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:

You can also access verdicts and recommendations using Westlaw Canada.

January

Maloney, Samuel

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: January 14
To: February 4, 2025
By: Dr. David Eden, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Samuel Maloney
Age: 35
Date and time of death: December 23, 2016
Place of death: 56 Duchess Avenue, London
Cause of death: gunshot wounds to the head and chest
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on February 4, 2025
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: Samuel Maloney

Jury recommendations
To: London Police Service (LPS):
  1. Develop and implement a unified procedure for dynamic (controlled) entries, that clearly addresses 1) the decision-making and authorization process, 2) the requirement for documentation that sets out all factors considered in the decision-making process. This procedure should include but is  not limited to the following considerations:
    1. Utilizing the completed threat assessment form to assist in identifying possible factors that could complicate the execution of the warrant, such as possible mental health issues, intimate partner violence, unpredictability, past incidents with police, presence of children.
    2. Have crisis/mental health support on standby when a controlled (dynamic) entry is executed on a residence in which occupants are suspected of having mental health challenges.
    3. Have crisis negotiating team members on standby when a controlled (dynamic) entry is executed.
    4. Where the purpose of a controlled (dynamic) entry is the preservation of evidence, controlled (dynamic) entry should only be approved if there is no other way for police officers to secure the evidence for the charge.
    5. The operational plan for controlled (dynamic) entry should include planning for the safety of children and/or vulnerable persons in the residence.
  2. Conduct a study to determine the benefits and feasibility of having a mental health professional consult during the development of an operational plan for controlled (dynamic) entry, when it is suspected the subject(s) and/or occupant(s) may have mental health challenges, to better consider how factors such as paranoia, distrust of authorities, and history of intimate partner violence may affect the subject(s) and/or occupant(s) reactions to a controlled (dynamic) entry.
  3. Consider prioritizing the implementation of body cameras for emergency response unit team members when conducting controlled (dynamic) entries.
  4. Ensure that debriefs are held for involved officers following a traumatic event and at the earliest possible opportunity following the conclusion of an special investigation unit investigation where no criminal charges were laid, and when there are no remaining legal proceedings or restrictions preventing the debrief from occurring.
  5. Engage with community partners to continue regularly promoting officer education on intimate partner violence, which may include but is not limited to:
    1. Recognizing signs of intimate partner violence during welfare checks.
    2. Identifying the potential aggressor in an intimate partner relationship.
    3. How to communicate with potential victims of intimate partner violence without putting them at greater risk of harm from their abuser.
  6. A copy of the search warrant should be carried by at least one emergency response unit team team member (preferably every member) entering the location and be provided to any subject that asks for it as soon as it is safe to do so, in order to de-escalate or prevent escalation during a controlled (dynamic) tactical entry.
  7. Review and amend the threat assessment form to include the mental health of the subject and intimate partner violence as a factor assessment.
  8. In consultation with the involved officer(s), mental health professionals and the administration, after a major incident, consider providing officers who are up for promotion or transfer with the choice to remain or be removed from their current team. Determine a reasonable frequency for emergency response unit members to be required to re-certify in Crisis Negotiation with the Ontario Police College.
  9. Continue to work towards having 24/7 emergency response unit coverage without relying on officers to extend shifts beyond regular hours.
  10. Continue to work with and expand the member wellness team to provide on-going officer supports and resources.
To: London Police Services Board:
  1. The LPSB should include in the scope of its current policy review, the development and implementation of the following:
    1. A policy for section 81 reports that:
      1. establishes requirements for the content of such reports
      2. directs the London Police Chief to develop a related procedure for section 81 reports
    2. A policy regarding controlled tactical entries, including a reporting requirements of its use and outcomes at LPS.
    3. The London Police Services Board should provide all board members with recent relevant inquest recommendations.
To: The Special Investigations Unit (SIU):
  1. Whenever possible, comply with the 120-day timeline to conclude an investigation under section 35(1) of the Special Investigations Unit Act, 2019, S.O. 2019, C. 1, Schedule 5, taking into account the wellness of all parties involved and recognizing
    1. trauma-informed approach for police officers, family, witnesses and community
    2. preserving and recalling best evidence
  2. Ensure that involved officers are clearly informed about the SIU investigation process, steps, expectations, legal standings, timelines, and at which point debriefs and/or communications amongst involved team members are allowed to occur.
  3. The SIU should consider expanding the Affected Persons Program to:
    1. Hire more affected persons coordinators.
    2. Increase crisis response, psychological first aid, emotional support, referrals, therapy or counselling service and advocacy available to affected persons.
    3. Ensure these services are available for both adult and child survivors irrespective of contributory behaviour or outstanding criminal charges, and irrespective of officer liability.
    4. Advise of any resources or services available for the removal of potentially biohazardous materials, including any financial support.
To: The Office of The Chief Coroner:
  1. Conduct inquests in as expeditious a manner as possible from the date of the death, recognizing:
    1. a trauma-informed approach for police officers, family, witnesses and community
    2. preserving and recalling best evidence
To: Children's Aid Societies (CAS):
  1. Ensure that CAS workers, as a best practice, do not interview suspected victims of intimate partner violence in the presence of their suspected abuser, taking into consideration:
    1. That conversations with suspected victims of intimate partner violence may be under heightened means of surveillance in the home.
    2. Developing alternate non-verbal means of asking interview questions to potential victims.
    3. Where appropriate and feasible, consider making inquiries to police forces regarding information on all prior charges or occurrences relating to intimate partner violence at a residence.
  2. Ensure that when a parent with an open CAS file is arrested or held in custody by law enforcement, a CAS worker reaches out to the incarcerating authority to connect with the parent or caregiver regarding the status of their children.

