with current industry standards and technologies.

To the College of Trades and the Technical Standards and Safety Authority:

8. That the College of Trades ensure that their curriculum reflect practical and hands-on training to prepare someone to engage in hoisting and rigging in the field.

To the National Elevator and Escalator Association:

9. Study the viability of and need for increased minimum staffing levels on all elevator installations, especially ones involving lifts.
10. Ensure that at least two fully accredited elevator mechanics (not apprentices) be present for elevator installations.

To the National Elevator and Escalator Association (NEEA) and the Ontario Contractors Association (OCA):

11. Study the practicality and value of adopting and sharing lift plans of elevators with their members, to facilitate easier installation of motors or other materials in a safe manner.
12. Ensure that, as new elevator technologies are introduced, NEEA and OCA collaborate to keep site supervisors appraised of the most up to date best building practices regarding said new technologies (especially with regards to machine room-less elevators).

To the Ontario General Contractors Association:

13. Consider a competency program for site superintendents working on construction sites of over 50 people (employees and sub-trades) to focus on communication, scheduling, human resources, health and safety, project management, and people leadership.
14. Further to a crane operator’s responsibility for lifting of loads, it is recommended that the industry seek more effective co-ordination between the crane operator’s swamper/rigger and other trades that are engaged in rigging and hoisting of their materials.

To the Canadian Society of Engineers:

15. Encourage engineers in the design and/or update of elevator shafts, to “engineer out” workplace hazards that could endanger elevator workers and others, especially in regards to the installation of new machine room-less elevator motors.

September

Elliott, Timothy Lloyd

Surname: Elliott
Given name(s): Timothy Lloyd
Age: 42

Held at: 189 Red River Road
From: September 28, 2020
To: October 1, 2020
By: Dr. Michael B. Wilson
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Timothy Lloyd Elliott
Date and time of death:  September 12, 2015 at 7:30 am
Place of death: Thunder Bay District Jail
Cause of death: Hanging
By what means: Suicide

(Original signed by: Foreperson)

The verdict was received on October 1, 2020
Coroner's name: Dr. Michael B. Wilson
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Timothy Lloyd Elliott

Jury recommendations

Regarding the new build:

1. The Ministry of the Solicitor General (the ministry) should continue advancing the plans for the new correctional institution in Thunder Bay that will replace the Thunder Bay District Jail (TBDJ). The ministry shall make best efforts to ensure that the new institution includes:
   1. more space, such as for inmate living, inmate programming, health care services, secured outdoor greenspace and staff duties
   2. increased access to computers for staff
   3. more privacy for meetings between inmates and health care staff, including at the admission and discharge area
2. In designing the new institution, the ministry should actively consider strategies to:
   1. ensure safe and effective nightshift tours
   2. reduce, as much as possible, potential suspension points in cells

Regarding staff shortages:

3. The ministry will continue, and where possible, enhance the local recruitment efforts to provide appropriate staffing levels at Thunder Bay Jail. This would include continuing to work with internal and external stakeholders for strategies and solutions regarding northern recruitment and continuing to utilize media campaigns to attract candidates.
4. The ministry should endeavour to secure more access to mental health services provided by psychiatrists or psychologists at TBDJ.

Regarding compliance with policies:

5. Work with educational providers to develop multiple platforms to deliver education and training programs on the safe use of hand-held masonry saws including online modules, face-to-face learning, mobile applications abbr title="et cetera">etc. Consider implementing mandatory regular reviews of safety knowledge to maintain employee qualifications.
   1. To ensure that cell lights are not covered and that there are no obstructions placed on the front of cell grills that could restrict officer view into the cell as set out in the TBDJ​ Standing Orders section 7.9.1.
   2. To ensure that during inmate counts, will provide direct observation as set out in the TBDJ​ Standing Orders section 5.32.
   3. That visual cell inspections are to be conducted as per TBDJ​ Standing Orders.

The memo will be reviewed with staff during morning “muster” meetings every day for 10 consecutive days and monthly thereafter.

