2024 coroner’s inquests’ 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:

• occ.inquiries@ontario.ca
• 1-877-991-9959

You can also access verdicts and recommendations using Westlaw Canada.

January

Yatim, Sammy

Held at:  virtual, Toronto
From: January 12
To: February 1, 2024
By: Dr. David Cameron, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Sammy Yatim
Age: 18
Date and time of death:  July 27, 2013 at 12:26 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 February 1, 2024
Coroner's name: Dr. David Cameron
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Sammy Yatim

Jury recommendations

Peer intervention

To the Ministry of the Solicitor General and all police services in Ontario:

1. Ensure or continue to ensure that bystander/peer intervention training programs become a mandatory component of annual requalification training for officers and be continually developed. Training should focus on improving policing culture by ensuring that officers are aware that there will be no repercussions for intervening when such intervention proves warranted, but that there is potential for misconduct for failing to intervene. The training should emphasize that officers are responsible for their own actions and have a duty to intervene when witnessing misconduct.
2. There should be or should continue to be express explicit protection in the policies and procedures of each police service (whistle-blower protection) for those who exercise peer intervention or report misconduct.

Monitoring

To the Toronto Police Service:

3. Consider the feasibility of instituting a quality assurance and audit position at every division, staffed by a sworn police officer, to ensure accountability, transparency, and efficiency of numerous compliance requirements (i.e. reviewing body worn camera footage), including detailed reviews of any early intervention reports and implementation of interventions that are deemed necessary.
4. At the Professional Standards Unit, undertake a review of the process for assessing early intervention program alerts to determine whether there is a need for another position to assist the Detective of Analysis and Assessment.

To all police services in Ontario:

5. For all services that provide body worn camera equipment to members, ensure or continue to ensure that relevant footage captured on the camera is reviewed in every case where an officer completes a use of force report or is the subject of an internal or external conduct complaint.

To all police services in Ontario that use IAPro/Professional Standards Information System (PSIS):

6. Conduct a systemic, evidence-based review of IAPro/PSIS), used in Early Intervention Reports, to examine:
   1. the appropriate threshold(s) of alerts, both in terms of quantity and type, that will best identify risk
   2. whether the time frame for events that trigger an alert should be greater than twelve (12) months in certain circumstances
   3. whether best practices require input of use of force reports to PSIS within a fixed period
   4. whether additional types of triggering events should be added (e.g., Special Investigations Unit (SIU) investigations, officer bystander in a Use of Force event)
   5. whether workload indicators (such as work hours and attendance) will assist in identifying risk
   6. the need for a process to document the analyst’s review and decision (e.g. a record of when the alert was reviewed, by whom, and the results of the review)
   7. the circumstances where discretion to advance the matter to the divisional level should become mandatory
   8. whether in all cases where discretion is exercised not to advance the matter further, an automatic review of that decision ought to be conducted by the analyst’s supervisor
   9. the implications of using historical alerts and/or previous intervention reports in the exercise of discretion not to advance a further investigation, or when assessing interventions
   10. how to record the results of the early intervention meeting, identify any follow-up steps, and record acknowledgement and alignment from both supervisor and affected officer
   11. how to record and track the results from follow-up steps
   12. the effectiveness of interventions and in particular the role of a member’s supervisor
   13. the required level of staffing to effectively manage the volume of alerts and
   14. the need for provincial standardization of system settings and processes.
7. With reference to recommendation #6, once the results of the evidence-based review are obtained, seek and receive input from community stakeholders and subject matter experts with respect to the appropriate triggering events and thresholds (type/frequency) before further customizing IAPro and the BlueTeam IAPro system enhancement feature.

To the Ministry of the Solicitor General:

8. With reference to recommendation #6, the Ministry of the Solicitor General will consider issuing grant funding to services seeking to undertake systemic reviews of IAPro/PSIS.

To the Toronto Police Service:

9. Review and consider expanding the role of in-house psychologists in qualitatively assessing threshold events and critical incidents. Where a threshold event leads to an intervention, consider the support a psychologist may provide:
   1. to the subject officer
   2. to supervisors in determining the scope of the intervention and
   3. in assisting to identify and address fitness for duty issues, including requiring further psychological assessment, in appropriate cases

Standardization

To the Ontario Police College, and all police services in Ontario who provide in-house training:

10. Establish a system of ongoing and improved information sharing between the Ontario Police College and police services in Ontario, regarding changes to be applied to best practices in police training and curriculum to ensure alignment of training expectations.

To the Ministry of Solicitor General, all police service boards in Ontario, all police chiefs in Ontario, the Ontario Association of Chiefs of Police, the Ontario Association of Police Services Boards, the Special Investigations Unit, the Office of the Independent Police Review Director and the Inspector General for Policing:

11. Consider jointly establishing a Centre for Excellence in Policing with a goal of continually improving and standardizing the training given to recruits, as well as the in-service training given to police officers across the province of Ontario and elsewhere in Canada. The Centre for Excellence in Policing should have a community advisory board and consideration should be given as to whether the Centre would be able to achieve a mandate to:
    1. improve policing in Ontario through collaboration and evidence-based research
    2. standardize best practices in police training, police leadership, and police governance, and
    3. integrate police, academic, and community resources

To the Province of Ontario, the Coalition for Canadian Police Reform, and the Government of Canada:

12. The Province of Ontario in partnership with the Coalition for Canadian Police Reform and the Government of Canada should explore the development of national certification criteria for Canadian police officers, which may be integrated into existing institutions’ curricula, or the establishment of a Canadian College of Professional Policing.
13. If a national certification program is developed for Canadian police officers, the certification program should include in its mission statement an acknowledgement that it was established because of the Jury recommendations at the coroner’s inquest into the death of Sammy Yatim.
14. If a Canadian College of Professional Policing is established, the College should acknowledge in its founding letters and mission statement that it was established because of the jury recommendations at the coroner’s inquest into the death of Sammy Yatim.

To all police services boards and all police services in Ontario:

15. Engage in public education and community outreach with a view to enhancing community awareness of peer intervention and the duty to report.

To all police services in Ontario:

16. Create an annual award modelled on the Toronto Police Services Board’s Mental Health Excellence Award to be presented to police officers throughout Ontario who have demonstrated excellence, compassion, and respect in their interactions with members of their community who experienced mental health crises during the police interaction.
17. In reference to recommendation #16, where appropriate, consider incorporating these positive encounters in scenario- based training during annual recertification.

To the Ministry of the Solicitor General and the new Inspector General of Policing:

18. Institutionalize a system that will continue to align the training provided at the Ontario Police College and the training occurring at the service level for/by coach officers, especially with respect to scenario-based training, de-escalation, anti-bias, and peer intervention.

Essential equipment

To the Ontario Ministry of the Solicitor General and the Ontario Association of Chiefs of Police:

19. Evaluate and consider mandating body worn cameras for all front-line police officers in Ontario to provide an objective source of information.

To the Ontario Association of Chiefs of Police:

20. Consider formalizing the process of sharing the results of candidate screening for new officers among police services including any reasons why an applicant was not selected.
21. Consider setting standardized guidelines for hiring and recruiting new officers across all of Ontario to ensure recruitment best practices are used across all police services.

To the Toronto Police Services Board and to the Toronto Chief of Police:

22. Consider formalizing the involvement of crisis nurses across the delivery of various training programs including annual recertification.

Implementation

To the Government of Ontario:

23. Enable and assist the Office of the Chief Coroner in making all inquest recommendations and responses publicly available on the Office of the Chief Coroner's website.
24. The Government of Ontario should review recommendations from previous inquests and public reports, including those to specific police services, to determine whether a systemic review should be undertaken. This review should consider whether there should be standardization in respect of specific requirements for police officers and should include community stakeholders. The results of this review should be reported publicly.

To the Government of Ontario:

25. In consultation with the Ministry of the Solicitor General, explore whether the responsibility to deal with inquest jury recommendations that are directed to all police services can be assigned to the new Inspectorate of Policing, and if not, then identify the correct body that can:
    1. engage all police services with respect to implementation of recommendations
    2. compile responses before they are forwarded to the Office of the Chief Coroner
26. Consider creating a government body that would track, coordinate, and report on the implementation of inquest recommendations. This body may also facilitate communication between affected parties who disagree on interpretation or implementation of an accepted inquest recommendation.

Support for family members

To the Government of Ontario:

27. Create or augment the availability and accessibility of immediate and on-going financial and mental health support for the family members of persons who were killed or seriously injured in an interaction with police.

Community advisory panels, strategies, and champions

To the Ministry of the Solicitor General, all police services in Ontario and all police services boards in Ontario:

28. Institutionalize community engagement in the areas of mental health (and related initiatives such as anti-bias, intersectionality, gender diversity, and anti-racism) through the creation of mental health advisory panels modelled on the Mental Health and Addictions Advisory Panel to the Toronto Police Services Board, and such panels should be properly composed to reflect the diversity of the community and to address the intersectionality of biases, mental health, and substance use.

To the Ministry of the Solicitor General, all police services in Ontario, and all police services Boards in Ontario:

29. Consider developing a rights-respecting mental health strategy for every police service in consultation with representative organizations of persons with relevant lived experience.

To all police services in Ontario:

30. Appoint a command level service member or senior member of the organization to be responsible for the police service’s mental health portfolio or strategy and, in the selection of that officer, ensure that they are committed to values aligned with community engagement, the engagement of persons with lived experience, and officer wellness.

Crisis incident response

To all police service boards and all police services in Ontario:

31. Support the development, implementation and/or continued operation of community-based and consent-based crisis response services, as an alternative to a police-led response to mental health related calls for service, where a police response is not required.
32. Consider stationing a crisis worker who is employed by community crisis service in Communications for onsite intervention. If crisis workers cannot attend a mental health call (e.g. time or safety), police use the crisis service to advise if possible. Records of calls that do not involve police stay solely with the crisis service.

To the Ministry of the Solicitor General:

33. Consider enhancing the use of force form to include layers or stages of de-escalation to provide clarity on the steps taken.

Wellness and officer supports to enhance good decision-making

To the Ministry of the Solicitor General, all police services boards in Ontario, and all police services in Ontario:

34. Adopt or implement, and continue to develop, front-line wellness and peer support/mentorship programs, including training to increase the number of officers who participate in offering these supports to their colleagues.

To the Toronto Police Service:

35. Consider regular reviews of the volume and nature of calls for service in each division to determine the need in each division for wellness support and whether existing supports adequately meet each division’s needs. Consider increasing or instituting regular officer wellness checks in divisions that may require it.

Funding

To the Toronto Police Service, Toronto Police Services Board, and the City of Toronto:

36. In considering the recommendations from this jury directed to the Toronto Police Service and Toronto Police Services Board, ensure that adequate funding is provided or existing funding is re-distributed for their effective implementation.

To all police services, police services boards in Ontario, and their respective municipalities:

37. In considering recommendations from this jury directed to police services and police services boards, ensure adequate funding is provided or existing funding is re-distributed for their effective implementation.

To the Province of Ontario:

38. Consider all the recommendations by this jury in identifying provincial community safety priorities and consider the establishment of provincial community safety grant programs to support any provincial priorities identified from these recommendations.
39. Consider designating the following as provincial community safety priorities and providing grant funding for those priorities:
    1. the development, implementation, and maintenance of evidence-based tools for evaluating the effectiveness of police training programs; and,
    2. the development, implementation, and maintenance of effective early intervention programs.

To the Federal Government of Canada:

40. In considering the recommendations from this jury directed to the Government of Canada, ensure adequate funding is provided for their effective implementation.

Apologies

To all police services in Ontario, all police services boards:

41. In consultation with relevant stakeholders, consider an approach to apologies, expressions of regret and recognition of loss following a critical incident, being mindful of legal and other considerations involved.

Police training and recruitment

To the Toronto Police Service:

42. Support individualized monitoring based on the specific needs and performance of the new recruits during their onboarding and probationary period to identify any areas of risk that should be assessed.

To the Ontario Police College and all police services in Ontario who offer training:

43. Continue to prioritize the non-application of force in all de-escalation training with an emphasis on calming the person in crisis and avoiding any use of force, whether demonstrated or used, whenever possible. To All Police Services in Ontario:
44. Make trauma-informed de-escalation and peer intervention training a mandatory component of annual requalification training for officers and commit to ongoing development and enhancement of this training. Ensure that the training continues to emphasize the importance of trauma-informed and anti-biased communication, and that officers are responsible for their own actions and have a positive duty to intervene.

To all police services in Ontario:

45. Consider implementing standardized evidence-based training on critical decision-making and trauma-informed de- escalation, to be delivered every twelve (12) months, in addition to annual recertification requirements.
46. Consider increasing annual use of force training to sixteen (16) hours, with a focus on critical decision-making practice and assessment (scenario-based stress modulation training).
47. Mandate a ‘Train the Trainers’ program for use of force instructors and require recertification and quality assessment no less than once every 3 years.

To the Ontario Police College and all police services in Ontario:

48. Consider the use of heart rate trackers (e.g. wearable fitness tracker) to aid when teaching existing courses related to breathing techniques to bring down heart rate and manage high-stress encounters. The heart rate data should be for the officer’s personal use and not collected in any way to ensure confidentiality.
49. To better evaluate the degree of training effectiveness in individual cases, replace pass/fail grading systems with a graduated marking system where appropriate.
50. With the application of graduated marking systems that track skill level, consider making individual evaluations accessible to current and future supervisors.

To the Ministry of the Solicitor General:

51. Review and consider whether the basic constable training offered at the Ontario Police College should be extended beyond the current 13 weeks.

To the Ontario Police College and all other police services in Ontario that offer in-house training:

52. Require and institutionalize the participation and feedback from persons with relevant lived experience in the design and evaluation of all use of force, de- escalation, anti bias, and peer intervention training provided to recruits and police officers.
53. Continue to conduct annual reviews of the training curriculum to ensure it remains in alignment with the needs of the community. This should include community engagement through feedback from the community to assess the impact of the training.
54. Explore in consultation with community stakeholders, ways to incorporate skilled community members with relevant lived experience in the delivery and debriefing of scenario-based training covering use of force, de-escalation, peer intervention, and anti-bias.
55. Continue efforts to make scenario-based training as realistic as possible by relying primarily on real-life scenario training (e.g. using scenarios from police related Coroner's Inquests). Such training should, where possible, employ professional actors and, where not possible, persons unknown to the trained police officers.
56. Consider the expanded use of multiple officer scenario training (involving 3 or more officers) that involve staggered officer arrival on scene and emphasize incident command, role assignment, and communication between officers.
57. Consider including radio use and the ongoing or continued receipt and transmission of information via radio in scenario training.
58. Incorporate or continue to incorporate evidence based self-regulation techniques and situational awareness into the training of all police recruits and police officers and embed the application of those techniques in all use of force, de- escalation, and peer intervention scenario-based training.

To the Ministry of the Solicitor General:

59. Examine and consider mandating mental health first aid as required training for police officers.
60. Continue to provide evidence-based anti-bias training to police recruits and police officers, including training on intersectionality and its effects, particularly on potentially exaggerated perceptions of risk. Continue to emphasize training on implicit biases, and critical self-reflection of individual biases, and include training to assist officers to learn the skill of impartial speech and questioning when interacting with members of the public.

To the Ontario Police College, the Ministry of the Solicitor General and all police services in Ontario:

61. Continue to emphasize a community-based approach to policing and ensure an ongoing emphasis on community policing in both culture and training, and that this emphasis is reflected in the policies and procedures of each police service. Recognizing that policing is a public service, review the value of a paramilitary structure to determine which, if any, aspects of this structure continue to serve a core purpose of policing. Continue to ensure that officers are aware of the crucial importance of individual responsibility for ethical decision-making and the need to hold each other responsible for their conduct.

To all police services in Ontario:

62. Continue the use of psychological testing at the recruit selection stage, with particular emphasis on identifying candidates who demonstrate strong critical decision-making skills, emotional competencies, and traits such as compassion, empathy, and ability to relate. Conduct ongoing research into the quality and types of tests used in recruit screening, as well as their effectiveness in detecting personality traits that are both compatible and incompatible with policing.

Training evaluation

To all police services boards of services that provide in-house training:

63. Institutionalize evidence-based evaluation of the effectiveness of training programs by incorporating its requirement into policy and by making it a specific budget line item.