Case, Jordan

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: January 20
To: February 3, 2025
By: Dr. Richard McClean, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jordan Case
Age: 22
Date and time of death: December 1, 2018
Place of death: Niagara Detention Centre, 1355 Upper’s Lane, Thorold
Cause of death: acute toxic effects of fentanyl and cocaine
By what means: undetermined

(Original signed by: Foreperson)

The verdict was received on February 3, 2025
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: Jordan Case

Jury recommendations
To the Ministry of the Solicitor General and the Niagara Detention Centre (NDC):
  1. Conduct regularly scheduled audits of persons in custody’s Offender Tracking Information System (OTIS) profiles to ensure accuracy with the most up-to-date and current information and alerts.
  2. Ensure that the history, risks, vulnerabilities, alerts, and other flagged information in records related to a person in custody, including OTIS are current and up-to-date and are considered when conducting compatibility assessments for potential cellmates.
  3. In situations where a person in custody is in distress and asking to be moved from a shared cell, correctional staff should consider speaking with the person in custody privately and in the absence of the cellmate to determine the reasons for wanting to move.
  4. All correctional staff shall maintain a duty book when on shift and shall keep them for a reasonable time.
  5. In recognition of the role that family can play in the wellness of prisoners, the Ministry should explore opportunities to work collaboratively with families and local and provincial agencies to enhance rehabilitation and reintegration efforts.
  6. When conducting compatibility assessments, full consideration should be given to the persons in custody's criminal record, criminal charges before the court, and history of smuggling illicit drugs into the institution as well as documented substance use and addiction issues. The risks of housing known drug traffickers with known drug addicts should be thoroughly assessed before housing such persons in custody together.
  7. All facility cameras should be kept in good working order and checked daily. If any cameras are not operational or are covered in any way, immediate steps should be taken to get them back online. If possible, sensors could be used to automatically notify staff when a camera is not operational.
  8. When the daily mental health status assessment of a person in custody worsens, social workers should consider conducting an in-depth assessment or, at minimum, report the change at shift change team huddle as soon as possible in order to understand the reasons for the change(s) and obtain a current assessment of risks due to the change(s).
  9. Explore and consider providing training for correctional staff on illicit drug use and/or licit drug abuse their methods of use in a correctional setting, recognition of symptoms of use, as well as recognition of signs of addiction and withdrawal.
  10. Provide compulsory, and regularly held, training for correctional staff on dealing with persons in crisis and acute distress, including individuals with mental health issues and those at risk of suicide. Training should be developed and delivered by licensed mental health professionals and should include de-escalation techniques and scenario-based training exercises tailored to a correctional context.
  11. Healthcare staff – including doctors, psychiatrists and nurses; social workers; and correctional staff should continue to regularly review whether a person in custody’s behaviour and or mental state merits any updates regarding mental health issues, substance abuse issues, and self-harm or suicide issues in OTIS for appropriate and current alerts in a timely manner.
  12. Recruit additional social work staff to ensure coverage is available on weekends at NDC so that persons in custody have ongoing and uninterrupted access to supports and services. Efforts should be made to provide support services in a confidential and private space.
  13. Ensure staffing of correctional officers is sufficient to escort persons in custody to meet privately and confidentially with healthcare staff and social workers.
  14. Locked covers should be placed over all flushing buttons for dry cells.
  15. As NDC moves to more digital record keeping, consider the feasibility of electronically flagging supervisory staff to any required forms that are not fully completed.
  16. Consider the feasibility of supervisors doing periodic audits on observation records by reviewing video surveillance of cell hallways to ensure they are being thoroughly done. Efforts should be made to ensure guards are taking the necessary time to observe every inmate every 20 minutes as required.
  17. If possible, all inmate request forms should be acknowledged with a documented action taken.

Deshane, Jamie

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: January 27
To: January 29, 2025
By: Dr. Murray Segal, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jamie Deshane
Age: 52
Date and time of death: July 23, 2019
Place of death: Kingston General Hospital, Kingston
Cause of death: methamphetamine, fentanyl and carfentanil toxicity
By what means: accident

(Original signed by: Foreperson)

The verdict was received on January 29, 2025
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: Jamie Deshane

Jury recommendations

No recommendations.

Rafter-Rycroft, David

Held at: virtual, Ottawa
From: January 27
To: January 30, 2025
By: Dr. David Creery, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: David Rafter-Rycroft
Age: 25
Date and time of death: February 16, 2021 at 4:06 p.m.
Place of death: Ottawa Hospital General Campus – 501 Smyth Road, Ottawa
Cause of death: complications of acute fentanyl toxicity
By what means: accident

(Original signed by: Foreperson)

The verdict was received on January 30, 2025
Coroner's name: Dr. David Creery
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: David Rafter-Rycroft

Jury recommendations
To Ottawa-Carleton Detention Centre (OCDC) and the Ministry of the Solicitor General:
  1. To promote the sharing of personal health information during admission, including information pertaining to substance use, conduct the Health Care Assessment in a location and manner that maintains and protects the confidentiality of the information being disclosed by the person in custody.
  2. All persons in custody should be advised of their right to privacy and confidentiality during interactions with health care staff at OCDC.
  3. Upon admission, provide timely access to a substance use counsellor to persons in custody who have identified a history of substance use.
  4. Continue to engage in “health teaching” for persons in custody upon admission and include in that teaching current information concerning the toxicity of the drug supply within the institution, the health risks associated with using substances alone, and the signs and symptoms of opioid toxicity.
  5. Evaluate the benefits of conducting a Clinical Opiod Withdrawal Scale assessment for every new admission who discloses street drug use.
  6. Continue the relationship with Ottawa Public Health to ensure that a list of substances and common “street names” of substances that may be used in the community is maintained and regularly updated by institutional health care managers in consultation with Ottawa Public Health. Ensure that this information is readily accessible and is regularly communicated to front-line health care staff.
  7. Ensure that substance use information, trends, and alerts relating to the local unregulated drug supply are received from Ottawa Public Health and communicated to operational and health care staff.
  8. Evaluate the feasibility of developing and implementing a provincial database of street drug nomenclature.

Security rounds and cell checks

  1. Review the current mechanical cell check recording system at OCDC with a view to utilizing this system or a similar system to mechanically record cell checks conducted during the day and evenings in individual living units when persons in custody are confined to their cells.
  2. Conduct a review of current institutional policies related to conducting cell checks to ensure that institutional policies set out when and under what circumstances correctional officers must enter the cell of a person in custody to conduct a health check. Ensure that staff are provided refresher courses.