New policy:

6. the management at Thunder Bay District Jail should consider following policy changes:
   1. that visual night inspection checks be done with flashlights by two officers within the day area
   2. when required use verbal communication if visibility of inmate is obscured
   3. any graffiti on cell walls or bunks during cell inspection should be cataloged and when necessary should be sent to a mental health nurse on site for timely review

Training:

7. The ministry should continue providing suicide prevention and awareness training during orientation at the Correctional Officer Training Centre and at regular refresher intervals.

Electronic medical records:

8. The ministry should consider implementing an electronic medical record system.

Lalonde, Mark

Surname: Lalonde
Given name(s): Mark
Age: 38

Held at: 25 Morton Shulman Ave, Toronto
From: September 14
To: September 16, 2020
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Mark Lalonde
Date and time of death:  August 1, 2017 at 9:51 a.m
Place of death: 251 Cookson Bay Crescent, Huntsville
Cause of death: Sharp force injury to the neck
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on September 16, 2020
Coroner's name: Dr. Geoffrey Bond
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Mark Lalonde

Jury recommendations

To the Ontario Ministry of Labour, Training and Skills Development (MLTSD):

1. Amend the Construction Regulations to include provisions to protect workers from the hazard of kickback in hand held masonry saws (also known as quick cut saws), including:
   1. A requirement that all hand-held masonry saws must be equipped with a kickback brake or a fixed guard that prevents use of the kickback zone. The MLTSD should consider a “grandfathering” clause for saws currently on the market and/or an extended notice period to allow time for employers and manufacturers to prepare for the new regulations.
   2. A provision stating that no worker shall use a hand-held masonry saw unless he or she has been adequately trained in its use. This should include a specific requirement for training on the hazards of kickback and methods of avoiding kickback
2. Amend the Construction Regulations or Occupational Health and Safety Act to include a requirement for mandatory training of all supervisors on construction projects about their duties to identify and eliminate hazards at the workplace. This should be over and above basic occupational health and safety awareness training. This training should instruct supervisors on incorporating safety into daily duties such as environmental and equipment scans. Training should also highlight the importance of hazard identification and rectification, supervisory monitoring, enforcing health and safety rules, and include skills training on how to manage and instruct workers.
3. Develop and publish a hazard alert explaining:
   1. the hazards involved in the use of handheld masonry saws
   2. how to protect workers from kickback
   3. where to find additional safety and training resources
4. Conduct a comprehensive review of all workplace injuries from hand held masonry saws that MLTSD has investigated since 2010.The review should include the suspected causes of those injuries. Provide the results of this review to:
   1. Chief Prevention Officer
   2. Infrastructure Health and Safety Association
   3. relevant section 21 committee(s)
   4. manufacturers of hand-held masonry saws
   5. Canadian Standards Association
   6. the general public
5. Consult with manufacturers of hand-held masonry saws to ensure they are aware of the hazards and are encouraged to develop products that better protect workers from kickback.
6. Work with educational providers to develop multiple platforms to deliver education and training programs on the safe use of hand-held masonry saws including online modules, face-to-face learning, mobile applications abbr title="et cetera">etc. Consider implementing mandatory regular reviews of safety knowledge to maintain employee qualifications.

To the Ontario Ministry of Labour, Training and Skills Development and Infrastructure Health and Safety Association

7. Conduct a comprehensive review of current strategies for engaging with owners of small construction companies and their employees. Develop and implement more effective strategies to ensure that these companies and workers:
   1. are aware of their legal obligations and rights under the Occupational Health and Safety Act and Construction Regulations
   2. have access to resources to help identify and eliminate hazards at their workplaces
   3. have access to training resources to protect health and safety of workers
   4. have opportunities to provide input on engagement and implementation strategies.

To the Government of Ontario

8. Develop an incentive program in collaboration with manufacturers to facilitate the wider adoption by the construction industry of hand-held masonry saws equipped with a kick back brake or a fixed guard.