Habib-Ptris, Hani
Moyano, Alcides Jose

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: January 22
To: January 25, 2024
By: Dr. Bonnie Goldberg, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Hani Habib-Ptris
Age: 31
Date and time of death:  October 17, 2018
Place of death: Oakville Trafalgar Memorial Hospital
Cause of death: blunt force head trauma due to descent from height
By what means: accident

Name of deceased: Alcides Jose Moyano
Age: 62
Date and time of death:  August 19, 2016
Place of death: 707 Eglinton Avenue West
Cause of death: multiple trauma
By what means: accident

(Original signed by: Foreperson)

The verdict was received on January 25, 2024
Coroner's name: Dr. Bonnie Goldberg
(Original signed by presiding officer for Ontario)

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

Inquest into the deaths of: Hani Habib-Ptris, Alcides Jose Moyano

Jury recommendations

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

1. Consider including a mandatory component on the dangers of complacency in the Working at Heights (WAH) Training Program Standard. The training material for this topic should include information and resources that highlight the dangerous impacts of complacency when working at heights, with particular emphasis on case studies of past fatalities that identify the risks no matter how experienced the worker, or how fleeting the task. This training should also:
   1. Be incorporated as a “Safety Talk” into existing “Working at Heights” training manuals and pedagogical resources.
   2. Be utilized in workplace posters, websites, and bulletins developed with external partners, as appropriate.
   3. Be a mandatory topic provided to all approved WAH training providers in Ontario.

Ministry of Labour, Immigration, Training and Skills Development; Provincial Labour Management Health and Safety Committee (as appointed under section 21 of the Occupational Health And Safety Act)

2. Develop and implement regulations that require standardized, mandatory training specific to “Elevating Work Platforms”, similar to the “Working at Heights Training” requirements.
   
   The training standard should:
   1. Be developed in consultation with external partners, as appropriate
   2. Be approved and reviewed at defined intervals by the Chief Prevention Officer.
   3. Require that the training provider be approved by the Chief Prevention Officer.
   4. Require continuing education for training providers when the standard is amended and require re-approval at defined intervals by the Chief Prevention Officer.
   5. Incorporate case studies of past fatalities or serious injuries caused by non-compliance or complacency involving “Elevating Work Platforms”.
   6. Be mandatory for workers and direct supervisors operating elevating work platforms.
   7. Require persons who are already certified on the competent operation of “Elevating Work Platforms” be retrained and recertified after a defined period of time.
   8. Include a thorough review of the obligations of employer(s) and worker(s) as defined in the legislative responsibilities of the pertinent act(s) and regulation(s).

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

3. Along with industry stakeholders consider the feasibility of changes to O. Reg. 213/91, s. 144 to include anti-tampering requirements for critical safety features such as limiter switches.

Gusak, Timi

Held at:  virtual, Office of the Chief Coroner
From: January 22
To: January 30, 2024
By: Dr. Murray Segal, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Timi Gusak
Age: 32
Date and time of death:  October 8, 2019
Place of death: Halton Healthcare Services – Milton District Hospital, 725 Bronte Street South, Milton
Cause of death: hanging
By what means: accident

(Original signed by: Foreperson)

The verdict was received on January 30, 2024
Coroner's name: Dr. Murray Segal
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Timi Gusak

Jury recommendations

To the Government of Ontario:

1. Conduct a comprehensive audit to determine the correctional staffing levels needed at the Maplehurst Correctional Complex. This audit should include consultation with the Maplehurst Correctional Health Care Unit and the Solicitor General’s Corporate Health Care Unit to recognize the increasing pressures that mental health needs of inmates are placing on operational staff.
2. Analyze the causes of correctional staff absenteeism and attrition at Maplehurst Correctional Complex and take appropriate action to encourage retention of staff.
3. Create an Action Plan based upon the results of the audit and the staff absenteeism / attrition analysis to increase the number of correctional staff at Maplehurst Correctional Complex to an appropriate complement and to maintain adequate correctional staffing levels.
4. Develop, implement, and maintain a long-term provincial plan to establish adequate and safe housing for inmates charged with sexual offences. This plan should prioritize the need to house and transfer these inmates with each other and keep them separate and apart from the rest of the inmate population. This plan should include adequate and appropriate staffing and infrastructure to prevent bullying and intimidation of these inmates by other inmates and / or correctional staff.
5. Develop educational programs for correctional officers who work with inmates charged with sexual offences to make them aware of the vulnerabilities of that population including (but not limited to): the likelihood of existing untreated childhood trauma, the possibility of increased levels of suicidality and the increased risk of bullying, intimidation, and physical violence due to the nature of their charges.
6. Develop a practice to ensure that correctional officers scheduled to work on units housing inmates charged with sexual offences recognize the need for and are willing to provide a safe and compassionate environment for these inmates.
7. Develop a training program that would assist correctional officers to understand the importance that a positive staff – inmate relationship has on inmate health, security, life promotion, future willingness to engage in treatment and reduction in recidivism.
8. Seek and allocate adequate funding and resources to implement these recommendations.
9. Advise inmates upon admission that a Code of Conduct exists for correctional officers and that inmates may request to review the publicly available summary of that Code of Conduct. Facilitate any requests made by inmates to review.
10. Implement an annual acknowledgment of the Code of Conduct by correctional staff.

To Maplehurst Correctional Complex:

11. Where possible and operationally feasible, continue to assign casual staff (fixed term) to those units that they are familiar with and where they have worked before.
12. Amend logbook policy and procedure to require logbook officers to identify, in writing, the specific officer who engaged in the actions recorded in the logbook. Require that all entries are legible and that the officer’s name is fully recorded and prohibit the use of initials or illegible signatures.
13. Issue a Standing Order that requires a physical and visual cell inspection to be completed by a correctional officer once an inmate has vacated a cell and the removal of all items (except the mattress) prior to a new inmate being housed in that cell. The officer’s name and the date and time that the cell inspection was completed should be documented.
14. Maintain and enforce policies relating to the removal of ligatures from cells and continue to encourage correctional officers to remove from all cells any loops, ligatures, and / or lines made from clothing or bedding or any other fabricated item that could pose a risk to an inmate.
15. Develop a policy or protocol that would require any corrections or health care staff member to immediately report (unless prohibited by confidentiality pursuant to PHIPA) any allegations of threatening or assaultive behaviour by another inmate or a staff member against an inmate. This policy should further require an immediate response to the allegations and immediate re-housing (if necessary) to ensure inmate safety and security.
16. Immediately discourage and discontinue any internal practices or procedures that encourage the completion of documentation that certifies that a cell inspection or unit tour was completed when it has not, in fact, been done.
17. Modify the existing daily cell inspection report to record the officer’s name, the date and time and the method of inspection (physical versus visual).
18. Increase the complement of psychologists, psychiatrists and social workers and actively engage in efforts to hire additional members of these professionals.
19. Implement a system that requires a multidisciplinary recovery care plan for inmates who are coming off suicide watch. This plan should be patient-centred and include health care professionals, social workers, the inmate and those correctional staff who will be interacting with the inmate. In the event that the multidisciplinary recovery care plan cannot be executed, it should be reevaluated with the inmate and the healthcare team prior to taking further action.  
20. Implement a system that encourages correctional officers to provide written observations to the health care team of behaviour from inmates coming off suicide watch that raise mental health concerns.
21. Explore creative use of existing spaces within the Maplehurst Correctional Complex that, while still maintaining the safety of health care professionals, permits inmates to meet with health care professionals without correctional officers present (such as the family or professional visit areas).
22. Continue training for correctional staff who are present for health (including mental health) meetings regarding maintaining the privacy of inmate’s health information.
23. Develop a policy or protocol to inform the inmate of their confidentiality rights in relation to their personal health information when interacting with a member of the healthcare team.
24. In conjunction with any related province-wide mandates, develop, and implement a long-term internal plan to establish adequate and safe housing for inmates charged with sexual offences. This plan should prioritize the need to house these inmates with each other and separate and apart from the rest of the inmate population. This plan should include adequate and appropriate staffing and infrastructure to prevent bullying and intimidation of these inmates by other inmates and / or correctional staff.
25. Ensure that all correctional officers are aware of the special needs of inmates charged with sexual offences including (but not limited to): the likelihood of existing childhood trauma, the possibility of increased levels of suicidality and the increased risk of bullying, intimidation, and physical violence due to the nature of their charges.
26. Include in any suicide awareness programs images and measurements of the bedding loop that Mr. Gusak used to take his life, to permit correctional officers to better understand how such an object can be utilized as a tool of suicide and the importance of removing such items from cells.
27. Increase the hours of mental health nurses such that a mental health nurse is available to provide in-person health care to inmates twenty-four hours a day, seven days a week.
28. Upon admission, inform inmates of their right to have health care services delivered in the absence of anyone who is not within the inmate’s circle of care and document the delivery of this information in the inmate’s health care file.

February

Mannisto, Erkki

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: February 5
To: February 7, 2024
By: Dr. Daniel L. Ambrosini , presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Erkki Mannisto
Age: 21 years, 11 months
Date and time of death:  September 7, 2018 at 2:01 p.m.
Place of death: Health Sciences North, 41 Ramsey Lake Road, Sudbury
Cause of death: acute cocaine intoxication complicated by hypoxic-ischemic encephalopathy and acute bronchopneumonia
By what means: undetermined

(Original signed by: Foreperson)

The verdict was received on February 7, 2024
Coroner's name: Dr. Daniel L. Ambrosini
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Erkki Mannisto

Jury recommendations

To the Ontario Provincial Police

1. Conduct a review of the radio communications system used by officers who report to the West Parry Sound detachment. The review should be directed at identifying limitations in officers’ ability to transmit radio messages to dispatchers while they are attending to calls, particularly in areas with high shielding or poor reception. The review process should include consultation with officers from the detachment.
2. Upgrade the radio communications system to address any issues identified in the review.
3. Review protocols and training to ensure that officers relay medically relevant events occurring on scene to Emergency Medical Services.

Baker, Terry

Held at:  virtual, Toronto
From: January 22
To: February 9, 2024
By: Dr. David Eden, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Terry Baker
Age: 30
Date and time of death:  July 6, 2016
Place of death: St. Mary's General Hospital, Kitchener
Cause of death: ligature strangulation
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on February 9, 2024
Coroner's name: Dr. David Eden
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Terry Baker

Jury recommendations

Mentions of CSC institutions below are aimed specifically at women's institutions. However, we invite CSC to take due consideration of whether these recommendations would be beneficial to men's institutions as well.

Oversight and accountability

1. That the Minister of Public Safety and the Commissioner of the Correctional Service Canada (CSC) publicly acknowledge that:
   1. Its institutions are not an appropriate setting to house persons in custody who have a severe form of mental illness and/or who are at risk of suicide or self-harm; and
   2. Self-injurious behaviours and suicide attempts by persons in custody be considered and treated first and foremost as requiring a health-focused response, not a security-directed response.

2. CSC immediately implement in full the following recommendations from the Inquest touching on the death of Ashley Smith verdict dated December 13, 2013: Recommendations 6-9, 16-18, 35, 36, 39, 40, 46, 48, 49, 61, 73-75, 83, 86, 87, 91, 96-98, 102, and 103. The verdict from the Inquest touching on the death of Ashley Smith dated December 13, 2013, is attached as Appendix “A” to this verdict.
3. CSC will take immediate steps to ensure that any person in custody who has a severe form of mental illness and/or who is at risk of suicide or self-harm is admitted to a psychiatric hospital or health facility that is suitable, secure, and safe.
4. To support the implementation of Recommendation 3, CSC will immediately engage with external psychiatric hospitals or health facilities to negotiate and enter into an agreement under section 16(a) of the Corrections and Conditional Release Act.
5. The Government of Canada should conduct an independent review of s. 29 of the CCRA to determine CSC's practices, and an evaluation of the barriers to using this provision, if any.
6. The Government of Canada should institute an independent oversight body to assess and evaluate processes of health care of persons with serious mental illness in federal corrections, which can be capable of intervening and addressing complaints related to that care. Ensure this body operates at arm's length of the CSC and follows community standards of healthcare.
7. The Minister of Public Safety should introduce legislative reforms to the Corrections and Conditional Release Act that would define “solitary confinement” consistent with the United Nations Mandela Rules. This definition should apply to all forms of isolated confinement, whether within the Structured Intervention Units or elsewhere in the prisons.
8. Pending implementation of recommendation 7, CSC will revise all policies, directives and procedures that refer to observation, seclusion, segregation, or structured intervention, to add a definition of “solitary confinement” consistent with the United Nations Mandela Rules.
9. Ensure that the Structured Intervention Unit (SIU) Independent Advisory Panel (IAP) is a permanent independent body to provide systematic oversight of the operation of the SIU across Canada.
10. CSC to work with the Canadian Association of Elizabeth Fry Societies (CAEFS) to establish a process for publicly publishing the letters written by CAEFS Regional Advocates to any of the five institutions designated for women operated by CSC, and any responses to letters received by CAEFS from an institution designated for women, while ensuring that processes are in place to maintain the personal privacy of persons in custody.   
11. Any institutions designated for women operated by CSC that receive a letter written by a CAEFS Regional Advocate following a site visit, must respond to that letter within 21 calendar days of receipt; and to implement the recommendations made by CAEFS Regional Advocacy Representatives where it is legally able to do so.
12. Public Safety Canada will work with CAEFS to ensure CAEFS has sufficient resources to sustainably and fully complete the work of CAEFS Regional Advocates to conduct monthly site visits, produce monthly letters, and to train and provide ongoing supervision and support to CAEFS Peer Advocates.
13. CSC work with CAEFS to bolster the Peer Advocacy program and ensure that peer advocates are given the broadest range of access possible within penitentiary environments to support individuals who may benefit from their assistance.

Institutional health care

14. Take immediate action to ensure that there are adequate resources in place at all CSC facilities for the provision of 24/7 on-site health care and mental health services for persons in custody. For greater clarity, we recommend that CSC ensure that a nurse is physically present on-site at every CSC institution 24 hours a day, 7 days a week. This is to include adequate back-up coverage when the usual health care providers are absent for any reason. 
15. That CSC prioritize and expedite the development and implementation of an external and independent patient advocacy model to provide all federally incarcerated individuals with an independent patient advocate.
16. Immediately provide persons in custody at institutions and regional treatment centres operated by CSC with the option of engaging an independent patient advocate when they undergo any form of assessment or interaction involving health care and/or mental health care staff, as required by the Corrections and Conditional Release Act.
17. Ensure that psychiatry is involved in the development of Interdisciplinary Management Plans for persons in custody in a federal correctional institution.
18. CSC to make clear to all staff that when a person in custody asks to be seen by one of the available institutional health care providers that that request is acted upon within 24 hours.

Mental health care, policy, and response

19. Until recommendation #20 is implemented, CSC institutions that house persons in custody who have been diagnosed with the most severe form of Borderline Personality Disorder, and who suffer from chronic self-injury and suicidal behaviours will take immediate steps to assess whether these individuals should be moved to a facility that can provide appropriate health care, such as the Institut Philippe-Pinel de Montreal (“Pinel”).
20. CSC National Headquarters will take immediate steps to negotiate and enter into an agreement with a psychiatric hospital or health care facility to provide in-patient treatment for persons in custody in an institution designated for women, who have been diagnosed with a severe form of Borderline Personality Disorder and require such treatment. Progress on this negotiation must be reported to the Commissioner of CSC and the Office of the Correctional Investigator every three months, with the first report to be provided by September 1, 2024.
21. That the Commissioner of CSC immediately and in writing direct all staff that persons in custody who engage in self-injurious behaviours shall not be referred to as “instigators”, and their behaviour should not be referred to as a “disciplinary problem” or “misconduct”, formally or informally, by any staff.
22. CSC will take immediate steps to review and revise all forms related to reporting self-injurious and/or suicidal behaviours to remove any references to “instigator” or “disciplinary problems”.
23. When a person in custody at a CSC institution or regional treatment centres is in a mental health crisis or is decompensating, CSC staff on their health care and case management teams must perform a thorough review of all of the person's past treatment plans to assess what may have been successful interventions in the past that could be considered and used in the present.
24. CSC will take immediate steps to revise Commissioner's Directive 843 - Interventions to Preserve Life and Prevent Serious Bodily Harm (CD-843):
    1. To clearly state that any form of suicide watch or mental health monitoring in which a person in custody is placed in an observation cell is considered to be isolation, seclusion or solitary confinement of the individual;
    2. To ensure that a person in custody is consulted and included in all meetings and reviews set out in CD-843. For greater certainty, revise CD-843 to ensure the person in custody will be present at all meetings and reviews unless (1) the person in custody expressly declines to attend; or (2) the person or persons conducting the meeting believe on reasonable grounds that the presence of the person in custody at the meeting would jeopardize the safety of any person present at the meeting, including the safety of the person in custody themselves;
    3. To require the Warden to visit the observation cells on a daily basis, including weekends and holidays, and conduct a walk, and inspect the conditions of confinement;
    4. To require the Warden to ensure that when the Warden is not present at the institution, the person of next highest authority at the institution will complete the visit and report, in writing, to the Warden the findings and the outcomes of the visit; and
    5. To require that a debrief be held with all staff involved in the application of Pinel restraints to a person in custody. This debrief should be held as soon as practicable following the application of the restraints and prior to the end of the shift in which the restraints were applied. The debrief must explore if any less restrictive measures could have been used to keep the person in custody safe and to preserve life. If any such measures are identified, they must be immediately attempted with the person in custody if they are still in restraints.