Crisis resource management

  1. Provide training on crisis resource management to health care and correctional staff when responding to a medical emergency in order to improve team performance and better manage the number of staff on scene.
  2. Explore the feasibility of procuring an automated chest compression device for the Health Care Unit to support the administration of cardiopulmonary resuscitation in medical emergencies.
  3. Conduct regular inventories of the emergency bags that are deployed in medical emergencies to ensure that all necessary supplies are stocked and available in the event of an emergency.

Contraband detection and prevention

  1. Ensure body scanner technology in use at OCDC remains up to date with current software updates to enhance the functionality of the body scan system as much as possible.
  2. Continue with current plans to have security netting installed over the open yards at OCDC to prevent contraband from entering the institution via drone technology.

Supports

  1. Review the supports presently offered or available to staff following a critical incident to ensure they are current with best practices and meeting the needs of staff who access them.
To Province of Ontario:

Funding

  1. Seek, secure, and maintain funding to support the implementation of the above recommendations.

McKechnie, Ryan Patrick

Held at: 25 Morton Shulman Avenue, Toronto
From: January 27
To: January 31, 2025
By: Dr. Richard A. Wells, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Ryan Patrick McKechnie
Age: 34
Date and time of death: June 29, 2017
Place of death: Hamilton Wentworth Detention Centre, 165 Barton Street East, Hamilton
Cause of death: combined fentanyl, methamphetamine and amphetamine intoxication
By what means: accident

(Original signed by: Foreperson)

The verdict was received on January 31, 2025
Coroner's name: Dr. Richard A. Wells
(Original signed by presiding officer for Ontario)

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

Inquest into the death of: Ryan Patrick McKechnie

Jury recommendations
  1. The Ministry of the Solicitor General (ministry) should update current training for correctional staff concerning the interpretation of a negative body scan to be clear that a negative body scan does not indicate that the individual is guaranteed to be free from contraband.
  2. The ministry should establish the negative predictive value of the body scanner employed at institutions, being the ability of the scanner to accurately predict that an individual is free of contraband.
  3. The ministry should implement policy that establishes body scan operators as a dedicated role. This should include a robust training regimen and regularly scheduled recertification to a high standard.
  4. The ministry should implement a dedicated training program within correctional officer training institutions specific to the role of body scan operator. The ministry should study existing training requirements in related fields (i.e. Canadian Air Transport Security Authority, medical imaging technicians, etc.).
  5. The ministry should consider an audit of the efficacy of detecting contraband through the use of the current body scan protocols and policies.
  6. The ministry should conduct an operational debrief as soon as is reasonably practicable in relation to the death of an inmate. The operational debrief should permit an opportunity for frontline staff to provide their perspectives on the lessons that may be learned from a death. The operational debrief should generate written recommendations to reflect those lessons learned, if any, and be made available to frontline staff in a timely manner.
  7. The ministry should explore avenues for collecting positive or negative staff feed back related to standing orders, policies and processes that are anonymous and allow for staff to express their perspectives without fear of consequences.
  8. The ministry should fund trauma-informed supports for families following the death of a loved one while in correctional custody.
  9. The ministry should review its processes in relation to the notification of next of kin following a death in custody. The ministry should explore steps that may be taken to ensure that information concerning the death is not disseminated by inmates or staff prior to the notification of next of kin.
  10. Where contraband is found on an inmate or in a cell pursuant to a search, serious consideration should be given to separation and close monitoring of each of the cell occupants until staff are satisfied that all contraband has been identified. Where inmates are not separated and closely monitored, the reasons for doing or not doing so should be documented and approved by a sergeant.
  11. Hamilton-Wentworth Detention Centre should implement additional measures to prevent the use of the air duct system for the storage and consumption of contraband (i.e. guard access to the vent system during searches, modernization of the vent system, etc.)
  12. The ministry should institute an enhanced policy concerning expectations with respect to clock rounds. The policy should clarify that staff are to identify signs of life (i.e. breathing, movement, change of sleeping position, etc.) and ensure that every inmate is not in distress for each and every clock round.
  13. The Hamilton Wentworth Detention Centre should conduct an audit of staff compliance with expectations with respect to clock rounds. In particular, the audit should ascertain whether staff are engaging sufficiently with each inmate to satisfy themselves that the inmate is not in distress.
  14. The ministry should consider a study on the effectiveness of clock rounds to fulfill its function related to detecting proof of life of inmates. The ministry should consider making changes based on the findings of the study (i.e. establishing a distinct and focused wellness check during night rounds in addition to regular clock rounds, etc.).
  15. The ministry should increase its efforts regarding improving the prisoner to correctional staff ratio.
  16. The ministry should consider consistent, long-term placement of permanent correctional officers assigned to a specific unit to fulfill staffing requirements and create knowledge and familiarity within their unit.
  17. The ministry should strive to ensure the full complement of supervisory staff is present at correctional facilities on a daily basis.
  18. The ministry should consider the creation of an inmate digital information file organized by inmate name. This is to facilitate continuity of understanding by each officer of the inmate’s wellness.

February

Van Vessem, Sabrina

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: February 3
To: February 5, 2025
By: Dr. Geoffrey Bond, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Sabrina Van Vessem
Age: 24
Date and time of death: May 21, 2020, at 5:15 p.m.
Place of death: Niagara Regional Police Service Central Holding Facility, 5700 Valley Way, Niagara Falls
Cause of death: fentanyl toxicity
By what means: accident

(Original signed by: Foreperson)

The verdict was received on February 5, 2025
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 death of: Sabrina Van Vessem

Jury recommendations
To the Niagara Regional Police Service (NRPS):
  1. Conduct a data driven review of the frequency and causes of non- compliance with section 3.100 of General Order 018.21 which stipulates that each person in custody at NRPS Central Holding Facility shall be visually checked at least every 30 minutes.
  2. Develop and implement a reasonable plan to address any gaps identified in the above-noted review.
  3. Develop and implement a reasonable internal review mechanism to audit compliance with section 3.100 of General Order 018.21.
  4. Prioritize the continued exploration into the use of biometric sensors at the NRPS Central Holding Facility.
  5. Evaluate staffing requirements to enhance in-cell prisoner monitoring.
  6. Enhance prisoner intake questionnaire to include question(s) regarding narcotic possession.