March

Deleary, Floyd Sinclair and Thompson, Justin William

Names of the deceased: Deleary, Floyd Sinclair; Thompson, Justin William
Held at: 6675 Burtwistle Lane, London
From: February 24, 2020
To: March 16, 2020
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Deleary
Given name(s): Floyd Sinclair
Age: 39

Date and time of death:  August 23, 2015 at 8:46 p.m.
Place of death: Victoria Hospital, 800 Commissioners Rd E, London
Cause of death: Acute fentanyl toxicity
By what means: Undetermined

Surname: Thompson
Given name(s): Justin William
Age: 27

Date and time of death:  October 31, 2016 at 7:59 a.m.
Place of death: Victoria Hospital, 800 Commissioners Road East, London
Cause of death: Acute fentanyl toxicity and cocaine toxicity
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on March 16, 2020
Coroner's name: Dr. David Eden​
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the deaths of: Floyd Sinclair Deleary and Justin William Thompson

Jury recommendations

To the Ministry of the Solicitor General

1. The Ministry of the Solicitor General (the ministry) should consider replacing Elgin-Middlesex Detention Centre (EMDC) with a new, modern facility designed to adequately accommodate, with dignity, the inmate population and to provide an environment with suitable space in which inmates may achieve rehabilitation and reintegration through training, treatment and services designed to afford them opportunities for successful personal and social adjustment in the community.
2. The ministry should include with the planning of a new facility an infirmary within the new institution. The ministry should consider implementation of the direct observation model currently established in Unit 4 in all other general population units at EMDC with consideration to improving audio monitoring capabilities in the correctional officer module within the unit.
3. The ministry should continue to explore the installation of electronic devices capable of monitoring vital signs and alerting staff and healthcare personnel when inmates' vital signs indicate medical distress.
4. The ministry should continuously monitor opportunities to purchase updated scanning equipment.
5. The ministry should ensure that all staff who may be required to initiate a medical alert be equipped with functioning radios.
6. The ministry should consider installing over-head netting above the outside yard area to prevent contraband from being dropped into the yard
7. The ministry should amend ministry policy and EMDC standing orders to require that correctional staff conduct security checks more than twice per hour and at irregular intervals.
8. The ministry should amend Ministry policy and EMDC standing orders to require that correctional staff, during their security checks, also scan the floor areas and remove all sources of contraband substances.
9. The ministry should ensure that correctional and health care staff at EMDC sign off on having reviewed new policies, procedures and standing orders.
10. In order to ensure compliance with written policies regarding security checks, inmate supervision, cell searches and other security and safety requirements, the Ministry should ensure that regular audits, including review of video recordings, be undertaken on a regular and frequent basis by senior institutional staff at EMDC, with appropriate follow-up for corrective action. Quarterly reports will be sent to the ministry.
11. In order to detect high-risk situations that may involve the presence or use of contraband, the Ministry should evaluate the feasibility of upgrading video monitoring capability within EMDC to reflect more modern and comprehensive coverage, including: Real-time active monitoring of all living units by trained personnel, improved monitors with high resolution at all staff stations and in a central monitoring location, and capability of equipment and training of staff to isolate or zoom in on areas where activity is detected that may involve the transfer of contraband.
12. In order to reduce the risk of contraband entering EMDC, the ministry should consider ways of preventing staff and other visitors from bringing in contraband, including limiting staff from bringing anything but approved items into the secure areas of the institution. Random searches of staff and others should also be considered where necessary and in compliance with applicable law. A standing policy is to be implemented for staff to address all activities directly and/or indirectly related to smoking on the living units.

Health Care Equivalency

14. The ministry should review all operational policies and procedures to ensure adherence to the principle of equivalency (entitling people in detention to have access to a standard of healthcare equivalent to that available outside prison and conforming to professionally accepted standards).
15. The ministry should conduct an assessment with respect to the health care needs of the inmate population to ensure that there is adequate physician and nursing staff to meet those needs. The ministry should increase the complement of full time physicians, nurse practitioners, and registered nurses in accordance with the needs assessment.
16. The ministry should abandon zero-tolerance policy with respect to drug use, recognizing that such policies stigmatize and punish people for behaviours that stem from underlying medical issues.
17. The ministry should take a non-punitive, harm reduction approach to the treatment of inmates who misuse substances. Stabilization and harm reduction opportunities for inmates who misuse substances should be the first approach in providing health care and rehabilitation. Substance misuse should be recognized as a chronic relapsing illness where relapse is common. Alternatives should be available to those who are not able to achieve abstinence.