25. CSC will recruit and retain more qualified health care professionals, including psychotherapists, psychologists, and psychiatrists with skills and first-hand experience in managing individuals with Borderline Personality Disorder within correctional institutions, and these individuals will be part of the treatment teams for persons in custody diagnosed with Borderline Personality Disorder.
26. CSC Health Services Sector will establish a team of highly trained professionals with expertise in both mental health and corrections, with expertise including but not limited to in Borderline Personality Disorder, to be available to provide consultation and second opinion to treatment teams in correctional facilities who are dealing with some of the higher risk and potentially lethal behaviours that can be associated with this condition. CSC will also ensure that all members of a treatment team for persons in custody diagnosed with Borderline Personality Disorder know that this team is available to provide consultation and second opinion.
27. CSC Health Services Sector will establish a team of individuals with expertise in mental health and research who are responsible for identifying and reporting on improved surveillance of peer reviewed medical literature and publications for new, evidence-based, and effective therapeutic treatment for individuals with personality disorders, including individuals with Borderline Personality Disorder. CSC shall provide a bi-annual report to the Commissioner of CSC on the availability of new interventions and ensure that applicable guidelines and Commissioner's Directives (CDs) are created and updated as new guidance becomes available. A policy bulletin should be issued within 1 month of any new guidance becoming available to provide immediate effect and the CDs should be reflected in the next review cycle.
28. For CSC policies that address federally sentenced persons with mental illness, and/or who are at risk of suicide or self-harm:
    1. For policies released in future, including revisions to existing policies, that indicators be identified and designed prior to release, so that they can be collected, tracked, and acted upon immediately upon release of the policy; and
    2. For existing policies for which indicators are not currently complete, that indicators immediately be designed, implemented, and acted upon.

Information sharing

29. CSC will ensure that all staff on a case management team or interdisciplinary health team of a person in custody, and especially the treating psychologist, receive all security and intelligence reports with information that may impact the health care or mental health of a person in custody as soon as such reports are signed by the Security Intelligence Officer.
30. CSC will ensure all frontline staff have access to the information they need to support persons in custody with complex mental health needs (for example, with the consent of the patient, mental health diagnoses, anticipated behaviours, behavioural triggers, and management of the same).
31. CSC will assist family/friends/support persons on positive interactions with incarcerated individuals. (for example, positive vocabulary, do's and don'ts, etc.). In situations where a medical or mental health diagnosis may be present, with consent provided by the patient, also provide information and supports to the family with background of their condition(s) and how they can support and interact with them in a positive manner.
32. CSC Health Services Sector will establish dashboards of daily, weekly, monthly, etc. data on self-harm, observation, and SIU use to be available throughout CSC to all sites, regional, national, and oversight levels. 

Inmate supports and rights

33. In partnership with CAEFS, JHSC and individuals with lived experience of incarceration, CSC will identify, review, and develop opportunities for increasing program support that is available to persons in custody related to employment and transferrable life skills. As part of this review, consideration should be given to identifying supports and skills programs that may additionally benefit persons in custody who are incarcerated at a young age. This team will regularly review and report on the type of programming that is available to persons in custody, successes achieved, uptake by persons in custody, and participant feedback.
34. CSC staff working at all institutions operated by CSC will ensure that when a person in custody requests to be moved to another unit, these requests are taken into serious consideration and that the person in custody is moved if a bed is available in the same security classification level. Similarly, when interpersonal challenges with other persons in custody are identified by a person in custody and determined to create a risk of harm to a person in custody, CSC staff shall immediately respond to and take steps to reduce and if possible, eliminate this risk.
35. CSC will ensure that if a person in custody files a grievance through the formal grievance process that doing so will not impact their privileges, unescorted and escorted temporary absences, or any other parole applications.
36. CSC will ensure that all grievances will be resolved within 45 calendar days of their submission.
37. CSC will ensure that persons in custody are made aware of the limitations of patient confidentiality in the prison environment. CSC will consult with frontline health care providers at CSC institutions and regional treatment centres to assess whether these limitations to patient confidentiality impact their ability to provide essential health care to persons in custody.
38. CSC will review its policies and programs, and engage with the Parole Board of Canada, to identify ways of ensuring that repeated or long-term stays by persons in custody at regional treatment centres or psychiatric facilities do not adversely impact the person's prospects of obtaining Escorted Temporary Absences, Unescorted Temporary Absences, Day Parole, or Full Parole.
39. CSC establish a mentorship program between new and existing inmates in women's institutions with a focus on orienting new inmates and providing additional supports throughout their sentence. Training for this program could be facilitated in consultation with CAEFS.
40. CSC to ensure that resources available to inmates (for example, CAEFS contact) should be continuously posted in a visible location. Should it be discovered to be removed, it should be replaced within 24 hours.

Institutional staffing, staff wellness and training

41. CSC will change the name of the Behavioural Counsellor position in all federal penitentiaries so that they do not refer to counselling or therapy in any way (for example, Behavioural Skills Coach, Behavioural Program Coordinator). CSC will notify all CSC staff of the change in position title. Additionally, CSC will review the job description and/or post order associated with the position, so it is clear to all staff at all levels of CSC that Behavioural Counsellors as renamed in accordance with this recommendation are not licensed health care providers, nor are they trained counsellors, and do not provide counselling.
42. At CSC institutions and regional treatment centres that have Behavioural Counsellors (as renamed in accordance with Recommendation #41), re-establish a formal mentorship opportunity for all Behavioural Counsellors to be mentored by mental health clinicians.
43. Institutional senior management at CSC institutions and regional treatment centres will ensure that there is adequate staffing coverage on all shifts to permit all staff, regardless of rank or position, to take regular lunch and health breaks in full.  Institutional senior management shall also ensure that adequate staffing exists to permit front line staff the ability to take periods of rest or relief during and/or immediately following their shift, as needed to cope with the emotional and mental impacts of their work.  For greater clarity, any such periods of rest and relief are to be granted over and above the regular allotment of sick leave, vacation or other forms of leave that form part of staff compensation and benefits.
44. At CSC institutions and regional treatment centres that have Behavioural Counsellors (as renamed in accordance with Recommendation #41), within the next 15 months, all Behavioural Counsellors should be registered for the Applied Suicide Intervention Skills Training (ASIST). Training should be provided by non-CSC staff and where possible be offered in-person in group settings outside of the correctional environment.
45. Within the next 18 months, all institutional staff who work at institutions and regional treatment centres operated by CSC should be registered for a course addressing empathy/compassion fatigue. Training should be provided by non-CSC staff and where possible be offered in-person in group settings outside of the correctional environment.
46. CSC will ensure that all staff working in institutional senior and middle management positions receive training on the impact that working in a federal penitentiary, and with individuals with complex mental health needs and who experience mental health crises, has on the emotional and mental health of correctional staff. Training must address the negative impact of shaming and blaming on the health and morale of frontline staff.
47. CSC will revise the National Training Standard for the Fundamentals of Mental Health to: (1) require that it be taken by all CSC staff who are not a licensed health care professional; and (2) require that it be taken once annually.
48. CSC will create a National Training Standard to require all frontline staff to be trained in recognizing and understanding the mental health issues predominantly experienced by incarcerated individuals.  This training must include information and suggestions to frontline staff in how to support persons in custody who suffer from personality disorders, in particular the specific characteristics of Borderline Personality Disorder. The training must be taken annually given the natural turnover in staff.
49. CSC will create a National Training Standard to require that all CSC staff who are not a licensed health care professional be trained to understand the reasons why a person may engage in self-injurious and/or suicidal behaviour and identify that a range of options must be considered and used by staff to respond to the behaviour that aims to identify and target the reason for the self-harm.
50. CSC will ensure that the training provided to frontline staff, and in particular Behavioural Counsellors (as renamed in accordance with Recommendation #41), includes training on providing interventions and/or program delivery (as applicable) for persons in custody with cognitive limitations.
51. In addition to currently available supports, ensure that frontline staff who work at institutions and regional treatment centres operated by CSC have benefits coverage that provides for services to respond to vicarious trauma, posttraumatic stress disorder and other impacts from working in a correctional institution. Provide a simple and straightforward way for staff to access these supports on an immediate basis and ensure all staff know what this procedure is.
52. Develop a process for all CSC staff to anonymously provide feedback on the support services available to employees (including but not limited to Employee Assistance Program, CISM, etc.), collect and review feedback, and make changes and add new and improved services as identified.
53. Develop a process for all CSC staff to anonymously provide feedback on gaps in training provided, collect and review feedback, and make changes and add new and improved training as identified.
54. CSC to ensure that all contract or casual employees receive training appropriate to their position about CSC facilities, the governing legislation, policies and procedures, and Commissioner's Directives.
55. CSC to ensure that training that relates to interacting with or responding to inmates with serious mental health illnesses includes a test, the results of which are monitored, including number of attempts to pass. Staff should retake any such training course in full if the number of attempts to pass exceeds 3. 

Conditions of confinement and use of restraints

56. CSC will ensure that any mental health crisis and/or medical emergency is not responded to in a security driven manner. CSC will re-develop the Engagement and Intervention Model to have a dedicated response path for mental health crisis and/or medical emergency that is first and foremost a health-focused response and places health care providers as the primary responders.
57. In partnership with persons with lived experience of incarceration and who have been placed in Pinel restraints in a federal correctional institution and/or regional treatment centre, CSC will review and update the Pinel Restraint Training for correctional staff to include the perspectives of being placed in Pinel restraints. The training must clearly state that the person in custody is the focus of attention of all correctional staff present in the room where restraints are being applied. Emphasize to all staff that words must be respectful of and recognize the seriousness of the experience for the person in custody, the deprivation of their liberty, and the suffering they are experiencing.
58. CSC will work toward the complete elimination of strip searches in penitentiaries designated for women and will immediately cease the routine use of strip searches in penitentiaries designated for women. In all cases if a strip search is employed, the reasons for the strip search must be recorded and provided to the institutional head and to the person in custody. CSC should explore less invasive alternatives.
59. CSC will revise all Commissioner Directives and policies related to any form of “solitary confinement” as defined in Recommendation #7 and 8 to specify that a person in custody must be released from the confinement on the same day the decision to release is made. CSC to review all forms associated with the release decision, and change the forms if necessary to remove an “effective date” for the decision.
60. CSC will revise all Commissioner Directives and policies no later than January 1, 2025 so that the calculation of time for any review of a person in custody's status be based on calendar days, not business days.

Culture of corrections

61. CSC will require all senior management and middle management staff (anyone who works Monday to Friday day shifts) in an institution designated for women to work an overnight shift shadowing Primary Workers, and an evening shift shadowing Behavioural Counsellors (as renamed in accordance with Recommendation #41) at minimum once a year. Ensure each member of the institutional senior management team completes the first of each of these shifts by no later than September 1, 2024, and every new person entering a senior or middle management role (in a substantive or acting capacity) within 6 months of their appointment.
62. CSC will create and implement a policy that prioritizes humanizing people in custody by strongly encouraging that they be addressed as “persons in custody” by correctional staff, and as a “patient” or “client” by health care and program staff.

Family wishes

63. CSC will ensure that the wishes of friends, family and next-of-kin of a deceased person in custody are prioritized over institutional considerations in any communications or interactions related to the death of a person in custody.

Record-keeping

64. CSC to ensure that all records and documentation related to persons in custody be retained pending the final outcome of all investigations or reviews following a death in custody. For greater clarity, this includes handwritten notes and correspondence, and applies when staff are transitioning to different positions or leaving a position with CSC.

Implementation

65. CSC to provide a separate and distinct response to each and every recommendation in this verdict.  This response shall be posted on the public CSC website within six months of the date of this verdict.
66. Within thirty (30) days of the receipt of this jury's verdict and recommendations, CSC will take steps so that the verdict and recommendations are:
    1. Permanently posted in writing in every institution and regional treatment centre operated by CSC, in a place or places that are frequented by all staff;
    2. Made permanently available for the public on the CSC website, and for all CSC staff on the CSC “Hub” (intranet site); and
    3. Sent to all staff (full-time, part-time, and contract or casual) by email by institutional senior management in every institution and regional treatment centre operated by CSC.

67. That the Office of the Correctional Investigator monitor and report publicly, and in writing, on the implementation of the recommendations made by this jury annually for the next 10 years.

Appendix A: The Ashley Smith Case Study

Held at:  Coroner's Court, Toronto
From: September 20, 2012
To: December 19, 2013
By: Dr. John Carlisle, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ashley Smith
Age: 19
Date and time of death:  October 19, 2007 at 8:10 a.m.
Place of death: St. Mary's General Hospital, Kitchener, ON
Cause of death: ligature strangulation and positional asphyxia
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on December 19, 2013
Coroner's name: Dr. John Carlisle
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Ashley Smith

Jury recommendations

We recommend:

1. That Ashley Smith’s experience within the correctional system is taught as a case study to all Correctional Service of Canada management and staff at the institutional, regional and national levels. This case study can demonstrate how the correctional system and federal/provincial health care can collectively fail to provide an identified mentally ill, high risk, high needs inmate with the appropriate care, treatment and support.  This case study can also demonstrate the lack of communication, cohesiveness, and accountability of a large organization such as Correctional Service of Canada.
2. That the Ashley Smith case study be designed for all existing and future CSC management and staff, offering a comprehensive understanding and gaps analysis of the practices that occurred leading to this case.  This case study will include documents and evidence presented throughout the Ashley Smith Coroner’s Inquest, specifically:
   • The Jury’s Recommendations, December 2013.
   • Report to Coroner Investigating the Death of Ashley Smith at Grand Valley Institution for Women (GVI), October 11, 2013, University of Toronto, Professor Kelly Hannah-Moffat (Exhibit 206).
   • A Preventable Death, June 20, 2008, Correctional Investigator of Canada (pages 1-30) (Exhibit 22).
   • The Ashley Smith Report, June 2008, Ombudsman and Child and Youth Advocate (excerpts) (Exhibit 6).

The provision of mental health care to federally sentenced women

A. Within penitentiaries

3. That, within 72 hours of admission to any penitentiary or treatment facility, all female inmates will be assessed by a psychologist to determine whether any mental health issues and/or self-injurious behaviours exist.
   1. That, should an inmate be identified as having high needs mental health issues and/or self-injurious behaviours, the Chief of Psychology will notify the Institutional Head, Rights Advisor and Inmate Advocate (RA-IA). (The role of the RA-IA is defined in Recommendations 73-75.) The role of the RA-IA is defined in Recommendations 73-75., Women Offender Sector, and the Regional Complex Mental Health Committee in writing within 48 hours of assessment.
   2. That this process of assessment will continue to be conducted on an on-going basis and as required by the inmate.
   3. That the Chief of Psychology implements a plan of effective treatment strategy which will be documented and shared as required.

4. That a full range of effective therapeutic interventions are:
   1. individualized to the needs of female inmates considering her self-identified needs, regardless of their security classification, status, or placement;
   2. enhanced to include de-escalation training, and art, music, or pet therapy;
   3. trauma-, age-, and gender-informed, and developmentally appropriate; and
   4. determined and authorized by mental health staff.

5. That Correctional Service of Canada (CSC) create a permanent peer support program, with highly trained and qualified peer support workers in each of the women’s penitentiaries that:
   1. is available to all women, including segregated women and regardless of security status, upon their request, 24 hours a day;
   2. provides training and on-going support for the peers by women-centred psychologists and social workers;
   3. ensures confidentiality between the female inmate and the peer to the greatest extent possible;
   4. can be utilized during an incident of self-injurious behaviour, if requested; and
   5. is offered to women actively engaged in self-injurious behaviour or at risk of engaging in self-injurious behaviour as a therapeutic intervention.