Panepinto, Christopher

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: February 3
To: February 12, 2025
By: Dr. Bonnie Goldberg, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Christopher Panepinto
Age: 33
Date and time of death: February 10, 2020
Place of death: 1450 Pickering Parkway, Pickering
Cause of death: blunt force injuries of the chest
By what means: accident

(Original signed by: Foreperson)

The verdict was received on February 12, 2025
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 death of: Christopher Panepinto

Jury recommendations
TO: Delgant (Civil) Limited and 1276713 Ontario Limited
  1. Carry out a review with all employees/workers of the importance of manuals, drawings, and hazards of formwork and falsework systems, on or before the first day of a project.
  2. Before appointing a designated competent worker for pre-pour inspections, an engineer that is retained by the employer or formwork contractor to attend the site and conduct pre-pour inspections, shall ensure that the required design drawings have been obtained, reviewed, and explained to the prospective designated worker, to ensure that the individual is competent to conduct pre-pour inspections.
TO: Ministry of Labour, Immigration, Training and Skills Development (MLITSD), Chief Prevention Officer, Infrastructure Health and Safety Association (HSA), and the Ontario Formwork Association
  1. Amend the Occupational Health and Safety Act, R.S.O. 1990, c. 0.1, to create a Formwork Training Standard for all formworkers that includes the following:
    1. A best practice to assist with the proactive inspection of formwork contractors by MLITSD inspectors. This could include developing a check list within the current documentation to help ensure that the contractor has arranged for the necessary critical resources and competent staff, and identify who is assigned to the job site as the contractor's engineer and/or competent person for onsite inspections. A new standardized proactive inspection should include verification that engineered drawings in either physical or digital formats were obtained, results of a complete walk-around inspection, and notes of discussions with onsite staff, which may include supervisors, senior employee/foreman, and any other on-site formwork employees. This check list may be shared with employers and constructors so that they can ensure compliance.
    2. A requirement that the formwork contractor/employer provide workplace site-specific training to all carpenters, carpenter helpers, carpenter form workers and any trades who perform duties on, around or near any formwork walls and shall cover all components of the formwork systems or engineered alternatives being used onsite. The formwork contractor/employer should ensure that the formwork system's user manual is reviewed with each employee/worker. Subject to the available resources of the formwork supplier(s), this site-specific training could include engaging and paying for the services of any suppliers of the formwork system to provide orientation to site workers about the safe use of the formwork system. This training shall be maintained and updated at appropriate intervals.
  2. Working collaboratively with stakeholders, develop and mandate a formwork awareness training program that identifies risks when working around formwork for all workers working on a project with formwork installation. An eLearning module is encouraged.
  3. Develop a training standard for supervisors in Ontario Regulation (O. Reg.) 213/91 that emphasizes documenting worker concerns and communicating with Health and Safety representatives, Joint Health and Safety committees and MLITSD, highlighting the importance of being available to workers when high-risk work (including adjusting or dismantling formwork or falsework) is being conducted.
  4. If the formwork contractor has created written general procedures for assembling, adjusting, and dismantling the particular formwork systems beyond what is set out in that formwork system's user guide or user manual, such written procedures must be made available to every employee who performs any duties on, around or near the formwork system. This must be done on or before the employee's first day on the job and must include a system to document and confirm each employee's acknowledgement of having received and reviewed these written procedures.
  5. Consider amending the Formwork Falsework provisions contained in O. Reg. 213/91 to include minimum qualifying criteria for a worker to be designated a competent worker for pre-pour inspections, which includes training and demonstrated on-site experience.
TO: MLITSD, and the Chief Prevention Officer
  1. Ensure that engineered design drawings that include site specific considerations and appropriate bracing requirements be made available onsite for access and review by all formwork workers. Ensure that the supervisor does not permit the erection of any formwork walls without first ensuring that the required engineered design drawings, guides, and manuals, are available on site in both physical and digital versions and reviewed with each crew that will be assembling, erecting, and plumbing the formwork walls for concrete.
TO: Infrastructure HSA
  1. Create a safety campaign to encourage workers to request a meeting at the location where the wall is to be placed to discuss the proper procedure and sequence for safely assembling, adjusting, and dismantling the forms, and to conduct a contemporaneous on-site risk assessment of site conditions, prior to assembling the first in a series of formwork walls. This campaign can be in either a written or video format, or both.
  2. Create a Safety Talk on the safe installation, adjustment, and dismantling of formwork, specifically related to following manufacturers' instructions, engineer drawings, supervision, and inspection. This Safety Talk can be in either a written or video format, or both.
  3. Issue an advisory on the use of constructing formwork, specifically related to following manufacturers' instructions, engineer drawings, supervision, and inspection. This advisory can be in either a written or video format, or both.
  4. Enhance the "See Something, Say Something" campaign to address issues and challenges relating to workplace culture on construction projects, including:
    1. The dangerous and ongoing impact of complacency while working with formwork.
    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. Informing employees on the stages of their rights (right to participate, right to know, and right to refuse) and the stages and actions before a work refusal is raised.
TO: Infrastructure HSA, and the Provincial Labour Management Health and Safety Committee
  1. Further to the ongoing work of the Highrise Forming Committee, continue to advocate for amendments related to O. Reg. 213/91 Formwork and Falsework provisions. Continue to develop Guidelines for the Design and Inspection of Formwork and continue to develop a typical book of details to assist the industry.
  2. Take steps to advocate for the enhancement of Canadian Standards Association S269.1 standard so that shoring instructions/ procedures indicate which steps are critical, why they are critical, and how they are to be inspected during formwork and falsework erection.
TO: LiUNA Local 183
  1. Communicate to your members that there is a formwork training program available for their employers to send them to.
  2. Investigate and potentially develop training to support and enhance your members' ability to read and understand engineer drawings.
  3. Consider creating a standard Clearance Certificate form that includes a field listing the worker's general and specific training.

