Names of the deceased: Mamakwa, Donald; McKay, Marlon RolandHeld at: Thunder BayFrom: October 11To:November 4, 2022By:Dr.David Cameron, presiding officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:MamakwaGiven name(s): DonaldAge:44, Date and time of death: August 3, 2014 at 12:03 a.m.Place of death:Thunder Bay Police ServiceCause of death:ketoacidosis, complicating diabetes mellitus, chronic alcoholism, and septicemiaBy what means:undetermined, Surname:McKayGiven name(s):Marlon RolandAge:50, Date and time of death: July 20, 2017 at 1:34 a.m.Place of death: Thunder Bay Regional Health CentreCause of death:hypertensive heart diseaseBy what means: natural, The verdict was received on November 4, 2022Coroner's name:Dr.David Cameron(Original signed by coroner). The Solicitor General of Ontario should provide oversight on the mandatory annual training curriculum and number of hours that are provided by local police services e.g. Provide adequate and sustainable funding and resources to ensure that a range of placement options and transition services, including independent and semi-independent living arrangements, are available for children and young people receiving services from childrens aid societies and Indigenous well-being agencies. Be staffed 24 hours a day and 7 days a week. Establish an independent Intimate Partner Violence Commission dedicated to eradicating intimate partner violence (, Driving change towards the goal of eradicating. consider the need for Navigators, in addition to resource persons, adult ally and circle of supportive persons to assist First Nations youth, as both a prevention and protection resource and for youth both on and off reserve, in navigating various systems such as child welfare and protection, mental health and criminal justice. Try to find out: the date the. Programs and other initiatives to address drug addiction and abuse should be encouraged, prioritized and promoted in prominent places throughout the facility where they are likely to come to the attention of persons in custody. Create the role of a Survivor Advocate to advocate on behalf of survivors regarding their experience in the justice system. It also ruled Don Mamakwa's death in 2014 had an . In recognition of the shortage of beds in detox/treatment (rehabilitation) facilities in the City of Thunder Bay, the number of beds in such programs should be increased to adequately meet the needs of the community. Peer support and appropriate circles of support. An inquest is a judicial process and a Coroner's Court is a court of law. Support all child protection staff in understanding the steps outlined in the internal policy related to Suicide Threats by Children/Adolescents in Care. Promote and utilize the participation of young people and youth-driven practices in services, tools and programs, such as: the Wise Practices resources and Life Promotions toolkit by Indigenous youth, that are about their own wellness and make space for the young people to put into practice tips and ideas from those services, tools and programs. Reinforce the policy requirement for a Part C health care summary to be completed in every patients health care record. The open verdict is an option open to a coroner's jury at an inquest in the legal system of England and Wales. All physician assistants and doctors ensure that workplace hazards are incorporated into the assessment of any medical emergency. The Board will consider yearly public reports setting out the initiatives taken by the Board, the progress of those initiatives and an expected timeline for completion of the initiatives. how to prevent heat stress and other heat related illnesses that may arise from working in high temperature conditions, and. Sources of Evidence and Disclosure . For conductive energy weapons consider high visibility markings (colour) to differentiate them from firearms. Review whether one on one supervision needs to be provided to individuals in custody who pose particularly high risk, such as individuals who expressed suicidal ideation. Inquests for this area are normally held at Archbishops Palace, Maidstone unless stated otherwise. The Toronto Police Service should improve delivery of relevant information to the inner perimeter where crisis negotiations are taking place without unduly disrupting the negotiation process. Measures to improve public awareness should be developed in consultation with content experts and community organizations that represent persons with lived experience. Create emotionally supportive debrief sessions for police officers at the division or platoon level for those involved in critical incidents resulting in serious bodily harm or death, with regard for the Special Investigations Unit investigative process. A health care manager and/or physician should be notified when an inmate brings a suspected opioid or prescription medication into the institution or when an inmate appears to be intoxicated while in custody. within hiring practices to ensure personality and culture fit, situational judgement, role-specific skills, incorporate in regular performance evaluations to ensure that the individuals values remain consistent with expectations. Coroners' Inquests Inquests are formal court proceedings, with a five- to seven-person jury, held to publicly review the circumstances of a death. The Boards Governance Committee will consider creating an implementation plan that includes but is not limited to: a timeline for implementation of all recommendations received through various reports, inquests and inquiries; a plan for how the recommendation will be implemented; and how consultation and follow-up with Indigenous community will take place. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. Regular meetings between mine emergency response team and. 12/09/2022. Ensure that all health care staff are trained in suicide prevention policies and documentation. Improve knowledge and awareness for police communicators, call takers, and dispatchers of the signs of mental health crisis, and ensure that communicators are trained to ask questions directed at determining whether a call involves a mental health crisis. Improved supervision of high-risk perpetrators released on probation, including informed decision-making when applying or seeking to modify conditions that impact the survivors needs and safety. The pilot whose plane crashed at the Shoreham Airshow in 2015, killing 11 men, has asked for permission to judicially review the inquest into their deaths. Section 14.6 states the following: We call upon Correctional Service Canada and provincial and territorial services to provide intensive and comprehensive mental health, addictions, and trauma services for incarcerated Indigenous women, girls, and. The Internal Responsibility System, with an emphasis on the importance of promoting a no-blame workplace safety culture that encourages an open relationship to discuss workplace safety. Enhance procedures for increasing communication and service coordination contained within the signed protocol between child welfare services and the services provided by urban Indigenous agencies, including but not limited to: De dwa da dehs nye s (Aboriginal Health Centre), Hamilton Regional Indian Center, Niwasa Kedaaswin Teg, the Native Womens Centre and the Niagara Peninsula Aboriginal Area Management Board (, Continue to prioritize the Child Welfare Sector Commitments to Reconciliation by transparently sharing data (without personal information and in accordance with Part X of the. The jury hears evidence from witnesses under summons (same as a subpoena) in order to determine the facts of a death. The ministry should consider changing the reporting structure for healthcare to ensure that the health care manager at the institutional level reports directly to Corporate Health Care. A British coroner will hear about the final hours of Amy Winehouse's life at the inquest into the soul diva's death. It is their duty to find out the medical cause of the death if it is not known, and to enquire about the cause of it if it was due to violence or was otherwise unnatural. Ensure that security patrols are completed during shift changeovers. Constructors, employers and supervisors shall ensure that workers are not endangered by cell phone use on construction projects. 05/09/2022. To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. Increase sustainable and equitable funding for community-based childrens mental health services, including residential placement options and family support, that are responsive to recruitment and retention needs of service providers to employ multidisciplinary staff and professionals and programs that are flexible, responsive, and facilitate the right services at the right time for children and young people with complex needs. . Roger and Bradley Stockton crashed on the second lap of last year's final sidecar race. Continue to facilitate learning events related to the youth presenting with complex suicide needs and remain an active community participant in the Youth with Complex Suicide Needs (. That the Thunder Bay Police Service review its jailer academic programming and, if not already included, incorporate an educational component on the Human Rights Code and training on cultural sensitivity. Rename crisis hotline services and create awareness campaigns to educate the public about their existence to make the public aware that these services are available before a person reaches the point of crisis. Names of the deceased: Frenette, Steven;Foreman, Daniel;Bullen, David;McConnell, Jonathan; Borja, SusanHeld at:virtual, Office of the Chief CoronerFrom:November 14To: December 1, 2022By:Dr.Robert Reddoch, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname:FrenetteGiven name(s):StevenAge:35, Date and time of death: September 20, 2018 at 7:38 p.m.Place of death: Ross Memorial Hospital, LindsayCause of death:central nervous system depression due to (or as a consequence of) combined fentanyl toxicity and diazepamBy what means: accident, Surname:ForemanGiven name(s):DanielAge:39, Date and time of death: October 3, 2018 at 9:10 p.m.Place of death: Central East Correctional Centre, LindsayCause of death:fentanyl intoxicationBy what means: accident, Surname:BullenGiven name(s):DavidAge:50, Date and time of death: December 29, 2018 at 7:52 a.m.Place of death: Central East Correctional Centre, LindsayCause of death:acute fentanyl toxicityBy what means: accident, Surname:McConnellGiven name(s):JonathanAge:36, Date and time of death: April 28, 2019 at 8:40 a.m.Place of death: Central East Correctional Centre, LindsayCause of death:carfentanil toxicityBy what means: accident, Surname:BorjaGiven name(s):SusanAge:50, Date and time of death: August 10, 2019 at 6:26 a.m.Place of death: Central East Correctional Centre, LindsayCause of death:toxic effects of oxycodone, methadone, quetiapine and pregabalinBy what means: accident, The verdict was received on December 1, 2022Coroner's name: Dr. Robert Reddoch(Original signed by presiding officer), Surname:CouvretteGiven name(s):Gordon DaleAge:43. Coroner's court returns verdict of medical misadventure after inquest into death of Linda Connell (41) five days after minor surgery to remove ovarian cyst That training be delivered to police officers and jailers relating to medical issues that may mimic intoxication, or that may be concurrent with intoxication, and that this be provided both at the Ontario Police College and to serving officers. Said education and instruction should occur prior to the commencement of work on any site where a skid steer is anticipated to be in operation. The funding formula should reflect the population of Thunder Bay and surrounding areas that uses Thunder Bay as a Hub for medical services. To support the cultural safety and well-being of First Nations children and young people and in keeping with the Truth and Reconciliation Commissions Calls to Action (2015), continue to support a range of Indigenous programs to include Youth Life Promotion initiatives which entail both school and land-based programs, Indigenous Mental Health and Addiction Workers in the Indigenous communities across the province, Mental Wellness Teams, Indigenous Professional Development and Tele-Mental Health. We recommend that Occupational Health and Safety be amended to allow Health and Safety representatives and Joint Health and Safety committees authority to keep confidential the name of any workers who report unsafe conditions. In recognition of the seriousness of alcohol/substance use disorder as a medical condition which may mask the appearance of other serious medical conditions, a program should be established in the City of Thunder Bay to provide medical alert bracelets to individuals at high risk for adverse medical outcomes. Inclusion of and consultation with Indigenous communities/agencies is essential. Expedite the processing, and provision of support (if warranted), to front-life provincial corrections staff claims when they are involved in inmate suicides. Recognition that, in remote and rural areas, funding cannot be the per-capita equivalent to funding in urban settings as this does not take into account rural realities, including that: economies of scale for urban settings supporting larger numbers of survivors, the need to travel to access and provide services where telephone and internet coverage is not available. [22] In this inquest the Coroner has examined the approach to be adopted in historical investigations of this nature. Police services and police services boards shall establish standing or advisory committees on race and impartial policing and on mental health in order to meet with representatives of peer-run organizations and members of affected communities on an ongoing basis to discuss concerns and facilitate solutions. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. As inquest concludes seven years after incident, coroner says pilot should have abandoned a manoeuvre he was undertaking Caroline Davies and agency Tue 20 Dec 2022 11.47 EST Last modified on Wed . In compliance with its by-laws, the Board will create terms of reference for its governance committee and make the terms of reference public. Review whether the policy for the care and handling of individuals in custody needs to be clarified, particularly in relation to which individuals in custody should be considered high risk. Specifically, they should consider the length or passage of time since a volunteer had any criminal convictions and the nature of the criminal conviction to determine criteria that would increase Indigenous volunteers participation in Indigenous programing and to provide peer resources in an effective way. The number of jurors generally ranges from 6 to 20. Evidence and release of body What happens when evidence is gathered and when a body can be released Inquests held. If a police service has a joint mental health-police team, give studied consideration to implementing a police policy that provides, once police officers attending a call identify a potential mental health concern and provided it is safe to do so, that the joint mental health-police team should be engaged. This would include training, equipment or work processes and the continued availability of safety data sheets. That joint training be scheduled on an on-going basis, allowing first responders to learn more about the roles and responsibilities of other agencies. Training should be given to establish who should lead the call when dealing with a potentially violent incident or crisis. Held at: TorontoFrom:June 29To: June 29, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Frank FerranteDate and time of death: July 28, 2015 at 8:34 p.m.Place of death:Southlake Regional Health Centre, 596 Davis Drive, NewmarketCause of death:heat strokeBy what means:accident, The verdict was received on June 29, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:YonanGiven name(s):MettiAge:66. Foster and support the co-development of life promotion programs such as Promote Life Together between Indigenous and non-Indigenous stakeholders to establish and develop meaningful programs and services, with an emphasis on the inclusion and engagement of Indigenous stakeholders from inception. Coroner training overview In conjunction with the Chief Coroner, the Judicial College delivers a varied training programme for all coroners involving induction, continuation and one-day training on specific topics. The death of Daniel Robert NELSON was drug related. Police services and police services boards shall establish permanent data collection and retention systems to record race, mental health issues, and other relevant factors on use of force incidents. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. Continue working with the Ministry's partners to provide public awareness campaigns and educational materials relating to: Highlighting the dangers and risks associated with working in high temperatures, How workers should prepare themselves to safely work in high temperatures. A requirement that all skid steer operators regularly clean and clear debris from the windows of the skid steer to ensure maximum visibility. We, the jury, wish to make the following recommendations: Surname:MacDougallGiven name(s):Quinn EmmersonAge:19. The Coroner usually conducts the inquest alone but will sometimes sit alongside a jury. The ministry shall ensure that supports are put in place to assist all the people in custody who experienced a death while in custody. The Coroner's Office can be contacted by email at coroners@cambridgeshire.gov.uk or by telephone on 0345 045 1364. Recognize that the best practice is to consider Indigenous Dispute Resolution by connecting with the First Nation regarding any challenges faced by a First Nations young person and/or family. The ministry should ensure that any of the Indigenous Liaison Officers and Indigenous elders are engaged in the provision of health care information and treatment when requested by patients. Indigenous people must be able to access spiritual rights as well as programs with regularity and without unreasonable delay. Change its name to one that better reflects its purpose. The ministry should explore the benefits and detriments of periodic re-screening for suicidal risk or mental health concerns akin to the admissions screenings to see if an inmates status has changed while in custody. Consider re-allocating more time to scenario-based de-escalation training during annual use of force certification at the, Post the verdict and recommendations of this inquest on the. The ministry should ensure cooperation between. Ensure that the employer properly identifies and reviews all potential chemical hazards at the mine site including, but not limited to, the dangers of cyanide. The ministry should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. The Coroner can hold an inquest even if the death happened abroad. Please note inquests can be changed at the last minute, please check before attending. Health and safety representatives are selected in a manner that ensures independence. A physician and/or nurse practitioner should be available to provide in-person health care services on weekends at the, Addictions counselors, discharge planners and social workers should be available to provide in-person services on weekends at the. Names of the deceased: Culleton, Carol; Kuzyk, Anastasia; Warmerdam, NathalieHeld at:1 International Drive, PembrokeFrom:June 6To: June 28, 2022By:Leslie Reaume, Presiding officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Surname: CulletonGiven name(s): CarolAge:66, Date and time of death: September 22, 2015.
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