Admission

18. The ministry should implement an enhanced admission screening form for individuals who disclose the use of street drugs during the admission process. This form will require an admissions nurse to identify: type(s) of drugs used; frequency of use; dosage; means of administration; number of consecutive days used prior to incarceration; and other information. This is to be used together with other assessment tools to determine a health care plan for the patient including suitability for suboxone, methadone, or slow release oral morphine.
19. The ministry will consult with the ministry of Health to ensure that no patient in custody is denied health care on the basis that they do not have immediate accesss to their health card.
20. The ministry will approve the present addiction nurse pilot project at EMDC as a full time program with access for individuals seven days per week with administrative support five days per week.

Opioid Agonist Therapy (OAT)

21. The ministry should ensure that all people in detention who meet criteria for evidence-based OAT (including methadone, Suboxone, and slow release oral morphine) and who consent to receiving treatment are offered, and have access to, opioid agonist therapy without delay.

Offer OAT to all who meet criteria

22. The ministry should ensure that all people receiving OAT in the community are able to continue, without interruption, an appropriate OAT upon admission to detention.
23. The ministry should connect anyone receiving OAT in detention to community-based addiction treatment to ensure uninterrupted continuity of care on release. Preparations for this transition should be started well before the release when possible date so all partners are aware and the transition is seamless.
24. The ministry should encourage all physicians and care teams practicing at correction facilities to have or to obtain the necessary qualifications to prescribe OAT medications. A detained person who is who is eligible for OAT should not be denied treatment on the basis that there is a lack of credentialed staff.
25. The ministry should update its policies concerning methadone maintenance treatment (MMT) and suboxone to ensure conformity with best practices, including:
    1. to prefer initiation of suboxone over methadone as a first-line therapy, where a patient meets clinical criteria for initiation of suboxone
    2. include slow-release oral morphine as a third line therapy option
    3. to confirm that withdrawal management from opioids should never be offered as a first-line therapy
    4. to reflect recent regulatory changes that now allow all physicians to prescribe MMT without a federal exemption under the Controlled Drugs and Substances Act
    5. while identifying a community OAT prescriber to assume care of a patient upon release remains a priority, OAT initiation should not be contingent on first identifying a community OAT prescriber (in which cases it will be necessary to work to align the patient with community treatment program after OAT initiation)
    6. to confirm that patients are never to be disqualified from OAT for behavioural management or as a disciplinary tool, or for security reasons, and continually evaluate and update these policies in consideration of evolving realities, research and practices
26. The ministry should update policy to allow and encourage incoming inmates who meet the clinical criteria to be initiated on Suboxone immediately (within 24 hours) of admission, and that treatment should not be delayed on the basis that a physician assessment is unavailable.
27. The ministry should update policy and standing orders to encourage the introduction of suboxone to persons in detention who have already gone through withdrawal (micro-dosing). Guidelines around this should be developed in consultation with experts who are currently using this approach.
28. The ministry should ensure that any treatment for substance misuse such as Suboxone or Methadone should be delivered in conjunction with mental health treatment, counseling, and education pertaining to the risks of continued drug use.  There should be on-going reassessments and continued attempts at enrolling individuals into counseling, Methadone or Suboxone treatment. Close monitoring to detect early relapse should be a part of the reassessment process

Naloxone

29. The ministry should take steps to ensure that naloxone is available within 30 seconds to inmates while they are locked in their cells or in common areas, for instance by putting kits in common areas.
30. The ministry should ensure that all staff who directly interact with inmates are equipped with naloxone spray while on duty, including corrections officers while conducting rounds.
31. The ministry should require corrections officers to immediately administer Naloxone to any person who is suspected of an opioid overdose, in addition to taking other appropriate emergency response measures.

Harm reduction strategies

32. The ministry should study whether harm reduction strategies similar to those used at supervised consumption sites can be incorporated within the EMDC. This includes strategies such as making fentanyl testing kits and sterile consumption equipment available in the health care unit.

Good Samaritan rules

33. The ministry should adopt “Good Samaritan” principles in operational policies and practices, such that inmates who call for help or try to help another person suspected of being in medical distress, or who come forward with information about drugs within the institution, will not be subjected to any investigation or misconduct for possession or use of contraband.