Campbell, Christopher
Hart, Fabian

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: February 21
To: March 6
By: Dr. John Carlisle, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Christopher Campbell
Age: 55
Date and time of death: October 11, 2018
Place of death: London Health Sciences Centre (Victoria Hospital), 800 Commissioners Rd. East, London
Cause of death: multi-drug toxicity (fentanyl, cocaine, methamphetamine, trazodone, ethanol)
By what means: accident

Name of deceased: Fabian Hart
Age: 34
Date and time of death: February 2, 2021
Place of death: London Health Sciences Centre (Victoria Hospital), 800 Commissioners Rd. East, London
Cause of death: methamphetamine - amphetamine toxicity
By what means: accident

(Original signed by: Foreperson)

The verdict was received on March 6, 2025
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 deaths of: Christopher Campbell,  Fabian Hart

Jury recommendations
To the London Police Service:
  1. Evaluate the feasibility of embedding medical professionals within the Headquarters Detention Unit. The medical professionals' role should include the following:
    1. conducting initial and ongoing assessments of the health of persons in custody
    2. providing acute medical care to persons in custody
    3. determining whether persons in custody require transport to the hospital
    4. providing training regarding relevant medical conditions when applicable
  2. Evaluate the feasibility of contracting with a stand-by health care professional or service to contact for immediate consultation and advice whenever the health of a person in custody becomes a concern.
  3. Install biometric sensors within holding cells at the Headquarters Detention Unit to monitor the vital signs of persons in custody. If all cells are not equipped with biometric sensors, best efforts should be made to ensure that persons in custody exhibiting medically concerning behaviour and/or expressing any concerns about their health should be placed in a biometrically monitored cell. Refer to other police services with a similar model to determine training required of biometrics for all Headquarters Detention Unit staff.
  4. Examine the feasibility of updating the computer software at the Headquarters Detention Unit to provide for easier access and/or searchability of previous detention records to increase access to information when booking a person in custody.
  5. Examine the feasibility of providing and/or integrating a drug database resource into the computer software at the Headquarters Detention Unit that could flag for high-risk medications. This could include considerations for medications that require monitoring or have contraindications. This should be done with input collaboratively with a pharmacist and/or medical professional.
  6. Amend procedure to ensure that when initial efforts to locate prescription medications are unsuccessful, further inquiries should be made of the person in custody. This should include:
    1. Further mandatory/prompting fields in the detention record regarding how medication could be obtained, who to contact, what attempts were made, and if they were not obtained.
    2. Documentation on what actions were taken and the outcome.
  7. Amend/standardize procedures for the detention record for the following:
    1. To require that all observable and/or reported health conditions be entered as soon as practicable.
    2. That information should be communicated to following and subsequent shifts during the debrief process to ensure that the current officer-in-charge has information about the person in custody's health, including any changes, throughout their time in custody.
    3. A standard template for shift-to-shift handoff that requires sign off by the officer-in-charge.
    4. Development of guidelines for mandatory status updates on persons in custody at regular intervals.
    5. Accurate information be provided to appropriate stakeholders, such as emergency medical services, Coroner's Office.
    6. Include relevant handoff information between arresting officers and Headquarters Detention Unit staff.
  8. Create a procedure to ensure that operational debriefs are held for officers involved in and/or impacted by a death in custody following the completion of an SIU investigation and once there are no remaining legal barriers or restrictions preventing the debrief from occurring. If applicable, update all staff on lessons learned and considerations to best practices.
  9. Ensure all front-line members, including members stationed in the Headquarters Detention Unit, receive training on the signs and symptoms of alcohol withdrawal, including information that alcohol withdrawal is a potentially life-threatening condition that may require medical attention. Where applicable, resources on assessment tools should be made available for reference, such as the Clinical Opiate Withdrawal Scale and Clinical Institute Withdrawal Assessment for Alcohol. This training should be reviewed and updated regularly in consultation with a medical professional. Front-line members should receive this training at orientation, as well as on a regular basis.
  10. Ensure that training for all members stationed at the Headquarters Detention Unit includes awareness that, in critical incidents, audio and video surveillance may be viewed in public proceedings where interactions between LPS members could be subject to review.
  11. Review the feasibility of adopting an electronic documentation system for cell checks that is efficient and uses standardized options.
  12. Examine the feasibility of performing internal audits for booking, documentation, and other processes related to the care of persons in custody at the Headquarters Detention Unit, to ensure efficacy of and compliance with procedures and training on a regular basis.
  13. Review stigma and bias training regarding substance use (drug and alcohol) and if this does not exist, have it created.
  14. Review the feasibility of increasing training and equipment to officers for testing at the scene of arrest, regarding alcohol and drug testing for impaired charges.
  15. Review scenario-based training to specifically include medical situations in the Headquarters Detention Unit.
  16. Review the “Medical Transportation Protocol from Headquarters Detention Unit” (Headquarters Detention Unit hospital flowchart) in collaboration with a healthcare professional and broadly disseminate to all service members, to assist in the management of persons in custody.
  17. Review the feasibility of updating audio surveillance within the Headquarters Detention Unit.
To the Ontario Police College:
  1. To have a best practice course or session relating to the care of persons in custody.

Quisses, Sherman Kirby

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: February 24
To: March 21, 2025
By: Dr. David Cameron, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Sherman Kirby Quisses
Age: 35
Date and time of death: June 4, 2012
Place of death: Thunder Bay Regional Health Sciences Centre
Cause of death: hypoxic-ischemic encephalopathy due to penetrating neck trauma
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on March 21, 2025
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: Sherman Kirby Quisses