6. That CSC ensure nursing services are present on-site for inmates on a 24 hour per day, 7 day per week basis, as well as available to staff for consultation.
7. That CSC access community mental health services by developing partnerships with external mental health experts.
8. That there be adequate staffing of qualified, mental health care providers with expertise and experience in treating a population with mental health issues, self-injurious behaviours, suicidality, and trauma, at every women's institution to provide services and supports to female inmates.  These providers will include:
   1. Psychiatrists;
   2. Psychiatric Nurses or Nurses;
   3. The Chief Psychologist (It is further recommended that, whether working in the position indeterminately or in an acting capacity, the Chief Psychologist must hold a Ph.D. in Clinical Psychology and be a member in good standing of the Ontario College of Psychologists, or provincial equivalent.)
   4. Psychologists;
   5. Social Workers;
   6. Behavioural Counsellors and/or Recreational Counsellors. (It is further recommended that behavioural counsellors have qualifications to counsel in behaviour.  Otherwise, it is recommended that the title of Behavioural Counsellor is amended to Behavioural Therapy Coordinator.)
   7. General Practitioners; and
   8. Other professional service providers, as required.

9. That CSC expand the scope and terms of psychiatrists’ contracts to enable them to fulfill their duties in a meaningful way.
10. That all staff providing mental health care will report to, and be accountable to, health care, not security, and that the therapeutic relationship should not be compromised by the assignment of security-focused assessments.
11. That CSC organize and fund secondments for nursing staff to psychiatric wards of local Schedule 1 hospitals, or other specialized mental health institutions.  These secondments are to be of sufficient length and completed with regularity.  This will ensure the continual improvement of their knowledge and skills in the provision of mental health care, services and supports to female inmates, and their knowledge of community nursing practices and standards generally.
12. That the decision to disclose information to security by a mental health care provider should be governed by the applicable legislation, and professional and ethical standards, bearing in mind that reporting may affect the therapeutic relationship.  The decision to disclose must also take into account the paramount duty of CSC to ensure the safety of the inmate.  Service providers should be encouraged to consult with their professional governing bodies or colleagues when determining the necessity of disclosure.
13. That CSC create an institutional social worker position or positions whose responsibility will include working in consultation with local Canadian Association of Elizabeth Fry Societies (CAEFS), and other community groups, to identify, coordinate and access available community services, including mental health services and supports.  The mandate of this position would include the dissemination of information regarding the availability of, and assistance with connecting to, such services and supports to female inmates and to staff (including contract-based clinicians).
14. That CSC be required to provide all contract physicians with copies of Commissioner’s Directives, including revisions to Commissioner’s Directives, that govern their practice within the penitentiary.

B. Alternatives to penitentiary

15. That female inmates with serious mental health issues and/or self-injurious behaviours serve their federal terms of imprisonment in a federally-operated treatment facility, not a security-focussed, prison-like environment.
16. That female inmates who have been identified as having serious mental health issues and/or self-injurious behaviours be promptly transferred to such a facility as soon as reasonably practicable.
17. That such a facility or facilities be made available at least on a regional basis, and particularly in Ontario.  It is urged that more than one federally-operated treatment facility is available for high risk, high needs women in the event that a major conflict occurs between the inmate and staff.  Furthermore, and specifically, that existing male federally-operated treatment facilities be adapted to accommodate a wing for female inmates.
18. That CSC negotiate arrangements with provincial health care facilities to provide long-term treatment to female inmates who chronically engage in self-injurious behaviour or display other serious mental health problems.  Further:
    1. that the Government of Canada sufficiently and sustainably funds the CSC to enter into such agreements;
    2. that this will include any and all capital and operating costs associated with the establishment of such facilities, and that the accommodation and treatment of female inmates therein will be the responsibility of CSC;
    3. that the focus of such a facility be on the preparation for treatment of, and treatment of, the inmate; and
    4. that a female inmate with mental health issues and/or self-injurious behaviour who is not consenting, and/or withdraws consent, to treatment remain in a pre-contemplative therapeutic environment for the purpose of allowing health care professionals to seek her consent to treatment.

19. That decision-making with respect to the clinical management and interventions of inmates with mental health issues are made by clinicians in consultation with the inmate, rather than by security management and staff.
20. That a treatment facility has the capacity to be designated as the home facility of a female inmate serving her sentence therein.
21. That such a facility in Ontario, or a part thereof, be designated as a Schedule 1 facility under the Ontario Mental Health Act.
22. That inmates in such facilities must have access to an independent patient advocate system, equivalent to the advocacy system to be provided to inmates in penitentiaries, pursuant to these recommendations, including the newly adopted RA-IA (see Recommendations 73-75).

Management of complex high needs female inmates

23. That a treatment team is created at the institutional level to support high needs female inmates with a consistent and dedicated team of qualified health professionals, which will include psychiatrists, psychologists and general practitioners, and that such a team:
    1. meet during the psychiatrist’s regular visits at the institution in order to provide on-going, timely, and regular care to inmates;
    2. support the inmate regardless of her security classification, status, or placement within the institution;
    3. seek input from the inmate about the efficacy of her therapeutic relationships and interventions on an on-going basis;
    4. seek input from frontline staff assigned to support the inmate with mental health care needs; and
    5. develop management plans for the purposes of therapeutic intervention and preventative measures.  This plan will take into account the inmate’s past experiences of trauma, and the potentially traumatic effects of being incarcerated, segregated and/or restrained, and further, that such management plans are developmentally-appropriate, and age- and gender-informed.

24. That the selection of the frontline staff assigned to a female inmate will consider:
    1. the skill and interest of the frontline staff;
    2. the wishes of the inmate
    3. input from the treatment team

25. That CSC maintain a roster of external psychologists and psychiatrists to provide a second opinion regarding treatment, services and/or recommendations when challenging behaviours are identified.
26. That an external and independent review be conducted of the Regional and National Complex Mental Health Committees to determine their efficacy, and identify opportunities for improvements.

Segregation and seclusion

27. That, in accordance with the Recommendations of the United Nations Special Rapporteur’s 2011 Interim Report on Solitary Confinement, indefinite solitary confinement should be abolished.
28. That there should be an absolute prohibition on the practice of placing female inmates in conditions of long-term segregation, clinical seclusion, isolation, or observation.  Long-term should be defined as any period in excess of 15 days.
29. That until segregation and seclusion is abolished in all CSC-operated penitentiaries and treatment facilities:
    1. CSC restricts the use of segregation and seclusion to fifteen (15) consecutive days, that is, no more than 360 hours, in an uninterrupted period;
    2. That a mandatory period outside of segregation or seclusion of five (5) consecutive days, that is, no less than 120 consecutive hours, be in effect after any period of segregation or seclusion;
    3. That an inmate may not be placed into segregation or seclusion for more than 60 days in a calendar year; and
    4. That, in the event an inmate is transferred to an alternative institution or treatment facility, the calculation of consecutive days continues and does not constitute a “break” from segregation or seclusion.

30. That conditions of segregation be the least restrictive as possible for inmates and determined on a case by case basis – female inmates in segregation should, as much as possible, have access to programs, activities, and facilities and have contact with other inmates, staff, visitors, and non-governmental organizations, such as CAEFS.
31. That, as a mandatory duty, the Institutional Head will visit all inmates in segregation, seclusion, or medical observation at least once every day, in addition to meeting with individual inmates upon their request.  This meeting is not to be accomplished through the food slot under any circumstance, and:
    1. that, on days when the Institutional Head is away, the visit will be conducted by the highest authority; and
    2. that any such authority must report in writing to the Institutional Head the findings and outcomes of such visits.

32. That, as a mandatory duty, a mental health professional will visit all inmates in segregation, seclusion, or medical observation at least once every day, in addition to meeting with individual inmates upon their request.  This visit will pay particular attention to both the mental and physical health of such inmates, with a focus on assessing the inmate’s tolerance to segregation. This meeting is not to be accomplished through the food slot under any circumstance.
33. That a sub-roster team of frontline staff is dedicated to complex high needs female inmates in the segregation unit, with a minimum of one (1) to two (2) consistent staff at all times.  Such a team will ensure comprehensive and consistent support for the inmate.
34. That CSC repeal its existing Review of Offender’s Segregated Status Working Day Review policies and replace them with five (5) and ten (10) day reviews that are administered by way of consecutive calendar days.  This review will focus on the inmate’s needs and behaviours with the goal of returning the inmate to the general population.
35. That CSC amend its current policies to ensure that female inmates held in “seclusion” or “mental health observation” are recognized as being on “segregation status” and are therefore entitled to all relevant reviews.
36. That CSC make every effort to ensure that female inmates, including those in segregation or observation cells, have access to, and the opportunity to meet in private with, the RA-IA, Office of the Correctional Investigator, Citizens Advisory Committee, non-governmental organizations and community agencies.
37. That, for the purposes of monitoring and tracking, the Institutional Head will notify the following bodies once any inmate has been placed in segregation or seclusion, and that they will also be responsible for conducting a yearly review.
    1. Women Offender Sector;
    2. Mental Health Services Branch;
    3. Office of the Correctional Investigator;
    4. RHQ – Members of the Regional Complex Mental Health Committee; and
    5. NHQ – Members of the National Complex Mental Health Committee.

Restraints (physical and/or chemical)

38. That, in the development of any new policy on the use of restraints, CSC move toward a restraint-free environment by implementing a least restraint policy, and that this recommendation is reflected in CD 843.
39. That the application of restraints must be authorized by a psychiatrist or psychologist, and that this recommendation is reflected in CD 843.
40. That any inmate placed in restraints is given one-on-one therapeutic support for the entire time in restraints, and that this recommendation is reflected in CD 843.

Body cavity searches

41. That body cavity searches for female inmates may only occur in the following circumstances:
    1. with the consent of the inmate; or
    2. in the absence of consent, only in exceptional circumstances.  For greater clarity, exceptional circumstances will only exist when, in the opinion of a physician, there is a risk of death or serious bodily harm to the inmate or another person and the risk cannot be mitigated through any other reasonably available means. 
       
       All examinations are to be performed by a licensed medical professional at an external medical facility, in a manner most compatible with the inherent dignity of the inmate.  Correctional Service of Canada staff escorting the inmate to the external facility is to request that the examination be conducted by a female.

42. That, for the purposes of continuity of care, the institutional psychologist is notified within 24 hours of any body cavity search conducted on a female inmate, including those in treatment facilities.

Self-injurious behaviours

A. Reporting of incidents

43. That all incidents of self-injurious behaviour must be reported as such.
44. That all reports regarding incidents of self-injurious behaviour, incident reports and Officer Statement Observation Reports, must contain a detailed description of the nature of the self-injurious behaviour and a detailed description of any physical injury or changes in physical well-being of the inmate.
45. That all reports regarding incidents of self-injurious behaviour must be forthwith distributed to, and read by the following:
    1. the warden
    2. the chief of healthcare
    3. the chief psychologist
    4. women offender sector (for female inmates)
    5. Office of the Correctional Investigator
    6. RHQ – members of the Regional Complex Mental Health Committee
    7. NHQ – members of the National Complex Mental Health Committee
    8. for additional clarity, the duty to read such reports is not delegable, except in circumstances when the responsible officer is on leave, and even then, the responsible officer is to read such reports forthwith upon return to the institution

46. That following each incident of self-injurious behaviour a Referral for Consultation Form be completed by nursing staff and a copy of the psychology assessment in relation to the incident be appended to this form and this package be forwarded to the institutional psychiatrist.  The Chief of Healthcare will be responsible for ensuring this package is also provided to the institutional physician.

B. Responses to incidents

47. That if frontline staff determine that immediate intervention is required to preserve life, there is no requirement that they seek authorization prior to intervening, or prior to calling 911.
48. That, when an inmate is engaged in self-injurious behaviours, health care staff are on-site, on a 24 hour per day, 7 day per week basis, to support the intervention.
49. That, when an inmate is engaged in self-injurious behaviours, the institutional psychologist are on-call, on a 24 hour per day, 7 day per week basis, for the purposes of supporting the intervention and de-escalating the incident when deemed necessary by frontline staff.
50. That CSC develop a new, separate and distinct model, from the existing Situation Management Model, to address medical emergencies and incidents of self-injurious behaviour.
51. That the Situation Management Model not be resorted to in any perceived medical emergency.

52. That, when reporting a Use of Force intervention to preserve the life of an inmate who has self-harmed, an expedited reporting system will apply.  Further, all such incidents should be reviewed, within 48 hours, by:

    1. the warden
    2. the chief of healthcare
    3. the chief psychologist
    4. women offender sector (for female inmates)
    5. Office of the Correctional Investigator
    6. RHQ – members of the Regional Complex Mental Health Committee
    7. NHQ – members of the National Complex Mental Health Committee

    The review will focus on the mental health needs of the inmate, her behaviour and its lethality, as well as the response of frontline staff, including its appropriateness. It will assist and support the well-being of the inmate, in addition to the efforts of the institution and frontline staff. It will also include strategies to manage the inmate in a safe manner, and encourage staff to exercise good judgment.

53. That CSC policy state that any item used by an inmate for self-injury be classified as contraband.
54. That any inmate engaged in self-injurious behaviour must have a Management Plan in place within 24 hours of the first self-injurious incident, and that plan must address how staff is to respond to self-injurious behaviours.

Responses to misconduct by inmates with mental health issues

55. That, to reduce institutional or criminal charges laid against an inmate, CSC adopts the methods of the St. Lawrence Valley Correctional and Treatment Centre model of care for disruptive or self-injurious behaviours symptomatic of a mental health disorder.
56. That, if a complaint is made to police in regard to alleged misconduct by an inmate with mental health issues, (occurring in the context of an incident of self-injurious behaviour), the Security Intelligence Officer will provide police with complete information.  This will include the:
    1. behaviour that is alleged to amount to a criminal offence
    2. context in which that behaviour occurred
    3. circumstances of the incident of self-injurious behaviour

57. That, if a criminal charge is laid in regard to alleged misconduct by an inmate with mental health issues, (occurring in the context of an incident of self-injurious behaviour), a staff member who was not involved in the incident, and is selected with input from the inmate (preferably a member of her interdisciplinary team), will:
    1. attend any court appearances with the inmate
    2. advise the prosecutor of his/her presence
    3. provide any information that is required by the court to deal appropriately with the charge.

Transfers / assignments of home institutions

58. That female inmates be accommodated in the region most proximate to her family and social supports.  This principle is a priority for young adults and/or female inmates with mental health issues and/or self-injurious behaviours.
59. That non-emergency transfers of female inmates with mental health issues and/or self-injurious behaviours will occur only when it is aligned with the clinical needs of the inmate.  Non-emergency transfers of female inmates with mental health issues and/or self-injurious behaviours will not occur for reasons related to constraints within the institution, or challenges related to the management of the inmate.
60. That subject to the above, a female inmate may be transferred to an institution or treatment facility so long as that transfer has the approval of clinicians (psychiatrist and/or psychologist) in the sending and receiving institutions.  Prior to her discharge a current written plan must be in place for re-integrating the inmate to her home institution.
61. That, in the event a female inmate is transferred away from her home institution, the following measures will address the disadvantages that result from being detained in a location away from home. Such measures may include, but are not limited to:
    1. Longer visits from family or support persons chosen by the inmate.
    2. Increasing the inmate’s access to family or support persons via telephone, videoconference, and/or web-cast, for example, Skype or Facetime.
    3. Providing the inmate’s family or support persons with appropriate access to telephone, videoconference and/or web-cast, when they are unable to visit the inmate due to financial restrictions.
62. That, in the event of a transfer, an inmate’s/patient’s medical file accompanies her during the transfer to ensure continuity of care.
63. That the receiving Treatment Team will connect with the sending institution’s Treatment Team to share best practices, success stories, triggers, and recommendations.
64. That CSC create and implement an electronic medical database to facilitate access to medical information between sending and receiving penitentiaries and treatment facilities.
65. That no transfer occurs on a Friday or holiday given the reduced number of on-site staff at these times.