Staff training

34. The ministry should consult with public health and community organizations regarding the opioid information training program and receive recommendations on changes or improvements to the program. This program should be evaluated and re-reviewed every two years at a minimum.
35. The ministry should deliver opioid information training for staff, including:
    1. information regarding opioids (kinds of opioids, appearance, potency, abbr title="et cetera">etc.), as well as non-opioid drugs
    2. recognizing signs and symptoms of overdose from opioids and other drugs
    3. how to respond to overdose, including hands-on demonstration of Naloxone, information about dosing, first aid / CPR response, and need to call for immediate medical help
36. The ministry should ensure that opioid information training be included in two-year first aid recertification. There should be additional training in regards to cultural sensitivity training and dealing with all types of challenging face to face encounters with other staff and incarcerated individuals.
37. The ministry should ensure that opioid information training be delivered jointly and cooperatively with health care and correctional staff. This training should include information concerning the social and historical context surrounding substance misuse, and the need for compassion and empathy for persons who experience substance use disorder.

Opioid training and information and support for inmates

38. The ministry should provide information to incoming inmates (by a health care practitioner), during the admission process and during subsequent consults, regarding: recognizing signs of drug overdose and what to do in the event of a suspected overdose or other medical distress situation; the Good Samaritan rule; information about OAT availability and options; harm reduction information for people who may access and use drugs; and information about rights to health care, health care privacy and consent.
39. The ministry should ensure that all staff and all inmates receive education on substances that may be in use at EMDC. Methods of education can be in group or one-on-one settings. Education should be completed on an on-going basis and should include updates on new substances. This education should be supplemented through printed material, video or multimedia, and should include information about the risks of:
    1. ongoing use of toxic opioids which exist throughout the drug supply, including risks, potency, effects, and other information
    2. what is loss of tolerance and what are the impacts of lost tolerance
    3. safe drug use practices, including the need to never inject/smoke or ingest substances or drugs alone
    4. the risk of simultaneously using other illicit drugs such as benzodiazepines and how to prevent complications
    5. recognizing signs of overdose and what to do in the event of a suspected overdose or other medical distress situation
40. The ministry should disseminate public health information by broadcast over TVs, posters throughout the institution, information cards or brochures distributed to every incoming inmate at intake, and/or other means.
41. The ministry should authorize and support peer health and support services for inmates who use drugs, including from community-based prison health organizations.

Monitoring and evaluation

42. The ministry should require correctional institutions to record, track and report annually to the Solicitor General:
    1. the number of suspected overdoses, and the general circumstances (including date, time, unit, and outcome)
    2. doses of Naloxone administered, including the date, time, location, and discipline who gave the drug
    3. other information relevant to tracking suspected overdoses, and results of interventions in response to overdoses
43. The ministry should centralize data collection of deaths in custody and publicly post all inquest verdicts, verdict explanations, and ministry responses to allow for appropriate trend analysis and follow up regarding the implementation of coroner's inquest jury and other relevant recommendations.
44. The Office of the Chief Coroner, in consultation with the ministry of the Solicitor General and interested persons, should compile and regularly update a summary of recommendations and responses from jail inquests. This summary should be designed to inform Coroner’s Counsel and the parties, and possibly to be admitted into evidence.

Cultural change

45. The ministry should institute a task force aimed at “transforming the culture of corrections,” in consultation with community health organizations, present and former in-mates, and other stakeholders. This will be aimed at identifying how the health care needs of people in prison can be met, applying an evidence-based analysis to security policies and practices, and identifying whether certain non-evidence-based security policies or practices may cause more harm than good for the well-being of the prison population, and identifying strategies for cultural transformation. To help facilitate this cultural change, EMDC will adopt a policy to stop using words, such as parade, welfare cell, in-mates, and offenders.

Electronic records

46. The ministry should implement an electronic health record system to: facilitate continuity of care through improved communications among professionals and enable safe clinical decision making; improve the ability to monitor health status, including substance use disorders and outcomes over time; enhance appropriate utilization of services, including health-related programs; collect data for future resource program planning, research or education; conduct quality of care reviews.