Jury recommendations

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

  1. The ministry should hire psychologists to be on staff at the Thunder Bay Correctional Center (TBCC) and explore means to incentivize competitive candidates.
  2. The ministry should continue to provide and improve opportunities for collaboration and communication between health care staff, contracted health professionals, and other multi-disciplinary members of patients' circles of care within the correctional setting, with the proper privacy protection of personal health information in place.
  3. The ministry should ensure all staff, including health care staff and contract staff, are knowledgeable about Indigenous program offerings, including by providing information on the programs.
  4. The ministry should ensure that regular review of the health care unit at the TBCC is conducted to provide adequate and timely consideration of improvements, and address potential concerns with respect to processes which support patients discussing their mental and physical health concerns with health care staff.
  5. While bunk beds are still in use at the TBCC, the ministry should develop a formal policy prohibiting people in custody from hanging any objects from bunk beds that might obstruct views of the dormitory.
  6. In the interim, the ministry should develop a formal policy outlining the actions to take to ascertain the whereabouts of a person in custody who is not present in their bed during bed checks.
  7. The ministry should ensure that a mental health unit is created in the new Thunder Bay correctional institution, where persons in custody experiencing mental health symptoms, or those being assessed for a mental illness diagnosis, can be housed, assessed and treated. Consideration should be given to:
    1. correctional officers, health care staff, Native Inmate Liaison Officers (NILOs), and other service providers sharing information regarding individuals in this unit, including sharing any observations made and needs for the day;
    2. correctional officers, health care staff, NILO and other service providers working together on this unit to provide a therapeutic environment; and
    3. ensuring that there is a focus on mental health treatment, assessment, and activities promoting optimal mental health both inside the institution and at the time of discharge into the community.
  8. The ministry should ensure that the new Thunder Bay correctional institution has sufficient dedicated Indigenous cultural space for programming, ceremonies and celebrations, including necessary infrastructure to conduct smudging ceremonies indoors. The ministry should consult Indigenous communities and organizations on the construction, design, and operational use of these spaces.
  9. The ministry should inquire into the new Thunder Bay correctional institution having space and resources for video meetings between Indigenous people in custody and their family, community, Council, and Elders.
  10. The ministry should ensure that there are post-incident supports available for people in custody immediately following a critical incident, including one on one counselling.
  11. The ministry should ensure that critical incident supports for all staff include aftercare and flexible options to access supports.
  12. The ministry should continue to ensure that NILO and Elder services are adequately resourced to meet the needs of Indigenous people in custody. Indigenous people should be able to access their spiritual rights as well as programs with consistency, regularity and without unreasonable delay. Specifically:
    1. The ministry should take measures to ensure that the NILO position is adequately funded as a full-time permanent position
    2. The ministry should consider increasing the NILO staff at the TBCC to meet the needs of Indigenous people in custody, so that programs and services are, at a minimum, representative of their needs or recognizes the number of Indigenous people at each institution
    3. The ministry should create policy and direction that recognizes the role and function of NILO staff and Elders as central to the delivery of Indigenous spiritual and cultural access and for health and wellness
    4. The ministry should support honoraria that is deemed appropriate by Elders as set out in its contracts with Indigenous service providers to ensure that Elders are being properly compensated for the important work they are conducting in facilitating Indigenous peoples’ access to their spiritual rights
    5. The ministry should revise both health and NILO policy to ensure access to cultural and spiritual supports is recognized as a fundamental healthcare right for all persons in custody
    6. The ministry should engage in community consultation on the development of Indigenous core programming with Indigenous leadership including First Nation, Métis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centers
  13. The ministry should take measures to recruit Indigenous operational and health care staff and managers, including Indigenous students studying in relevant fields.
  14. The ministry should translate the Security Assessment for Evaluating Risk (SAFER) tool informational posters into Indigenous languages and post them in frequently accessed areas in the TBCC.
  15. The ministry should ensure appropriate supports are available to assist individuals in custody who may request a review of their SAFER score, including relevant information contained in an individual’s Offender Tracking Information System (OTIS) profile, and provide such supports.
  16. The ministry should ensure that misconducts previously inputted on an individual’s OTIS profile are updated following the outcome of the misconduct and adjudication.
  17. The ministry should ensure policies are in place for documenting and communicating behavioural concerns or issues related to mental health between staff members in a consistent and uniform way.
  18. The ministry should require that all front-line staff and individuals in a managerial or supervisory role at the TBCC take Indigenous-specific training. The training should try to achieve culturally appropriate and trauma-informed models of care specifically for Indigenous people in custody and include information about colonialism, the impacts of trauma and intergenerational trauma. It should also include the use of Indigenous celebration, ceremonies and cultural events to promote awareness of Indigenous communities, strengths and resilience. The training should be designed and delivered by Indigenous people.
  19. All front-line staff working at the TBCC should have ongoing mental health education and learning opportunities, including training on all mental health tools in use at the TBCC. Recognition of acute behavioural changes related to mental illness, non-violent de-escalation techniques, the risk and recognition of psychosis and lessons learned from critical events which may occur in the institution should be part of this ongoing learning.
  20. The ministry should ensur that there are post-incident supports available for NILOs immediately ollowing a critical incident within the facility.
  21. The ministry should encourage staff participation in Indigenous ceremony and celebrations to promote better understanding of the strengths of Indigenous cultural practices. This participation should be considered part of staff members’ operational duties and, if necessary and practicable, changes in staffing should be made to accommodate this requirement.
  22. The ministry and the TBCC should initiate consultation with Indigenous communities through political territorial organizations (i.e., Nishnawbe Aski Nation), tribal councils (i.e., Matawa Tribal Council) and/or First Nation communities to achieve a greater understanding of the communities to which Indigenous people in custody belong. This is for the purpose of creating community profiles, either written by or approved by the same Indigenous communities. Through this consultation, the community profiles should include, but not be limited to, information about an Indigenous individual’s community location/geography, language, history, foods, hunting seasons, its members’ experiences with Indian Residential Schools and/or day schools, and any other specific challenges or strengths. The community profile should be included in their OTIS profile and be readily accessible to all staff.
  23. The ministry should ensure that, upon request, individuals are provided with their SAFER score in writing along with information about their right to request a review.
  24. The ministry should consider the gaps that exist in assessing and recording an individual’s involvement in a misconduct and how those gaps affect that individual’s SAFER score even if they are found not guilty of the misconduct.

March

Jenkins, Troy

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: March 3
To: March 4, 2025
By: Dr. Bonnie Goldberg, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Troy Jenkins
Age: 55
Date and time of death: June 9, 2021
Place of death: Michael Garron Hospital: 825 Coxwell Ave, East York
Cause of death: cocaine toxicity
By what means: accident

(Original signed by: Foreperson)

The verdict was received on March 4, 2025
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 death of: Troy Jenkins

Jury recommendations

No recommendations.