Transition protocol for young adults

66. That CSC establish separate and distinct programs and services for young adults, that is, 18-21 year olds, within adult institutions which will be geared toward their cultural and developmental needs (for example, educational, vocational, therapeutic, as appropriate to specific needs and situations).
67. That CSC develop training to prepare staff to recognize and respond to the particular issues faced by a young adults housed in an adult institution.
68. That CSC develop a transition protocol that begins before a young adult is placed in, or transferred to, an adult institution, and which has the following features:
    1. provides clear and structured process for transition which is understood by incarcerated young adults and institutional management and staff;
    2. provides guidance on roles and responsibilities for those involved in the transition process
    3. provides guidance on identifying needs and sharing information during the transition process
    4. helps build relationships between young offender and adult institution in order to support continuation of care

Contact with family for young adults

69. That CSC facilitate, support, and document, at minimum, weekly communications by:
    1. increasing the inmate’s access to family or support persons via telephone, videoconference, and/or web-cast, for example, Skype or Facetime; and
    2. providing the inmate’s family or support persons with appropriate access to telephone, videoconference and/or web-cast, when they are unable to visit the inmate due to financial restrictions.

70. That CSC streamline the approval process for visits and contact with families and support persons of young adults.  In particular, it will be conducted at a national level such that their families and support persons are not subjected to a repeated approval process at each institution.
71. That health care professionals advise young adults of the benefits of providing consent to disclose health information to their families or support persons.
72. That, at an institutional level, young adults are consulted on an on-going basis to determine if their needs for particular activities and programs are being met.

Oversight

A. Internal mechanisms

73. That CSC implement an independent RA-IA for all inmates, regardless of security classification, status, or placement. The institution will be responsible for advising all inmates of the existence of, and their right to contact, the RA-IA.
74. That the RA-IA will be responsible for providing advice, advocacy and support to the inmate with respect to various institutional issues, including:
    1. transition into institutions
    2. transfers
    3. security classification, status, or placement
    4. parole and release eligibility, including escorted and unescorted absences
    5. temporary absences
    6. use of restraints – physical and chemical
    7. seclusion and segregation
    8. complaints and grievances
    9. consent to treatment and capacity to consent
    10. consent to medication, including available alternatives
    11. consent to disclosure of information
    12. institutional and criminal charges

75. That inmates are protected from reprisals related to contacting the RA-IA and exercising their rights.

B. External mechanisms

76. That the Citizen Advisory Committee have unrestricted and unannounced access to local CSC-operated institutions at any time and be provided with the opportunity to speak with any female inmate, including those in segregation.  These discussions will take place in private, out of hearing of staff.
77. That Citizen Advisory Committees are required to publish annual reports, and that CSC facilitate the publication of these reports on their website.
78. That non-governmental organizations, including CAEFS advocates, have broad access to local CSC-operated institutions at any time and be provided with the opportunity to speak with any female inmate, including those in segregation.  These discussions will take place in private, out of hearing of staff.

Safety and security

79. That CSC improve the layout of the electronic control panel that opens pod and segregation doors to minimize human error. Specifically, do not have segregation buttons directly beside pod buttons.

Ethics / whistleblower protection

80. That an enhanced Code of Ethics be created that explicitly applies to all Correctional Service of Canada employees, from the Commissioner down to frontline staff, and that this enhanced Code will:
    1. address preservation of life;
    2. include provisions with the following language: “staff should be allowed to refuse to follow orders or directions without fear of discipline or reprisal whether they are right or wrong as long as there was an air of reality to the ethical/legal objection”;
    3. include a provision that affirms the right of all CSC staff members to report an order they believe to be illegal without fear of reprisal;
    4. include a provision that addresses the individual accountability of all CSC staff and management, for example:
    5. “Prison staff at all levels shall be personally responsible for, and assume the consequences of, their own actions, omissions or orders to subordinates”; and
    6. include a provision that addresses the obligation of all CSC staff to respect and protect everyone’s right to life, the obligation to ensure the full protection of the health of persons in their custody and the obligation to secure immediate medical attention whenever required.

81. That this enhanced Code of Ethics be taught in CORE and management training.  Additionally, refresher courses will be conducted at the institutional level for all CSC staff, contract and otherwise.
82. That all management are responsible, and held accountable, for ensuring that this enhanced Code of Ethics is communicated to their staff.

Policy development

83. That inmates who have experienced mental health issues within correctional systems be involved in planning, research, training and policy development with respect to the provision of mental health care for female inmates.
84. That CSC repeal the section dealing with “Involuntary Admission and Treatment” in CD 803, or revise it to conform with community medical practices to ensure equivalency of care for inmates. Specifically, that CSC revise or repeal the requirements that:
    1. a physician must assess a patient in-person before providing orders for involuntary medical treatment; and
    2. all orders for involuntary health interventions be made in writing.

85. That CSC establish separate and distinct policies for young adults, that is, 18-21 year olds, within adult institutions which will be geared toward their cultural and developmental needs (for example,. educational, vocational, therapeutic, as appropriate to specific needs and situations).

Staff burnout

86. That, upon recognizing burnout in themselves, staff are responsible for raising their concerns to management, and further, that management is responsible for acting upon these concerns and facilitating support.
87. That, to alleviate pressures and avoid staff burnout, the Institutional Head implements mandatory regularly scheduled respite intervals to frontline staff who primarily deal with complex high needs inmates.

Training and education

88. That CSC develop training to prepare staff to recognize and respond to the particular issues faced by a young adults housed in an adult penitentiary.
89. That managers and frontline staff who are designated to support high needs female inmates with mental health and/or self-injurious behaviours be offered training in the following areas:
    1. fundamentals of mental health issues and self-injurious behaviours;
    2. First Aid / CPR (current certifications based on community standards);
    3. impacts of segregation on mental health, including that of young adults;
    4. trauma-informed care (for example,. post-hostage-taking); and
    5. medical distress and its intervention (delivered by an external clinician).

90. That all newly appointed Wardens and Deputy Wardens (whether the positions be on an acting or indeterminate capacity) have weekly mentoring sessions with an experienced mentor.  These mentoring sessions will take place for at least one full year to provide the mentee with guidance, advice, and support throughout their first year in their newly appointed position.  Ideally, the mentor is located in a region different from the mentee.
91. That CSC provide training and education to staff on restraint minimization and de-escalation techniques, and that any such training includes hearing from persons with lived experience who have directly experienced being placed in restraints.
92. That CSC provide all management and staff with essential refresher training to ensure they maintain the appropriate knowledge and skillsets to fulfill their roles and responsibilities.
93. Authority Of The Deputy Commissioner For Women
94. That the Deputy Commissioner for Women has direct line authority over all matters relating to female inmates.  This gives clear authority and accountability to a single body that provides specialized correctional services to female inmates.
95. That the female inmates’ institutions be grouped under a reporting structure independent of the Regions.
96. That, in the formation of this new reporting structure, careful consideration is given to the assignment of new positions specifically so that current employee’s qualifications, skill sets and competencies are considered for best fit into the newly formed positions.

Research and knowledge transfer

96. That CSC foster working relationships with qualified mental health professionals from academic health sciences organizations (for example,. Centre for Addiction and Mental Health) and research universities. These partnerships will focus on developing treatment strategies and therapeutic practices, as supported by current literature of evidence of effectiveness, specifically for women with mental health illnesses including those engaging in self-injurious behaviour and those in segregation.
97. That CSC revitalize and continue with the research on the emergence of the third group of women who do not respond to psychotherapy or dialectical behavioural therapy.
98. That CSC implement communication structures between units conducting research at National Headquarters (for example,. Research Unit and Women Offender Sector) and local institutions to effectively disseminate information to staff through regular institutional visits.  Research staff will share relevant literature on effective therapeutic interventions with health care, mental health staff and senior management.
99. That CSC implement ongoing, internal communication structures between frontline, mental health, and health care staff as well as senior management, to effectively disseminate information. Health care and mental health staff will allocate time to meet and discuss relevant literature, complex cases and effective therapeutic interventions with frontline staff and senior management.

Accountability

100. That an independent, external audit be contracted by the Minister of Public Safety of CSC’s compliance with this jury’s recommendations.  This audit will be conducted in consultation with the Office of the Correctional Investigator, and the results of such audit will be released publicly during the 2016-2017 and 2023-2024 fiscal years.
101. That the Auditor General of Canada conduct a comprehensive audit of the jury’s recommendations and that the results of such audit be released publicly in 2019-2020.

Verdict and recommendations

102. That this jury’s verdict and recommendations regarding the Inquest into the Death of Ashley Smith is posted in writing in every institution and treatment facility operated by the Correctional Service of Canada, in a place accessible to all staff, within thirty (30) days of the receipt of the verdict and recommendations.
103. That an electronic copy of this jury’s verdicts and recommendations is made available for the public on the CSC website, for staff’s reference on the CSC intranet, and that staff are immediately made aware by management.
104. That the Office of the Correctional Investigator monitor and report publicly, and in writing, on the implementation of the recommendations made by this jury annually for the next 10 years.es années.

Maguire, William Dean
Bruin, William
Gerrard, Norman

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: February 5
To: February 13, 2024
By: Dr. Bonnie Goldberg, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: William Dean Maguire
Age: 60
Date and time of death:  March 27, 2018 at 10:33 a.m.
Place of death: Billy Bishop Toronto City Airport, Toronto
Cause of death: blunt impact head trauma
By what means: accident

Name of deceased: William Bruin
Age: 33
Date and time of death:  September 15, 2017 at 1:18 p.m.
Place of death: St. Michael’s Hospital, Toronto
Cause of death: multiple trauma
By what means: accident

Name of deceased: Norman Gerrard
Age: 48
Date and time of death:  March 20, 2019 at 5:30 a.m.
Place of death: Sunnybrook Health Sciences Centre, Toronto
Cause of death: multiple blunt force trauma
By what means: accident

(Original signed by: Foreperson)

The verdict was received on February 13, 2024
Coroner's name: Dr. Bonnie Goldberg
(Original signed by presiding officer for Ontario)

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

Inquest into the deaths of: William Dean Maguire, William Bruin, Norman Gerrard

Jury recommendations

To the Ministry of Labour, Immigration, Training and Skills Development (MLITSD):

1. Amend Ontario Regulation 213/91: Construction Projects to require an employer to ensure that a site and task-specific fall protection work plan be developed in writing prior to a worker working at heights, implemented while a worker is working at heights and updated as necessary to identify new hazards and controls. The required fall protection work plan must be reviewed with any worker(s) working at heights.
2. Amend the Working at Heights Training Program Standard to require that the following information is included:
   1. Real-life stories of workers, such as William (Dean) Maguire and other workers who have experienced workplace tragedies resulting from falls from heights, including, for example, the circumstances surrounding their deaths, the safety lessons to be learned and the impact on their families, friends and co-workers.
   2. Issues and challenges relating to workplace culture on construction projects, including:
      1. The dangerous and ongoing impact of complacency while working at heights.
      2. The importance of a worker complying with the requirement to report health and safety concerns to a supervisor or employer to protect other workers and trades on site (i.e. "if you see something, say something").
   3. An employer’s requirement to ensure that a site and task-specific fall protection work plan be developed prior to a worker working at heights, implemented while a worker is working at heights and updated as necessary to identify new hazards and controls, should the amendment to Ontario Regulation 213/91: Construction Projects described in Recommendation #1 be made.

To the MLITSD and the Infrastructure Health and Safety Association:

3. Develop a campaign to communicate the new regulatory requirement for a site and task-specific fall protection work plan, should the amendment to Ontario Regulation 213/91: Construction Projects described in Recommendation #1 be made.

To the Infrastructure Health and Safety Association (IHSA:

4. Develop educational information and resources to be promoted and distributed as part of the campaign to communicate the new regulatory requirement for a site and task-specific fall protection work plan described in Recommendation #3, should the amendment to Ontario Regulation 213/91: Construction Projects described in Recommendation #1 be made.
5. Develop a campaign to increase industry and public awareness of issues and challenges relating to workplace culture on construction projects, including:
   1. The dangerous and ongoing impact of complacency while working at heights.
   2. The importance of a worker complying with the requirement to report health and safety concerns to a supervisor or employer to protect other workers and trades on site (i.e. “if you see something, say something”).
   3. The importance of a constructor ensuring that site inspections by their supervisor(s) are sufficient to ensure that the set up and use of fall protection equipment will not endanger a worker.
6. Develop educational information and resources to be promoted and distributed as part of the campaign to increase industry and public awareness of issues and challenges relating to workplace culture on construction projects described in Recommendation #5. This campaign must feature real-life stories of workers, such as William (Dean) Maguire, who have experienced workplace tragedies resulting from falls from heights, including, for example, the circumstances surrounding their deaths, the safety lessons to be learned and the impact on their families, friends and co-workers.
7. Update the IHSA’s Working at Heights Training Course to include the following information:
   1. Real-life stories of workers, such as William (Dean) Maguire, who have experienced workplace tragedies resulting from falls from heights, including, for example, the circumstances surrounding their deaths, the safety lessons to be learned and the impact on their families, friends and co-workers.
   2. Issues and challenges relating to workplace culture on construction projects, including:
      1. The dangerous and ongoing impact of complacency while working at heights.
      2. The importance of complying with the requirement to report health and safety concerns to a supervisor or employer to protect other workers and trades on site (i.e. “if you see something, say something”).
   3. The new regulatory requirement for a site and task-specific fall protection work plan, should the amendment to Ontario Regulation 213/91: Construction Projects described in Recommendation #1 be made.
8. Publish a health and safety advisory on the safe set-up and use of self-retracting lifelines. This advisory would focus on anchor point locations and capabilities, fall clearance calculations and the importance of following the manufacturer’s operating manuals, and would include information regarding how and where these operating manuals can typically be accessed (i.e. in paper format or online).
9. Publish a health and safety advisory on the importance of inspecting fall protection equipment before use and the importance of following the manufacturer's operating manuals. This advisory would highlight the risks of a worker using fall protection equipment that does not belong to themselves or their employer.
10. Enhance the IHSA’s Supervisor Training to include information on how to fulfill supervisory duties, including responsibilities for working at heights.
11. Enhance the IHSA's Fall Protection Work Plan to include the contact information (phone number, website etc.) of the supervisor, constructor and MLITSD.

To the MLITSD and the Government of Ontario:

12. Provide additional funding to the IHSA to support the development of new and enhanced educational campaigns, information, resources, training and advisories described in Recommendations #3-11.