Supports for Indigenous people

47. The ministry should ensure that each institution: develops Indigenous specific programming which reflect the local Indigenous communities and agencies surrounding the institution; provides Indigenous inmates with access to Indigenous healing practices including Knowledge Keepers and Elders.
48. The ministry should ensure that Native Inmate Liaison Officer (NILO)/Indigenous Liaison Officer (ILO) services are adequately resourced and funded to meet the needs of Indigenous people. Indigenous people should be able to access spiritual rights as well as programs with regularity and without unreasonable delay. Specifically:
    1. The ministry should ensure that all NILO/ILO positions are adequate funded and strive to achieve more equitable compensation so that they can recruit, retain and keep NILO/ILO staff in full time, permanent positions
    2. The ministry should create policy and direction that recognizes the role and function of NILO/ILO staff as central to the delivery of Indigenous spiritual, cultural access and for health and wellness
    3. The ministry should consider increasing NILO/ILO staff at each Institution to meet the needs and services of the Indigenous inmate population, so that programing for Indigenous inmates is, at minimum representative of the needs or recognizes the number of Indigenous inmates in each institute
    4. Spiritual Elders, knowledge keepers and helpers should be provided honoraria or some form of financial compensation for the important work they are conducting as part facilitating inmates' access to their spiritual rights or as part of culturally relevant programing, and that the ministry should revise both health and NILO/ILO policy to recognize cultural and spiritual support as a fundamental healthcare right to all
    5. The ministry should engage in community consultation on the development of Indigenous core programing with Indigenous leadership including First Nation, Metis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres
49. The ministry should analyse the data they collect to determine where there are gaps in service delivery of programs at particular institutions. Where gaps exist, the ministry should explore and research means to increase actual programing at Detention and Correctional Centres:
    1. 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.
    2. 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.
    3. The ministry should consider evaluating and modifying their policies on allowing volunteers into the facility that have a criminal record. Specifically they should consider the length or passage of time since a volunteer had any criminal convictions and the nature of the criminal conviction to determine criteria that would increase Indigenous volunteers’ participation in Indigenous programing and to provide peer resources in an effective way.
50. EMDC should report to the ministry on any steps or progress being taken at EMDC to implement a medicine garden, sweat lodge and tipi. The ministry should research and report on, with a mind to exploring the development of programs and facilities with Indigenous community consultation on the health and wellness benefits of similar Indigenous practice and resources.
51. The ministry should ensure cooperation between NILO/ILO and addiction and mental health nurses with respect to discharge and community reintegration. The NILO/ILO team should be seen as crucial members for integrated assessment, treatment and reintegration plans for any self-identifying Indigenous person.

Other rehabilitation supports

52. The ministry should ensure that EMDC has sufficient space to permit private interactions between inmates and nurses, including addiction and mental health nurses, social workers and counsellors.
53. The ministry should ensure that inmates have reasonable phone access, including a phone system that permits calls to cellular phones to validate numbers.
54. The ministry should take immediate steps to improve opportunities for inmates to access recreation and exercise facilities and programs.

Training

55. The ministry should implement training to communicate that staff at EMDC are expected to conduct security checks in lock up or lock down situations more than two times per hour and at intervals of less than 30 minutes. This training should include specific direction on what is required to verify an inmate’s well-being.
56. The ministry should establish and communicate an expectation for ensuring security checks are being complied with at EMDC. This would include regular audits of the Brooklyn Computer System data, logbooks, and video footage of inmate occupied areas to ensure compliance by the EMDC compliance officer.
57. The ministry should ensure that EMDC enforces the standing order governing shift changes to ensure that both the outgoing and incoming Correctional Officers assigned to a unit conduct shift change tours together.
58. The ministry should enforce the standing order governing security checks to ensure that the outside officer maintains direct observation of inside officer(s) for the entirety of the security check.
59. The ministry should ensure that Correctional Officers who find an inmate in distress discontinue their security round until a medical alert is initiated.
60. The ministry should implement recurring ethics training for both correctional and health care staff at EMDC.
61. The ministry should implement training that would emphasize that one of the principal functions of the Ministry is to create for inmates an environment in which they may achieve rehabilitation and reintegration in the community.
62. The ministry should implement regular scenario based training at EMDC to permit correctional and health care staff to practice responses to medical alerts.
63. The ministry should implement enhanced training at EMDC with respect to the use of the body scanner.