Lewis, Calvin

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: March 3
To: March 11, 2025
By: Dr. Ronald Goldstein, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Calvin Lewis
Age: 32
Date and time of death: July 19, 2021
Place of death: Ottawa Civic Hospital, 1053 Carling Avenue, Ottawa
Cause of death: pulmonary thromboembolism due to deep vein thrombosis
By what means: natural

(Original signed by: Foreperson)

The verdict was received on March 11, 2025
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: Calvin Lewis

Jury recommendations
To the Ministry of the Solicitor General (SOLGEN) and to the Ottawa-Carleton Detention Centre (OCDC):

Staffing

  1. Conduct a review of the model of health care and mental health care at OCDC. The review should explore the following:
    1. Hiring of additional staff psychologists at the OCDC, including the possibility of part-time positions.
    2. On an ongoing basis, endeavouring to ensure remuneration does not become a chronic challenge for mental health practitioners working in provincial correctional institutions.
    3. Identifying and addressing the number of unfilled staff positions in the Health Care Unit (e.g., nurse practitioners, psychiatrists).
    4. Additional measures that can be taken to attract and retain staff to these positions, as well as steps to fulfill all existing contract hours as contracted with the Royal Ottawa Hospital.
    5. Ensuring that there are adequate resources in all provincial correctional institutions for the provision of 24/7 on-site attendance of mental health professionals (e.g., psychiatrists, psychologists, mental health nurses).
    6. The implementation of an on-call schedule for psychiatry services to ensure the mental health needs of persons in custody are addressed and advocated for at all times.
    7. Establishing a frequency of review of appropriate staffing levels for health care professionals at the OCDC, including physicians, registered nurses and mental health nurses, to provide a reasonable ratio of health care providers to persons in custody on each shift.
    8. Consider the addition of other health care professionals such as registered practical nurses, and increasing the complement of pharmacists, and/or pharmacy technicians, making full use of each professionals scope of practice.

Individuals housed at a provincial correctional institution should not be allowed to remain in conditions of squalor. In keeping with the "An Obligation to Prevent" report of 2021, "the right to health care is not surrendered upon entering the correctional system."

  1. Review job descriptions, work assignments and duties, and/or standing orders in order to ensure that correctional officers are always made available to escort health professionals providing care to persons in custody.
  2. Seek opportunities to create partnerships with educational institutions and professional bodies such as the College of Nurses of Ontario and the Ministry of Colleges and Universities in order to prioritize outreach at colleges and universities and at nursing job fairs to increase the awareness of nurses and students to the potential career opportunities in provincial correctional institutions.
  3. Evaluate the feasibility of the use of centralized recruitment processes for nursing staff at a provincial or multi-institution level, as alternatives to recruitment by individual institutions.
  4. Consider reviewing the selection criteria in order to identify correctional officers who are interested in working in an acute health care environment alongside the health care team and provide additional training so that they may be assigned to stabilization units in order to work closely and effectively with the health care team in these environments.

Health care/mental health care

  1. Evaluate the feasibility and impacts of the creation of an embedded mental health unit at the OCDC, over and above the current stabilization unit, to better support and meet the needs of persons in custody who require additional mental health support or supervision. This unit should be staffed by operational and health care staff who have expressed interest, and who have specialized training, in providing mental health care and support to persons in custody.
  2. Explore ways to streamline interdisciplinary communication, for example to use the electronic medical record system to include psychologist assessment with referrals to facilitate more timely access to psychiatric services for persons in custody who are experiencing serious or severe mental health symptoms.
  3. Explore and expand the implementation of an in-house pharmacy at all provincial correctional institutions to assist with the packaging and dispensing of medications, including any necessary funding, and staffing resources that may be required, based on individual institutional needs.
  4. Take steps to source and implement the use of pre-packaged medications (e.g., blister packs) at all provincial correctional institutions to reduce the time spent by nursing staff preparing and dispensing medications for persons in custody as well as reduce the possibility of medication errors.

Improved record-keeping

  1. Continue to prioritize the next phase of the implementation of the ministry-wide electronic medical record (EMR) system to ensure it is fully available and functional at the OCDC and all provincial correctional institutions.
  2. Explore the benefits and feasibility of incorporating into the EMR system an alert process to flag when updates have been made to a patient's Health Care Record for staff involved in their care.
  3. Ensure that Health Care Observation forms are used for the monitoring and observation of any person in custody who is placed on a suicide watch or enhanced watch, with particular attention to persons in custody presenting with severe mental health symptoms, and a live, electronic format be considered.
  4. Continue with ongoing efforts to improve Health Care Observation forms in use at the OCDC and all provincial correctional institutions, and/or create new electronic forms, to improve the flow of information between correctional officers and health care staff and, if possible, reduce duplication of data capture in overlapping forms.
  5. Perform regular audits of logbooks, observation records, and health care files by management at the OCDC, as well as in all other institutions, to:
    1. ensure compliance with Ministry policies, and institutional standing orders
    2. identify any deficiencies in documentation and record keeping
    3. implement corrective measures as may be identified

A record of the audits and any outcomes should be kept. The frequency of audits should be codified in policy and standing orders.

  1. Ensure that upon admission to a correctional institution, new arrivals are asked for contact information for emergency and/or emergency contact support person. Develop consent-informed policy and procedures for the use of this contact information for health care situations including transfer to hospital.