Smellie, Mark

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: February 12
To: February 15, 2024
By: Dr. Ronald Goldstein , presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Mark Smellie
Age: 54
Date and time of death:  March 15, 2019
Place of death: Muskoka Algonquin Health Centre, Huntsville Memorial District Hospital
Cause of death: cocaine toxicity
By what means: undetermined

(Original signed by: Foreperson)

The verdict was received on February 15, 2024
Coroner's name: Dr. Ronald Goldstein
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Mark Smellie

To the Ontario Provincial Police (OPP):

1. When a person is detained roadside who is suspected of being in possession of an illegal substance and or drug, notes should be made as soon as practicable regarding:
   1. Behaviour of the detainee, including but not limited to characteristics of speech, eye contact, emotional state, gait and cognition – any signs of drug consumption.
   2. Any actions which suggest ingestion and or secretion.
   3. Any observations of disposal of drugs.
   4. Officers should be wearing body worn cameras.
2. At the scene of detention, when a person who is detained is suspected of ingesting and or secreting illegal drugs and or substances; a caution should be read warning the person about sharing that information and the medical consequences of not sharing that information. Notes should be made of the time the warning is given and what was said.
3. A transportation officer who is transporting a detained person in a police vehicle who is suspected of ingesting or secreting illegal drugs or substances should pay attention to the detained person’s behaviour and make detailed notes.
4. During the booking process, in an OPP detachment, if a detained person is suspected of ingesting and or secreting illegal drugs and or substances, then, the caution on the wall signage should be pointed out, read out loud and the detainee should be asked to read the sign. Notes of the time and what was said should be made. Require that the arrested person acknowledges with signature that they have read and understands the caution.
5. If a strip search is ordered (based on the suspicion of drug ingestion or secretion) and does not yield any results, then, determination of whether the detainee needs to be taken to a hospital for a medical assessment and imaging should be discussed and documented in the notebooks of any officers participating in the discussion.
6. There should be, in a dry cell, a caution on the wall which mirrors the caution in the booking area to remind the detainee of the dangers of ingesting and or secreting illegal drugs and or substances and the importance of sharing that information.
7. The caution on the wall signage at the entrance to the cell should be read out loud and pointed out to the detainee when the detainee is lodged in the dry cell.
8. If a privacy gown is provided, close observation of the detainee should be conducted to ensure that the detainee is not removing any illegal drugs and or substances from their body.
9. Video surveillance of the dry cell should have audio as well.
10. There should be focused training, on protocols and policies, for guards and police, in respect of detainees who are detained and suspected of ingesting and or secreting illegal drugs and or substances.
11. Guards, in the detachments, should record conversations with detainee by using a recording device or notes in a notebook; and or be wearing a body worn camera if feasible.
12. The binder of rules, procedures and training, should be accessible (on-line) so that prison guards have access to the binder at all times.
13. OPP orders, which include policies and procedures, should be universally available online with appropriate secure credentials.
14. There should be designated training periods for the detachment guards in respect of protocols for observing a detainee who may have secreted or ingested illegal drugs and or substances and experiencing medical crisis.
15. Consider a universal caution used by all OPP detachments which outlines the potential for a body scan.
16. Consider performing body scans when circumstances require it other than in exigent circumstances.
17. A policy should be developed in regards to dry cells
    1. lear understanding between the detachment guard and the detachment SGT as to steps taken to ensure the dry cell is prepared to accommodate the detainee
    2. what should be provided to the detainee being watched; blanket, privacy gown
    3. how often observations are recorded
    4. ensure all water turned off to the cell and the detachment guard is made aware of any steps taken

Elliot, Jayson

Held at:  virtual, Ottawa
From: February 26
To: March 1, 2024
By: Mr. Selwyn Peters , presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jayson Elliot
Age: 50
Date and time of death:  May 11^th, 2021, at 8:57 p.m.
Place of death: Ottawa-Carleton Detention Centre 2244 Innes Road, Ottawa
Cause of death: choking on food
By what means: accident

(Original signed by: Foreperson)

The verdict was received on March 1, 2024
Coroner's name: Mr. Selwyn Peters
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Jayson Elliot

To the Ottawa-Carleton Detention Centre (OCDC):

1. Provide cellular telephones to on-duty correctional officers at the Sergeant level and above for use in notifying Emergency Medical Services (EMS).
2. Enhance current scenario-based training provided to nursing staff and correctional officers. This training should:
   1. Be done on a recurring basis and should be mandatory for nursing staff and correctional officers.
   2. When possible, utilize external entities such as such as the Ottawa Hospital or other local hospitals and external medical staff.
   3. Include realistic scenarios involving persons in custody where the person is unresponsive and/or is suffering from an obstructed or damaged airway.
   4. When possible, be conducted in a facility or environment that can accommodate training scenarios and/or simulate the environment of a correctional institution.
   5. Include training on coordination, cooperation, and communication between correction officers and nursing staff during a medical emergency, including training on “closed loop” communication when appropriate.

To the OCDC, the Ministry of the Solicitor General, and the Government of Ontario:

3. Conduct regular audits of on-site medical equipment at the OCDC and at all provincial correctional facilities to:
   1. Ensure that all available medical equipment is up to date.
   2. Review and add to medical equipment as necessary to be consistent with the needs of medical/nursing staff.
   3. Ensure that medical/nursing staff is properly trained on the use of all medical equipment.
   4. Assess and determine whether medical “crash carts” can be made available at correctional institutions.
   5. Explore options for new, more compartmentalized medical bags to be made available at correctional institutions.
4. Consider providing enhanced Basic Life Skills training to nursing staff similar to that provided to first responders and advanced cardiac care providers.
5. Review and revise nursing emergency response protocols to include:
   1. Nurses responding to a medical emergency, when reasonably possible, should bring with them a fully equipped portable medical response bag or crash cart.
6. Conduct a review of current peer support and other support offered to nursing staff, correctional staff and witnesses following a critical incident to ensure that it is consistent across the province and consistent with other peer support programs provided to first responders which is trauma-informed, and which includes voluntary debriefings when appropriate.
7. Should consider providing access to the same radio communication tools that correctional officers use for nurses.
8. Provide institutional nursing staff with motorized suction devices for use in clearing a patient’s obstructed airway.

To the Government of Ontario and the Ministry of the Solicitor General:

9. Should consider annual meetings of medical/nursing leads across institutions in Ontario to review critical events for the purpose of identifying opportunities for improvement.
10. Seek and allocate adequate funding and resources to implement these recommendations.

Cudini, Luigi
Jennings, Shane

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: February 26
To: March 7, 2024
By: Dr. Mary Beth Bourne, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Luigi Cudini
Age: 54
Date and time of death:  March 27, 2015 at 11:22 a.m.
Place of death: 1830 Bloor Street West, Toronto 
Cause of death: blunt force head injury due to fall from height
By what means: accident

Name of deceased: Shane Jennings
Age: 37
Date and time of death:  March 27, 2015 at 11:59 a.m .
Place of death: St. Michaels’ Hospital, Toronto 
Cause of death: blunt force body injury due to fall from height
By what means: accident

(Original signed by: Foreperson)

The verdict was received on March 7, 2024
Coroner's name: Dr. Mary Beth Bourne
(Original signed by presiding officer for Ontario)

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

Inquest into the deaths of: Luigi Cudini and Shane Jennings

To the Ministry of Labour, Immigration, Training and Skills Development (MLITSD):

1. Amend Ontario Regulation 213/91: Construction Projects to require that mast climbing work platforms (MCWPs) be specifically referenced in the table at section 144(6) to require that those who design MCWPs adhere to Canadian Standards Association (CSA) standard B354.9, as may be amended.
2. Amend Ontario Regulation 213/91: Construction Projects to require that those who manufacture, use or train others to use MCWPs adhere to CSA standards for mast climbing work platforms B354.10 (Safe Use) and B354.11 (Training), as may be amended.

3. Given:

   1. the passage of almost 9 years since the deaths of Luigi Cudini and Shane Jennings
   2. the fact that CSA standards contain best practices for the design, manufacture, use and training with respect to MCWPs, and
   3. the fact that CSA standards for MCWPs existed at the time of this fatal accident but were not referred to in Ontario Regulation 213/91: Construction Projects

   we urge MLITSD to give priority to the above two recommendations, in order to prevent any further deaths.

4. Urgently consider and investigate whether non-destructive testing of MCWPs should be conducted annually or more frequently than outlined in the current CSA standards, and if so, amend the regulations accordingly.
5. Forthwith update and publish annually the Alert previously issued on June 22, 2015, because of these deaths, pending any regulatory changes that may currently be underway and/or pending the implementation of recommendations 1, 2, 3 and 4 above.
6. Develop and implement a campaign to communicate the new regulatory requirements when Ontario Regulation 213/91: Construction Projects is finally amended, as recommended in 1, 2 and 4 above.
7. Forward a copy of these recommendations to the Construction Legislative Review Committee, a sub-committee of the Provincial Labour Management Health and Safety Section 21 Committee.

To the Infrastructure Health and Safety Association and the Provincial Labour Management Health and Safety Committee:

8. Issue an alert/bulletin to the industry highlighting the recommendations of this Inquest. This alert/bulletin should contain a recommendation that all manufacturers and owners of MCWPs review and implement all CSA recommended inspections forthwith, including non-destructive testing as outlined in CSA-354.10-17 Section 12.7. Any required repairs should be implemented before the MCWP can be used. The alert should also reference the existing CSA welding standards for MCWPs.
9. Issue an alert/bulletin to the industry recommending that all owners of MCWPs implement the use of configuration-specific load charts mounted on the platform near the operator’s station, in all circumstances where the manufacturer’s load chart does not already adequately communicate the allowable load for the specific configuration or use.  The load charts should be clearly communicated through plain language and diagrams, and include the following information, to be updated anytime there is a change to the configuration of the MCWP:
   1. the allowable distributed load
   2. the location of the permissible distributed loads
   3. the allowable concentrated/point load and best location for this load on the platform
   4. the allowable number of workers on the platform corresponding to each of the above
10. Establish a working group and committee to review the elevating work platform regulations and examine the following areas of concern:
    1. Best practices with respect to design and manufacture of MCWPs
    2. Best practices with respect to quality control and inspections of all modules of MCWPs, with consideration of the best test methods to use and the frequency of inspections.  In this regard, reference can be made to similar existing requirements for tower cranes.
    3. Best practices with respect to safety protocols for the use of MCWPs.
    4. Development of and/or potential improvements to training programs so that users of MCWPs are educated about how to calculate the weight of loads more accurately, and where to place and distribute loads on a MCWP.  Consider requiring forklift operators who deliver loads to MCWPs to also receive the above training.
    5. Potential improvements to the required signage on MCWPs so that there is improved communication with respect to load capacities and load distribution.
    6. Potential improvements to record-keeping with respect to training, inspection, service, and maintenance of MCWPs, including consideration to require:
       1. That all records with respect to testing, maintenance and repairs be provided to any new owners when purchasing used MCWPs,
       2. That each MCWP module should be uniquely identified with a permanent serial number to facilitate record-keeping, and
       3. That a site binder be maintained and stored in the drive module of the MCWP containing a copy of all engineering drawings, maintenance and inspection records for an appropriate period of time, field assessments, and a list of trained workers.
    7. Whether prior to allowing a MCWP to be used, meetings with all users and potential users of MCWP be made mandatory whenever a MCWP undergoes a configuration or location change that affects loading limits.
    8. Whether non-destructive testing of critical weld connections be required annually or at intervals more frequent than the current 10-year CSA standard.

To the Infrastructure Health and Safety Association

11. Develop educational information and resources to be promoted and distributed as part of a campaign to increase industry awareness of the circumstances surrounding the deaths of Luigi Cudini and Shane Jennings, and an understanding of the issues and challenges that were discovered at this Inquest.  This campaign must feature the safety lessons to be learned from this tragedy as well as information about the impact on the families, friends and co-workers.
12. Work in partnership with the MLITSD to develop and implement the campaign to communicate the new regulatory requirements when Ontario Regulation 213/91: Construction Projects is finally amended, as per recommendation #6 above.

To Daniels Corporation:

13. Provide the Infrastructure Health and Safety Association and the CSA with a generic copy of “Appendix B – B1.1 – Mast Climbing Work Platforms Contractor Safety Package:  Site Safety Requirements”, and “Work Permit – Hazard Assessment Form” as an example of best practices for ensuring the safety of MCWPs at construction sites.

To the CSA Technical Committee for MCWPs:

14. Consider and investigate whether non-destructive testing of MCWPs should be conducted annually or more frequently than outlined in the current CSA standards, and if so, amend the standards accordingly.
15. Consider whether to update the CSA standards for MCWPs to require the use of a checklist, similar to “Appendix B – B1.1 – Mast Climbing Work Platforms Contractor Safety Package:  Site Safety Requirements”, and “Work Permit – Hazard Assessment Form”.
16. Review whether the existing design standards with respect to critical welded connections of tubular trusses should be updated, with particular attention to potential issues with respect to proper stress flow and load path through tubular trusses.
17. Consider the recommendations of this Inquest prior to publishing the next revision to the CSA standards for mast climbing work platforms.
18. Immediately review and consider amending the current CSA standards to require that any imported mast climbing work platforms that originate from a jurisdiction that does not adhere to the international standards for MCWPs be subject to a certification process before use in Canada.

March

Brown, Olando

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: March 4
To: March 7, 2024
By: Dr. Richard McLean, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Olando Brown
Age: 32
Date and time of death:  June 22, 2018 at 4:29 p.m.
Place of death: Royal Victoria Regional Health Centre, Barrie
Cause of death: airway obstruction by a foreign body
By what means: accident

(Original signed by: Foreperson)

The verdict was received on March 7, 2024
Coroner's name: Dr. Richard McLean
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Olando Brown

Jury recommendations

To the Ministry of Health:

1. Revise the Basic Life Support Transfer of Care standard to address transfer of care between paramedic teams.
2. Continue ongoing work to improve the efficiency and accuracy of ambulance dispatch services across the province.
3. Collaborate with other relevant ministries to make training on crisis management a mandatory part of basic paramedic education.
4. Conduct a further systemic, evidence-based review of the advanced care paramedic (ACP) deployment on patient outcomes. Consider whether, based on the evidence from this review, provincial standards should be established regarding ACP deployment and target ACP response times.
5. Review and if necessary, update the medical directive relating to the treatment and/or rapid patient transport where there is a possibility that a patient has a foreign body airway obstruction.
6. Review and if necessary update the medical directive relating to the assessment of a foreign body airway obstruction in an unconscious patient, including the techniques used to assess whether there is a partial or complete airway obstruction.
7. Review and if necessary update the responsibility for care provisions in the Advance Life Support Patient Care Standards to ensure clarity regarding the medical management of a patient by paramedics including when there is a paramedic supervisor on scene.

To the County of Simcoe:

8. Continue training all paramedics on a formalized, structured, and standardized protocol for transfer of care between paramedic teams, including the importance of communicating a pertinent incident history between paramedics. Training on this protocol should include the use of simulations.
9. Review and if necessary amend County of Simcoe policies to ensure they contain a mandatory requirement that paramedics maintain communications with Central Ambulance Communications Center (CACC) through the use of portable radios or other portable communication devices, at all times while on duty, as appropriate.
10. Conduct regular training and performance management to ensure compliance with this policy. Training should include a focus on the importance of paramedics acknowledging receipt of critical information from CACC.
11. Based on the results of a Ministry of Health evidence based systemic review and other relevant information, assess the appropriateness of current advanced care paramedic / primary care paramedic (PCP) ratios, regardless of provincial standards. If the conclusion is that an increased ACP / PCP ratio would result in beneficial outcomes, consider the feasibility of increasing the ratio including factors such as provincial ACP availability.

To Barrie Police Service and County of Simcoe Paramedic Services:

12. Consider developing standards and training regarding the reporting of incident history by police to paramedics when Barrie Police Service officers are the first to arrive on scene at a medical emergency. Engage in cross-training among the Barrie Police Service and County of Simcoe Paramedic Service and
13. Consider developing standards and training on how police and paramedics can effectively partner during a first response situation.
14. Barrie Police Service and County of Simcoe Paramedic Services: In collaboration, develop best practices for police officers regarding information that should be communicated to ambulance dispatch when requesting paramedic services. This should include ensuring that the party contacting Ambulance Services has all the pertinent information related to the case. Provide training on those best practices.

To Barrie Police Service, County of Simcoe and Barrie Fire:

15. County of Simcoe to invite Barrie Police Services and Barrie Fire to participate in the County of Simcoe's Quality Care Program with the goal of continuing to strengthen partnerships and communication during medical emergencies.

To Barrie Police Service and County of Simcoe:

16. Wherever possible, policy reviews should be conducted in consultation with corresponding agencies in other jurisdictions with related experience, where appropriate.

Havers, Travis

Held at:  virtual
From: March 4
To: March 8, 2024
By: Daniel Lamberto Ambrosini , presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Travis Havers
Age: 31
Date and time of death:  December 5, 2020 at 2:03 a.m.
Place of death: Sarnia Jail – 700 Christina Street North, Sarnia
Cause of death: asphyxia by hanging
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on March 8, 2024
Coroner's name: Daniel Lamberto Ambrosini
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Travis Havers

To the Sarnia Jail and Sarnia Police Service

1. Explore the development of a written protocol between the Sarnia Police Service and the Sarnia Jail regarding information sharing of inmates coming into custody who may be a risk of harm to themselves or suicide.

To the Ministry of the Solicitor General

2. Assess the feasibility of modifying the cells to remove anchor points to assist in prevention of suicide by hanging.
3. Explore the potential of improvements to Offender Tracking Information System (OTIS) alerts that would allow for correctional officers to not be encumbered by excess or outdated information about offenders who have an OTIS history of suicide/self-harm to avoid missing important alerts.
4. Explore reducing the time within the policy that it takes for the mental health nurse to follow up with an inmate after a referral by a registered nurse.
5. Any entering inmate with a history of suicide should automatically be placed on an enhanced watch until a physician/competent professional is able to deem them safe to return to normal watch.
6. Review the practice at the Sarnia Jail to require the scheduling of medical staff from the Health Care Unit to provide medical coverage 24 hours a day 7 days a week to improve the quality of health care for inmates.
7. Explore the requirement of implementing live monitoring of video surveillance by a correctional officer(s) of all cells at the Sarnia Jail while maintaining the privacy of inmates. This should include the positioning of video surveillance cameras to allow for improved monitoring.