Staffing

64. The ministry should implement the Institutional Security Team Pilot Project as a permanent initiative.
65. The ministry should ensure the deployment of correctional staff dedicated to the movement of inmates at EMDC is sufficient to permit reasonable access to programs.
66. The ministry should ensure that there is sufficient staffing levels at EMDC to allow for at least one correctional officer to be available to supervise each and every unit housing inmates at all times.
67. In order to provide a safe environment and deliver services in which inmates may achieve successful rehabilitation and reintegration, the ministry should develop and adopt measures and plans, including contingency plans, to ensure that EMDC is fully staffed at all times.
68. The ministry should adopt measures to address absenteeism at EMDC to prevent to inmate lockdowns and disruption of the delivery of programs.
69. In order to improve rapport and enhance information sharing between inmates and correctional staff and to more effectively assist keeping inmates safe and providing an environment for successful rehabilitation, the ministry should review current staffing procedures at EMDC and, where feasible, offer extended assignments to specific living units.

Procedures following a critical incident

70. In order to support correctional and healthcare staff following a critical incident at EMDC, including drug overdoses, the ministry should ensure that all parties involved be convened, in a timely manner, to review all aspects of the incident with a view to improving procedures and to make recommendations in regard to future events.
71. In order to support mental health of inmates who may have witnessed a critical incident, the ministry should ensure that critical incident debriefing and assistance in dealing with the related trauma should be offered and provided to affected inmates immediately following any critical incident.
72. The ministry will follow-up as soon as a coroner's report is finalized with the staff involved with the critical incident and are still emplolyed to confirm the cause of death.

Other recommendations specific to EMDC

73. Implement a policy for the "Red Bag" for the male population. When an individual is going to court and is released from court, prior to going, a staff person should prepare a bag with personal belongings, discharge documents, continuing care contacts, and a bus ticket. The staff accompanying the individual to court will have this bag.
74. Review times for when medications are distributed on the living units, especially in regards to the  timing of sleeping pills.
75. EMDC will review medical dispensing systems at other institutions and move towards upgrading the current system at EMDC to a more efficient, less labour intensive process.
76. EMDC will enact a policy that requires Correctional Officers on the night shift at times when cells are poorly lit to utilize flashlights when conducting security checks.
77. EMDC will implement safe and effective barriers to mitigate the risk of fishing between cells on the units at EMDC.
78. On an ongoing basis, the EMDC should consult with experts in order to keep current on recent developments with respect to new or evolving risks with the drug supply circulating in the community and about latest strategies to combat the associated health issues, including the opioid crisis. Rapid response strategies to quickly implement new or updated evidence-based harm-reduction strategies in prisons should be developed.
79. The EMDC should ensure that is has reviewed all relevant information about a candidate for promotion, including potential questionable working practices.

To the Government of Ontario

80. We recommend that adequate funding and resources be provided to implement our recommendations.

Kay, Kieran

Surname: Kay
Given name(s): Kieran
Age: 26

Held at: 85 Frederick Street, Kitchener
From: March 9, 2020
To: March 12, 2020
By: Dr. John Carlisle
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Kieran Kay
Date and time of death:  May 22, 2017 at 11:13 p.m.
Place of death: Cambridge Memorial Hospital - 700 Coronation Blvd., Cambridge
Cause of death: Acute cocaine toxicity
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on March 12, 2020
Coroner's name: Dr. John Carlisle
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Kieran Kay

Jury recommendations

To the Special Investigations Unit (SIU):

1. It is recommended that the SIU have a protocol in place for advising victims/families of available victim services and for contacting victim services to attend at the location at the time of the incident, if appropriate.
2. It is recommended that if there is a potential conflict in the provision of victim services offered through the police service involved, the SIU should have an alternative in place.