Training and education

  1. Provide all operational and health care staff in provincial correctional institutions with training on the risks of prolonged immobility among persons in custody, to improve awareness and promote prevention of potentially serious health complications that may arise from immobility, (i.e. deep vein thrombosis). This training should be included in employee onboarding / orientation materials and reviewed periodically. In the interim, issue a bulletin to all provincial correctional institutions alerting staff to the risks inherent with prolonged sitting/immobility and symptoms to monitor for.
  2. Create opportunities for frontline staff, including health care (e.g. nursing), at the OCDC and all other institutions to engage in regular knowledge transfer sessions to help foster a culture of mentorship and encourage the sharing of best practices.
  3. Consider developing and implementing formal learning opportunities where physicians, nurses, psychologists, and other health care professionals involved in the care of persons in custody can meet, discuss, and share experience and/or knowledge, for example, with regards to the presentation, identification and treatment of complications that may arise from medication side-effects, withdrawal, and prolonged immobility.
  4. To ensure improved compliance with ministry policy, provide enhanced training to operations staff who are working in stabilization units at the OCDC, and other correctional institutions focused on how to better support individuals in custody who may be presenting with significant mental health symptoms. This enhanced training should include a review of applicable policies, standing orders, and procedures concerning the identification, placement, and monitoring of persons in custody who are experiencing significant mental health issues. This training may, if applicable, reinforce the use of forms (as per recommendations 12 and 13), or the result of audits (as per recommendation 14).
  5. Ensure that all staff with access to the EMR system receive training and ongoing support in its use to ensure efficient and optimal use of the system.
  6. Staff should be encouraged to continue to share any concerns with the appropriate corrections supervisor or health care staff with the aim of protecting the health of persons in custody.
  7. Through training and the issuance of a bulletin to all staff, reinforce the requirement that the Jail Screening Assessment Tool is to be completed as soon as possible and no later than 96 hours from when the criteria in the Brief Jail Mental Health Screen is met.
  8. When a critical incident occurs in a provincial correctional institution, such as the death of a person in custody, an in-depth quality of care review shall be conducted as soon as possible with all operational and health care staff involved in the individual's care, while considering any privacy and/or legal privileges. Operational, health care, and other frontline staff should be encouraged to provide their perspectives on the lessons that may be learned from circumstances surrounding the death. The review should analyze all relevant records to:
    1. assess issues surrounding the care or monitoring of the individual
    2. to identify issues that may have contributed to the critical incident/death
    3. to consider all solutions that may be implemented to address these issues

Any solutions that are identified should be communicated to all staff in a timely manner.

The process to perform the quality-of-care review should be established in policy and standing orders, as appropriate.

  1. To support education and training (as per recommendations 16, 18, 19), and in collaboration with health care professionals and mental health experts, develop a case study modelled on the circumstances of Calvin Lewis' death. The case study should emphasize the potential significance of the various symptoms that Calvin Lewis was exhibiting and should also consider the opportunity for and timing of various potential emergency responses.
  2. Advocate to medical schools and professional bodies for the inclusion of learning materials specific to the delivery of health care and mental health care considering the unique challenges that persons in custody face prior to, during, and after incarceration.
  3. Explore ways to improve the continuity of care between correctional institutions, hospitals, and community health care providers. Perform ongoing outreach efforts to improve awareness and understanding of the unique health care needs of incarcerated persons, as well as understanding of the health care capacity and role that correctional institutions play in the overall health care system.
To SOLGEN:

Communication with family

  1. Create, implement, and report on a family-centered communication protocol that is compassionate and supportive of the family of individuals who die in custody. Input for the creation of this protocol should be sought from correctional staff or fee-for-service providers, such as chaplains, Native Inmate Liaison Officers, and social workers, and from any community-based organizations to whom grieving family members may be referred to for supports.

Rights advisor

  1. Consider establishing an Independent Rights Advisor and Prisoner Advocate at all provincial correctional institutions to serve all persons in custody with a serious mental illness, as defined in Ministry policy. The advocate should be responsible for providing advice, advocacy, and support concerning corrections policy and practice, housing placement decisions, and the right to health care. The advocate must be notified immediately upon any increase to the person in custody's conditions of confinement.

April

Garlow, Robyn

Held at: virtual, 25 Morton Shulman Avenue, Toronto
From: April 1
To: April 4, 2025
By: Dr. Geoffrey Bond, presiding officer for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Robyn Garlow
Age: 30
Date and time of death: October 20, 2018
Place of death: Hamilton General Hospital Site 237 Barton Street East
Cause of death: gunshot wounds to torso
By what means: homicide

(Original signed by: Foreperson)

The verdict was received on April 4, 2025
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 death of: Robyn Garlow

Jury recommendations
To the Hamilton Police Service:
  1. Provide new recruits with crisis intervention training before they receive use of force training so that the skills that are learned during crisis intervention training can be applied during use of force training.
  2. Extend the availability of Mobile Crisis Rapid Response Team (MCRRT) units to 24 hours a day and increase the number of MCRRT units to respond to calls regarding persons in crisis.
  3. Consider implementing a dedicated MCRRT unit(s) for central Hamilton, following needs-based analysis.
  4. Explore the feasibility for all communicators to have access to and be trained on utilizing local records management system in order to provide responding officers with background information, specifically for high priority incidents, including but not limited to queries on involved people and addresses.
  5. Add the following to the Suicide or Attempt Policy for Communicators under the responsibilities of dispatchers:
    1. Query Location of Interest and provide results to the responding officers.
    2. Query CPIC and provide the results to the responding officers.
  6. Conduct annual refresher training on the Suicide or Attempt Policy for Communicators, emphasising the role and responsibilities of the call taker and dispatcher.
  7. Conduct an annual refresher on crisis intervention training for front-line officers.
  8. Implement a voluntary operational debrief process for involved Hamilton Police Service members, including communications staff, after the conclusion of a Special Investigations Unit investigation. Update all staff on lessons learned.
  9. Consider using the facts from the inquest into the death of Robyn Garlow to develop a training- based scenario for officers to complete during their annual recertification training.
  10. Explore the necessity for training that addresses trauma-informed approaches specific to Indigenous populations.
To all police services in Ontario:
  1. Consider providing crisis intervention training as part of the post-Ontario Police College curriculum for all officers.
  2. Consider providing crisis intervention training before they receive use of force training so that the skills that are learned during crisis intervention training can be applied during use of force training.
  3. Consider providing an annual refresher on crisis intervention training for front-line officers.
To the Ontario Police College and the Ministry of the Solicitor General:
  1. Consider changing the online component of the Ontario Police College's Mental Health and Crisis Response Education and Applied Training to in-person.
  2. Consider including conductive energy weapon training as part of the mandatory curriculum for police recruits at the Ontario Police College.