To the Sarnia Jail

8. Explore whether one mental health nurse at the Sarnia Jail is sufficient to provide a reasonable ratio of client to mental health nurses, delivering quality mental health care.
9. Adhere to the policy of no contraband in the cells, specifically the practice of placing items of clothing, towels, bedding, or other items on the cell bars at the Sarnia Jail.

Thomson, David Bartholomew

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: March 18
To: March 20, 2024
By: Mr. Selwyn Pieters, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: David Bartholomew Thomson
Age: 33
Date and time of death:  November 3, 2019 at 11:55 p.m.
Place of death: Days Inn, 460 Fairview Drive, Brantford
Cause of death: gun shot wound of head with skull fractures, intracranial haemorrhage
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on March 20, 2024
Coroner's name: Mr. Selwyn Pieters
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: David Bartholomew Thomson

Jury recommendations

No recommendations.

Ibrahim, Abdelaziz
Neumann, Thomas
Saunders, Stanley
Wood, Adam

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: March 18
To: March 28, 2024
By: Dr. Geoffrey Bond, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Abdelaziz Ibrahim
Age: 25
Date and time of death:  August 16, 2022 at 8:40 a.m.
Place of death: Central East Correctional Centre 541 Kawartha Lakes County Road 36, Lindsay
Cause of death: acute toxicity of fentanyl
By what means: accident

Name of deceased: Thomas Neumann
Age: 21
Date and time of death:  March 5, 2021 at 8:42 a.m.
Place of death: Ross Memorial Hospital, 10 Angeline St. North, Lindsay
Cause of death: toxic effects of fentanyl and etizolam
By what means: accident

Name of deceased: Stanley Saunders
Age: 59
Date and time of death:  January 2, 2021 at 12:09 p.m.
Place of death: Ross Memorial Hospital, 10 Angeline St. North, Lindsay
Cause of death: fentanyl and possible etizolam toxicity
By what means: accident

Name of deceased: Adam Wood
Age: 35
Date and time of death:  August 23, 2020 at 11:45 p.m.
Place of death: Central East Correctional Centre 541 Kawartha Lakes County Road 36, Lindsay
Cause of death: fentanyl toxicity
By what means: accident

(Original signed by: Foreperson)

The verdict was received on March 28, 2024
Coroner's name: Dr. Geoffrey Bond
(Original signed by presiding officer for Ontario)

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

Inquest into the deaths of: Abdelaziz Ibrahim, Thomas Neumann, Stanley Saunders, and Adam Wood

Jury recommendations

To the Ontario Ministry of the Solicitor General:

1. a) Conduct a comprehensive review of the Central East Correctional Centre's (CECC) implementation of the opioid agonist treatment (OAT) Policy and management of opioid withdrawal policy. The review should be directed at identifying barriers to compliance with these policies.
   
   b) The review should be expedited and should include:

   • collecting and analyzing data on wait times for eligible patients to be offered OAT treatment and to be assessed by a prescriber
   • collecting and analyzing data on the number of overdoses at the CECC since the policy was implemented
   • analyzing barriers to compliance from health care and operational branches of the CECC
   • determining the correctional and health care staffing levels needed to achieve compliance with the policies and meet the needs of the inmate population.

   
   c) Develop and implement a strategy to address the barriers to compliance identified in the above-noted review with the goal of bringing the CECC into compliance with these policies.

2. Develop and implement a strategy to increase the amount of one-on-one addictions counselling, group counselling and programming available at the CECC. This should include an assessment of the physical infrastructure, staffing and operational resources required to support increased counselling and programming.
3. Prioritize the planned changes to staff reporting structures so that healthcare staff at the CECC report to the ministry’s health services branch.
4. Conduct a comprehensive post audit to determine the correctional staffing levels needed at the CECC. The post audit should include consultation with the CECC health care unit and the SOLGEN corporate health care unit.
5. Analyze the causes of correctional staff absenteeism at the CECC and take appropriate action.
6. Complete an action plan based on the results of the post audit and staff absenteeism analysis. The action plan should be completed in consultation with the CECC health care unit and the SOLGEN corporate health care unit and should include a plan to maintain adequate correctional staffing levels.
7. A physician and/or nurse practitioner should be available to provide in-person health care services on weekends at the CECC.
8. Ensure physicians and nurse practitioners working at CECC are properly trained/certified to prescribe OAT.
9. Prioritize and expedite:
   1. The work of the staff services review.
   2. The proposed health workforce analysis with a focus at CECC on evaluating the need for a dedicated mental health and addictions health care manager, additional addictions counsellor(s) and the need for additional resources for nursing at night shift.
10. All personal protective equipment be provided and replenished. In particular, front-line staff should have at least gloves and a CPR filter mask to allow for CPR with breath even if the bag valve mask isn’t immediately available.
11. Consider providing additional human resources for the institution security team.
12. Evaluate the effectiveness of the inmate cleaner role.
13. Consider having an extra body scanner available as a backup and provide level 1 and 2 training for the staff operating the body scanner equipment.
14. Implement a formal internal system of communicating that a bad batch of narcotics/opiates is present in the facility.
15. Consider the implementation of dedicated corrections staff assigned to assist health care program (e.g. medical parade, inmate appointments).

To the Office of the Chief Coroner:

16. Clarify the process for investigating coroners to obtain laboratory testing for suspected cannabis.

To the the Province of Ontario:

17. Consider lifting the province wide hiring freeze as it exacerbates the current opiate crisis in correctional facilities.

Romanick, Chad William

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: March 25
To: April 4, 2024
By: Selwyn Pieters, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Chad William Romanick
Age: 34
Date and time of death: September 15, 2017 at 2:11 p.m.
Place of death: 1502 Betts Avenue, Windsor
Cause of death: shotgun wound to the head
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on April 4, 2024
Coroner's name: Selwyn Pieters
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Chad William Romanick

Jury recommendations

To: Windsor Police Service (WPS)

1. Subject to operational exigencies, ensure that all calls for assistance and/or offers of assistance from the WPS Emergency Services Unit that originate from an outside police service, be routed through the E911 communications centre to enhance information access, management, and facilitation of efficient communication among the agencies involved.
2. Incorporate the two 911 calls made by Chad Romanick into existing scenario-based training for 911 Communicators with respect to calls involving persons in crisis and consider developing a checklist for communicators specific to persons in crisis.
3. Provide enhanced training for Windsor Police Service officers, 911 communicators, dispatchers, and others accessing the CAD system on limitations and query results. Consider generating this training by means of matrices or other reference chart(s), deliverable by memo and/or directive(s).
4. Explore opportunities to enhance 911 communicator training with scenario-based approaches that include role- playing situations where crisis intervention and de-escalation techniques are needed in cases where calls evolve into persons-in-crisis calls.
5. Explore opportunities to implement continual refresher training plans or courses for 911 communicators for crisis intervention and de-escalation techniques with scenario-based approaches that may include role-playing situations.

To: WPS, Windsor Regional Hospital (WRH), and Hotel Dieu Grace Healthcare (HDGH)

6. Working through the Police-Hospital Committee, that the WPS consider adding the crisis response team, which includes a social worker and/or nurse police team, which includes a nurse and a patrol police officer, be added to the "emergency callout" list on Code 200 calls at the discretion of a critical incident commander.
7. Working through the police-hospital committee, identify opportunities for additional coordination with the WRH, HDGH and WPS, including but not limited to:
   • crisis response teams
   • nurse police team
   • dedicated hospital officer/code crisis pilot project

This would include establishing more formal arrangements /protocols to determine which mobile crisis team should be strategically deployed to a crisis call and optimizing hours of coverage to meet service demands.

To: WRH and HDGH and WPS

8. Explore the availability of training and/or resources to enhance the ability of healthcare professionals involved in assessing patients with mental health presentations in their ability to receive and assess the reliability, validity, and potential significance of collateral information, with a view to incorporating into existing training.
9. Review existing training to consider implementation of counselling on access to lethal means (CALM) training into the existing required training plan for mental health healthcare workers.
10. Collaborate with local mental health and addictions partners, in consultation with other relevant stakeholders, to share resources for families, caregivers, and loved ones of persons in crisis that will assist with accessing the available supports in community mental health and addiction services.
11. Collaborate with local mental health and addictions partners, in consultation with other relevant stakeholders, to explore opportunities to expand existing follow-up services to include more touchpoints with patients to ensure referral plans are proceeding and to assist in accessing the available supports in community mental health and addiction services.
12. Collaborate with local mental health and addictions partners, in consultation with other relevant stakeholders, to explore feasibility to provide follow-up services for families, caregivers, and loved ones who have experienced trauma as a result of a loved one’s mental illness and/or addiction offered through various means (examples include: card, brochure, text/call/email follow-up opt-in) to ensure multiple means of access to existing services in the community.
13. Collaborate with relevant stakeholders on the feasibility of expanding the services offered through the Mental Health Addiction Urgent Care Clinic to provide 24-hour coverage for persons in crisis.
14. Collaborate with local mental health and addictions partners, in consultation with Ontario health and other relevant stakeholders, to establish targets for timely access to mental health and addiction services. This should include developing and implementing evidence-based target timelines in the assessment and treatment of patients presenting with the most urgent categories of mental health and addiction concerns.
15. Collaborate with local mental health and addictions partners, in consultation with Ontario health and other relevant stakeholders, to: (1) establish a common definition of “wait time” (as many organizations define and track wait times differently); and (2) make wait times available to partners to inform planning and referral.

April

Shannon, Clinton

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: April 15
To: April 23, 2024
By: Dr. Richard McLean, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Clinton Shannon
Age: 44
Date and time of death: January 24, 2019 at 8:58 a.m.
Place of death: St. Joseph Health Care Centre, 30 The Queensway, Toronto
Cause of death: blunt head injury with the following contributing conditions: antiphospholipid antibody syndrome; thrombocytopenia and anticoagulant (warfarin) use
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on April 23, 2024
Coroner's name: Dr. Richard McLean
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Clinton Shannon

Jury recommendations

Ministry of the Solicitor General (the ministry):

1. The ministry should ensure that all persons in custody who have experienced head trauma be immediately assessed by a nurse or primary care practitioner. The assessment should include the following elements, each of which should be documented:
   1. taking a history of the event and reviewing the past medical history and medications
   2. elicit a history of amnesia, loss of consciousness, vomiting, visual changes, or seizures
   3. scoring on a standardized concussion screening tool – by preference and familiarity of local nursing
   4. Glasgow Coma Score tool
   5. pupillary response to light
   6. strength of each limb
2. The ministry should ensure that any video of the events surrounding a head trauma incident be made available to the health care provider at the request of the assessing clinician who is conducting the initial assessment.
3. The ministry should implement a head injury protocol that would trigger a transfer to hospital for further assessment in circumstances where any of the following criteria are met:
   1. a person, with or without findings below, who is therapeutically anticoagulated or has an untreated bleeding disorder.
   2. b. A person with any of amnesia, loss of consciousness, vomiting, visual changes, or seizures.
   3. a person who meets the Canadian CT Head injury/Trauma Rule (CCHR)
      1. GCS< 15 at two hours after injury
      2. suspected open skull fracture
      3. any sign of basal skull fracture
      4. vomiting two or more episodes
      5. age 65 or higher with amnesia, loss of consciousness, or confusion
      6. amnesia before impact of 30 minutes or more
      7. dangerous mechanism (high momentum, e.g., hit by vehicle, fall from height)
   4. a person with abnormalities in pupillary response to light
   5. person with abnormalities in strength of each limb.

4. The ministry should ensure that the person who has experienced head trauma is closely monitored by a nurse in accordance with the following protocol when the threshold for transfer to hospital is not met at the time of the initial assessment after head trauma: There should be a low threshold for a judgment call to extend the duration of this monitoring.
   1. This monitoring should include a documented head injury routine every hour for 12 hours and if normal every two hours for another 24 hours. This head injury routine should include:
      1. eliciting any history of amnesia, loss of consciousness, vomiting, visual changes, or seizures
      2. Glasgow Coma Score tool
      3. pupillary response to light
      4. strength of each limb.
5. The ministry should strengthen the ministry’s policy “Use of the Glasgow Coma Scale in Neurological Assessment” and related protocols and tools to incorporate:
   1. critical risk factors to trigger an escalation for assessment and care following a head trauma that include but are not limited to: anticoagulant use, age, and relevant medical and neurological history such as prior strokes and blood-clotting disorders
   2. information and protocols for potential chronic or insidious brain bleeds in addition to acute brain bleeds
   3. the mandatory use of the Vital Signs Record, which includes the Glasgow Coma Scale, to assess and document the patient status where head injury is suspected.
6. The ministry should ensure that the monitoring protocol following head trauma continues until an order is made by a qualified primary care practitioner to discontinue it.
7. The ministry should implement professional development for all health care staff concerning the assessment and monitoring of persons who have experienced head trauma. This training should include the most current understandings and best practices concerning the recognition of, treatment for, physiology of, and risk factors for traumatic brain injuries. This should include a record of the healthcare staff who have had such training.
8. The ministry should implement electronic medical records for persons in custody as soon as possible. This can include an electronic system via tablet, terminals, or computer.
9. The ministry should ensure that, once electronic medical records are implemented, the records will be available to consulting health care professionals, including but not limited to the Forensic Early Intervention Service.
10. The ministry should create a role of “most responsible practitioner” (MRP) to the infirmary and medical units at the Toronto South Detention Centre (TSDC) to improve communication and continuity of care. The person assigned in the role of MRP should conduct a daily review of the patients in the infirmary and medical units and assess patients in person if indicated.
11. The ministry should initiate and document care plans for all patients who are in the infirmary and the medical units. The care plan should include diagnoses, a summary of the medical history, current medications and treatment. The care plan should be available to all health care staff.
12. The ministry should implement policies and procedures that clearly delineate: admission and discharge criteria; documentation requirements; and nursing, nurse practitioner and physician responsibilities for the infirmary at the TSDC. Health care staff and physicians should be made aware of these policies and procedures.
13. The ministry should conduct a review of the model of primary care delivery at the TSDC. In particular, the review should consider the efficacy of the part-time and contract model of deploying physicians in a correctional setting, as well as the model of daily and weekly primary care practitioner coverage.
14. The ministry should identify a physician lead for primary care practice at the TSDC. This individual should be responsible for issues of general medical care of the inmate population, and work in partnership with the manager of Health Care Services at the TSDC. The Ministry should ensure that staffing levels are sufficient to allow for and support this role.
15. The ministry should ensure that the compensation for nursing staff is above industry standard. This could include but not limited to additional healthcare benefits (physiotherapy, psychotherapy, etc.)
16. The ministry should continue to ensure that nursing staffing levels are sufficient to allow for a dedicated 24- hour nurse in the infirmary at the TSDC.
17. The ministry should ensure that court attendance does not interfere with timely access to a qualified primary care practitioner for persons in custody. This should include ensuring that qualified primary care practitioners are available to provide care to people before or after court, and that health care requirements are properly communicated to court officials where necessary.
18. The ministry should institute a patient safety/quality improvement process in respect of any event involving the death or other “sentinel event”. These events should be flagged and brought to the immediate attention of senior ministry health care leadership. A formal structured root cause analysis involving frontline staff, primary care practitioners (physicians and nurse practitioners), and managers should be initiated. This process should be led by trained facilitators. This process should report directly up to the ministry’s Sentinel Events Committee or its equivalent. The recommendations of the process should be fully documented. Protection for the review process should be under legislation.
19. The ministry should pursue health care accreditation through Accreditation Canada or an equivalent accrediting agency. Prior to the achievement of accreditation, the ministry should ensure that it is delivering health care to persons in custody that meets the standards prescribed by Accreditation Canada.
20. The ministry should endeavor to use virtual meeting technology for court proceedings when inmates require medical attention to ensure that medical care is prioritized in the event of head trauma or any other critical medical event.
21. The ministry should implement mandatory briefing rounds at the beginning of a physician's shift with the assigned medical unit nurse(s).
22. The ministry should ensure weekend in-person physician care availability.
23. The ministry should develop an improved system of triage to ensure that patients who have missed scheduled appointments with a physician do not go unseen for extended periods of time. If an appointment is missed, for whatever reason, alerts should be sent to healthcare staff that involve a routine check-up and a documented assessment.