To the Ministry of the Solicitor General:

3. It is recommended that Police (including 911 and dispatch) be educated on directives binding on paramedics to not engage with a patient who is being aggressive, combative, or violent due to possible excited delirium or drug overdose to allow them to fully assess the urgency of a call and police prioritization.
4. It is recommended that police review policies in cases involving medical calls relating to aggressive/violent patients. This review should consider when a police officer should be immediately dispatched to such calls.
5. It is recommended that police (including 911 and dispatch) review the procedures relating to dispatching an officer to a call involving violent individuals.

To the Region of Waterloo Paramedic Services and the Ministry of Health:

6. It is recommended that the communication systems be enhanced to provide live dispatch within all stations.

February

Dhesi, Jatinder

Surname: Dhesi
Given name(s): Jatinder
Age: 21

Held at: 25 Morton Shulman Ave, Toronto
From: February 18
To: February 18, 2020
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jatinder Dhesi
Date and time of death:  June 30, 2015, morning
Place of death: Sunnybrook Trauma Centre
Cause of death: Crush injury of head
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on February 18, 2020
Coroner's name: Dr. Geoffrey Bond​
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the death of: Jatinder Dhesi

Jury recommendations

To the Province of Ontario:

1. Consider the feasibility of the creation of and requirement for a specific certification in the installation, repair, and maintenance of heavy hydraulic equipment.

To the Canadian Standards Association and the Province of Ontario:

2. Consider the feasibility of the requirement for an "emergency bleed valve"- a device that could reliably bleed hydraulics at a slow, constant rate for the use in situations where normal operation has failed, and that would be mandatory for all heavy equipment used in Ontario

Agzamov, Jamshid and Kang, Kihwan

Names of the deceased: Agzamov, Jamshid; Kang, Kihwan
Held at: 25 Morton Shulman Avenue, Toronto
From: February 3
To: February 4, 2020
By: Dr. Robert Boyko
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Agzamov
Given name(s): Jamshid
Age: 38

Date and time of death:  November 27, 2015, 12:03 p.m.
Place of death: St. Michael’s Hospital, 30 Bond Street, Toronto
Cause of death: Multiple blunt force trauma
By what means: Accident

Surname: Kang
Given name(s): Kihwan
Age: 26

Date and time of death:  September 27, 2008   5:40 p.m.
Place of death: Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto
Cause of death: Blunt force craniocerebral trauma
By what means: Accident

(Original signed by: Foreperson)

The verdict was received on February 4, 2020
Coroner's name: Dr. Robert Boyko
(Original signed by coroner)

We, the jury, wish to make the following recommendations:

Inquest into the deaths of: Jamshid Agzamov and Kihwan Kang

Jury recommendations

To the Ministry of Labour, Training, Skills and Development (MLTSD)

1. That the Chief Prevention Officer revise the Working at Heights curriculum to include a section on hazards related specifically to skylights.
2. That Subsection 26(6) of the Occupational Health and Safety Act (OHSA) and Regulation for Construction projects be reworded to say, “falling through an opening on a work surface, including but not limited to skylights.”
3. That the OHSA should require that a daily record of site orientation and safety instructions be kept by the constructor/employer and provided to the building/business owner.  These records should be kept by the building/business owner and be made available to the MLTSD.
4. Consider studying the effectiveness of current Working at Heights Training in reducing fall related deaths.
5. A regulation be added to the OHSA requiring a human spotter when a roof opening is exposed until a secure covering is in place of sufficient strength that would prevent a worker from falling through.
6. Consider implementing mandatory training for supervisors/forepersons with regards to the hazards/risk of working at heights.

To the Ministry of Labour, Training , Skills and Development and the Infrastructure Health and Safety Association

7. Consider preparing and issuing "Safe Practices" guidance material / advisory material for the movement of large sheet roofing materials from ground to roof (similar to the Low Slope / Flat Roof  Safety guide).

To the Ministry of Municipal Affairs and Housing

8. Ontario Building Code be amended to include a requirement that skylights through which persons may fall shall be designed to be capable of withstanding a load of 2.4 kilonewtons per square meter; or be guarded by a standard skylight screen capable of withstanding a load of at least 2.4 kilonewtons per square metre; or be equipped with a fixed skylight railing on all exposed sides to a measurement of 36 to 42 inches high.