Hegedus, Leslie

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: April 22
To: April 24, 2024
By: Dr. Jennifer Clara Tang, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Leslie Hegedus
Age: 71
Date and time of death: July 15, 2020 at 11:47 a.m.
Place of death: Haliburton Highlands Health Centre - Emergency Department, 7199 Gelert Road, Haliburton
Cause of death: gunshot wound of right back
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on April 24, 2024
Coroner's name: Dr. Jennifer Clara Tang
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Leslie Hegedus

Jury recommendations

Ministry of the Ontario Provincial Police:

1. Review all directives relating to Emergency Response Team uniforms to ensure that officer compliance with said directives does not adversely impact officer safety or officer response time.
2. Review all directives and policies relating to the Ontario Provincial Police communications centre to ensure, where known, complete and accurate addresses, including postal codes, are provided to responding officers to maximize officer response time.

May

Csanyi, Attila

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: April 30
To: May 14, 2024
By: Dr. JenniferScott, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Attila Csanyi
Age: 28
Date and time of death: May 2, 2020
Place of death: Jackson Square Mall, 2 King Street West, Hamilton
Cause of death: combined drug toxicity of fentanyl and methamphetamine
By what means: accident

(Original signed by: Foreperson)

The verdict was received on May 14, 2024
Coroner's name: Dr. Jennifer Scott
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Attila Csanyi

Jury recommendations

To the Province of Ontario and the City of Hamilton

1. Conduct a comprehensive review of the quality of housing and services provided by Residential Care Facilities (RCFs) in Hamilton. The review should be conducted jointly by:
   1. The City of Hamilton,
   2. The Ontario Ministry of Municipal Affairs and Housing,
   3. The Ontario Ministry of Health, and
   4. Any other Ministry with expertise in the relevant issues.
2. The review should include assessments of:
   1. The needs of the individuals who currently live in RCFs in Hamilton,
   2. Whether RCFs in Hamilton are responsive to those needs,
   3. The types of housing models needed to meet those needs,
   4. Services needed to meet those needs in-house and, in the community,
   5. Supports needed for housing operators and workers including education programs relating to client needs, and measures to ensure the safety of residents, workers, and operators,
   6. The need for provincial oversight.
3. The review should have input from an advisory committee that includes representation from community stakeholders and others with relevant expertise, such as:
   1. Healthcare providers (including allied health workers) that care for individuals with chronic mental health conditions, such as schizophrenia and substance use disorders,
   2. Organizations working with and serving the needs of unhoused or precariously housed individuals,
   3. Housing providers,
   4. RCF residents and their supportive family members,
   5. Other jurisdictions which have a track record of providing housing and services to vulnerable members of society, and
   6. Academics with relevant expertise in housing issues.
4. Based on the results of the above-noted review, design and implement models of housing in Hamilton that are responsive to the needs of the above-noted population. These new housing models should include:
   1. Non-custodial housing models,
   2. Supported housing models,
   3. Supportive housing models.
5. This review should be an ongoing process to ensure that any resulting policies or procedures are kept up to date. Initial suggestion for 5-year intervals.
6. Adopt a Housing First approach to the commitment to end homelessness through the continuum of housing options.
7. Implement trauma-informed care principles within the continuum of supportive housing options.
8. Develop mechanisms for governmental oversight of RCFs to ensure that the care needs of RCF residents are being met. This could include the creation of new provincial legislation, new provincial licensing, proactive inspections, compliance and enforcement powers, and complaint lines akin to those afforded to residents in long-term care homes in Ontario.

To the Ontario Ministry of Municipal Affairs and Housing

9. Integrate needs-based data points into Homelessness Prevention Plan (HPP) funding so that funding can be responsive to local population needs (such as increased housing, staffing and/or training needs).

To the City of Hamilton

10. Explore opportunities to designate certain RCFs to provide harm reduction housing that is low barrier for tenants with substance use disorders.
11. Collect data that tracks displacement from RCFs, including:
    1. Evictions under section 69 of the Residential Tenancies Act (RTA), transfers under section 148 of the RTA, voluntary transfers, and voluntary termination of tenancy, and
    2. The result of that displacement (that is, where the tenant goes).
12. Amend Schedule 20 to:
    1. Include additional provisions that recognize each RCF resident’s right to security of tenure under the RTA, and
    2. Include mandatory education for all RCF operators on preserving and terminating tenancies in accordance with the RTA.
13. Explore amendments to Schedule 20 that would facilitate engagement between RCFs and residents’ supportive family, subject to the residents’ consent and the Personal Health Information Protection Act.
14. Develop and implement a program to provide training on the relevant provisions of the RTA, including residents’ rights to security of tenure, to:
    1. All City of Hamilton Staff involved in licensing and inspecting RCFs,
    2. All RCF operators and workers.
15. Develop and implement a program to inform RCF tenants about their rights under the RTA.
16. Develop and implement a program to train RCF operators and workers on the effects of housing instability on health and well-being.
17. Develop a process to assist RCF operators and tenants to resolve tenancy-related disputes.
18. Develop documentation required to be posted in each facility that explains the rights and responsibilities of both RCFs and Tenants under any applicable acts or legislation.  This should include support contact information pertaining to the various rights. This should also detail where complaints can be submitted.
19. Establish a centralized system which would enable individuals and organizations seeking placements within an RCF to get information such as the availability of single rooms and shared rooms by facility.

To the City of Hamilton, Ontario Ministry Municipal Affairs and Housing and Ontario Ministry of Health:

20. Seek and allocate funding to implement these recommendations.

To Sampaguita Lodge and Rest Home:

21. Within 30 days, the operator, and all staff:
    1. Complete training on the RTA, and
    2. Ensure that all residents are advised about their rights under the RTA.

Morfitt, Robert John

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: May 27
To: May 31, 2024
By: Dr. Daniel Lamberto Ambrosini, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Robert John Morfitt
Age: 36
Date and time of death: June 7, 2018 at approximately 00:41 a.m.
Place of death: Sunnybrook Hospital, Toronto
Cause of death: multiple gunshot wounds
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on May 31, 2024
Coroner's name: Dr. Daniel Lamberto Ambrosini
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Robert John Morfitt

Jury recommendations

Toronto Police Services

1. Review its officer training curricula and consider, if not already implemented, whether and to what degree the curricula should:
   1. Continue to provide training to officers/cadets that involves more than three days of reality-based scenarios, and evaluate whether any portion of such training should be separate from evaluation to avoid interfering with learning;
   2. include a variety of live reality-based scenarios to ensure that officers are required to learn the skills for both individual and coordinated police responses (that is, multiple officers);
   3. implement brief weekly training in the form of officer-led visualization scenarios;
   4. explicitly train and evaluate the skills that enhance situational awareness;
   5. include training for high-risk, low frequency cases using scenarios with potentially inaccurate and/or dynamic information;
   6. explicitly train and evaluate physiological stress management and self-regulation, (including the one breath technique and the recovery breath technique as outlined in the outlined in the “iPREP protocol” published in the Journal of Applied Psychophysiology and Biofeedback, 2024);
   7. be subject to periodic independent third-party program evaluation to ensure the overall effectiveness and relevance of the program, along with appropriate pedagogical approaches to gradually increase the complexity of the training content; and  
2. Consider enhancing opportunities to review the training that dispatchers receive to ensure:
   1. Receipt of high-quality and accurate situational information from caller (including the use of comprehensive follow-up questions to validate information);
   2. caller receives instructions to ensure civilian safety at scene; and

Ontario Police College

3. Review its officer training curricula and consider, if not already implemented, whether and to what degree the curricula should:
   1. explicitly train and evaluate the skills that enhance situational awareness;
   2. include training for high-risk, low frequency cases using scenarios with potentially inaccurate and/or dynamic information;
   3. explicitly train and evaluate physiological stress management and self-regulation, (including the one breath technique and the recovery breath technique as outlined in the outlined in the “iPREP protocol” published in the Journal of Applied Psychophysiology and Biofeedback, 2024); and
   4. be subject to periodic independent third-party program evaluation to ensure the overall effectiveness and relevance of the program, along with appropriate pedagogical approaches to gradually increase the complexity of the training content. 

George, John Paul

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: May 27
To: June 5, 2024
By: Etienne Esquega, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: John Paul George
Age: 42
Date and time of death: April 9, 2020 at 9:27 p.m.
Place of death: Temiskaming Hospital 427 Shepherdson Road, New Liskeard
Cause of death: multiple gunshot wounds to the torso
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on June 5, 2024
Coroner's name: Etienne Esquega
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: John Paul George

Jury recommendations

To the Ontario Provincial Police:

1. Consider reviewing the training that 9-1-1 call-takers and dispatchers receive to ensure:
   1. receipt of high-quality and accurate situational information from callers
   2. appropriate guidance is provided to callers, if necessary, to ensure safety of individuals on the scene and the general public
   3. complete information is conveyed from call-takers to dispatchers
2. Use the facts and circumstances of this occurrence, or portions thereof, as part of a practicum or scenario-based police training.
3. Recognize the importance of Indigenous cultural competency training by making it mandatory.
4. Continue working towards increasing awareness about vicarious trauma, compassion fatigue , and post-traumatic stress disorder so that strategies, policies, and resources can promote recognition of these issues for officers and their co-workers.
5. Offer voluntary and supported debriefing opportunities for officers involved in cases of death resulting from use of force once there are no longer any legal barriers to meeting as a group of impacted officers or civilian members for their health and wellness, and at an appropriate time.
6. Continue to develop and implement strategies for reducing use of force cases involving civilians experiencing mental health crises.
7. Recognize the importance of Mental Health Crisis Response training, including substance use disorder, by making it mandatory and recurrent (or regular).

To the Ontario Provincial Police and the Ontario Police College:

8. Review and revise (if necessary) training programs to ensure that sufficient attention is given to on-scene officer communication, and scene management when multiple officers are present.
9. Training on Indigenous cultural competency, anti-racism, anti-bias, and Mental Health Crisis Response should include competence and knowledge acquisition. Recognize the importance of this training by making it mandatory and recurrent (or regular). Explore approaches to establishing criteria for officers to “pass” the course using objective measures and evaluations.
10. On a continuing basis, review the policing research literature to identify emerging best practices with respect to use of force.

To the Ministry of the Solicitor General:

11. Improve data to understand circumstances surrounding police use force, to identify disparities, and to inform training, policy, and practice.
12. Indigenous communities should be consulted with respect to the collection, retention, analysis, and dissemination of race-based use of force data on Indigenous people on an ongoing basis.
13. Use improved data to track whether de-escalation strategies reduce the proportion of incidents involving police use of force, the severity of use of force, and racial disparities in use of force.

June

Clee, Dustin

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: June 3
To: June 7, 2024
By: Dr. David Cameron, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Dustin Clees
Age: 28
Date and time of death: April 20, 2017
Place of death: St. Michael’s Hospital, Toronto
Cause of death: asphyxia due to hanging
By what means: suicide

(Original signed by: Foreperson)

The verdict was received on June 7, 2024
Coroner's name: Dr. David Cameron
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Dustin Clees

Jury recommendations

To the Barrie Police Service (BPS), the Royal Victoria Regional Health Centre (RVH), and the Ministry of the Solicitor General (SOLGEN):

1. Create a working group regarding the sharing of information about a person experiencing mental health issues, and/or suicidal ideations or thoughts of self-harm, whose custody is being transferred, and who had or will have contact with a hospital, BPS, the Ontario Provincial Police (OPP) and/or Central North Correctional Centre (CNCC), to develop methods to share information in a way that balances the privacy of individuals, the safety of the person, and to facilitate the provision of health care in a timely manner.

To BPS, OPP and SOLGEN:

2. Develop a single form for use when transferring individuals to or from the custody of BPS (including the Barrie Courthouse), the OPP and CNCC, that would notify and be recorded or updated between all agencies that an individual may have risk of suicide or self-harm, and provide details of that risk assessment.

To BPS:

3. Work with the OPP and CNCC to standardize a written flag system for detainees who are at risk for suicide who are transferred or transported between CNCC, the Barrie Courthouse and a detachment.
4. Provide all police officers and special constables, including special constables working at the Barrie Courthouse, with mandatory mental health awareness training. Ensure this training:
   1. includes explanation of the difference between a suicide attempt, suicidal ideations and being suicidal or at risk of self-harm
   2. addresses chronic and acute suicidality and self-harm, and the fluidity of mental health disorders and a person’s state of mind
   3. is reviewed on an annual basis.
5. Ensure the Prisoner Transportation Form is completed and the Risk Assessment and Detention Logs contained within the Arrest Booking Report for a person booked and held by the BPS in the cells at a BPS station, is printed and both forms are provided to the agency picking up the person to transport them, including the OPP Offender Transportation Program cpecial constables, or the BPS special constables who work at the Barrie Courthouse.
6. Ensure that any information that may be relevant to the safety and security of a person or others is provided in writing to the OPP Offender Transportation Program special constables who pick up that person to transport them to CNCC.

To the OPP:

7. Ensure that CNCC staff who receive persons into custody from the OPP Offender Transportation Program are provided with the BPS Risk Assessment and Detention Log contained within the Arrest Booking Report, received from the BPS when they pick up the person the OPP Offender Transportation Program is transporting to CNCC.
8. Ensure any information the OPP Offender Transportation Program special constables have that may be relevant to the safety and security of a person or others is provided in writing to CNCC staff when that person is transferred to CNCC.
9. If OPP Offender Transportation Program special sonstables pick up a discharged person from a hospital and transports them to CNCC, the special constables must inform CNCC staff upon arrival that the discharged person was picked up at a hospital and provide the name of the hospital.
10. Review the name of the OPP Offender Transportation Program to remove the word “offender”.

To SOLGEN:

11. Ensure there is a policy or standing order that individuals detained at CNCC are not permitted to cover the windows of their cells by any method, either completely or partially.
12. Explore providing persons in custody a method of identifying for correctional officers that they are using the toilet in their cell, such as a memo to correctional staff reminding them of the policy referenced in recommendation 11.
13. Ensure all units housing persons in custody can be continually monitored by video, without visual obstruction.
14. Consider revising the policy titled “Management of Personal Health Information” to include that when a person has disclosed hospitalization that may be relevant to care continuity or safety, correctional health care staff will obtain the necessary relevant records to facilitate the provision of health care.
15. Explore whether the Offender Tracking Information System (OTIS) could be made available to police services in Ontario, including the OPP and BPS, and including at courthouses such as the Barrie Courthouse.
16. Ensure that any information or documentation provided by OPP Offender Transportation Program special constables to CNCC staff is recorded in the OTIS profile and health care file of the person to whom it pertains.
17. Explore whether the NICHE police records management system can be made available to Correctional Officers working in correctional facilities in Ontario.
18. Review existing training programs for Correctional Officers to determine if additional training could be provided to increase mental health awareness and knowledge of the signs that someone may be at risk for suicide or self-harm while in custody at CNCC.
19. Review the scheduling of orientation and onboarding process for newly hired nurses working in provincial correctional facilities to aim to provide all aspects of a nurse’s orientation and onboarding as soon as possible.

To RVH:

20. Work with SOLGEN to develop a policy for use by all staff at RVH that would include, but not be limited to, the sharing of personal health information with:
    1. Health care staff at a provincial correctional facility for the purposes of continuity of patient care when a person who had been a patient at RVH is admitted to custody at a provincial correctional facility; and
    2. The use of sections 40(2) and 40(3) of the Personal Health Information Protection Act.
21. The policy referred to in recommendation #20 should include a statement that SOLGEN health care staff may be within the “circle of care” for patients that have been treated at RVH and are now in custody at CNCC.
22. Consider whether it is feasible to add scanned documents to Connecting Ontario Clinical Viewer.

Wert, Allan

Held at:  virtual, 25 Morton Shulman Avenue, Toronto
From: June 18
To: June 20, 2024
By: Dr. James Kovacs , presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Allan Wert
Age: 57
Date and time of death: November 25, 2021 at 11:53 a.m. 
Place of death: 374 Devitts Road, Bobcaygeon
Cause of death: gunshot wound to the left shoulder 
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on June 20, 2024
Coroner's name: Dr. James Kovacs 
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Allan Wert

Jury recommendations

To the Ontario Provincial Police (OPP):

1. As part of ongoing post-incident wellness support, provide subject and witness OPP officers with a summary of what mandatory related investigations and processes will follow, including coroner’s Inquests. Further, for those subject and witness OPP officers who wish to be informed, provide regular updates on those investigations and processes as well as information on how to ask questions and access resources.
2. Ensure that OPP officer training includes the importance of a thorough background check on all persons of interest, where possible, prior to making initial contact, regardless of the perceived threat level.