Openings. Expedite the processing, and provision of support (if warranted), to front-life provincial corrections staff claims when they are involved in inmate suicides. When operationally feasible, the ministry should run the scenario-based. To the extent that this training is not already provided, that educational institutions such as colleges and universities provide training for first responders on the history of colonization; residential schools; trauma informed approaches; anti-Indigenous racism; cultural safety, and unconscious bias. There are no fees attached to this service. The plan should include adequate staffing and infrastructure to avoid triple bunking and to accommodate intermittent inmates and inmates in need of specialized care or stabilization. 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. Inclusion of and consultation with Indigenous communities/agencies is essential. Appropriate perpetrator programs and supports needed to accompany electronic monitoring. Increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. 'Short form' verdicts such as accident or misadventure; natural causes; suicide; and homicide make up the majority of all verdict conclusions. The ministry should engage in community consultation on the development of Indigenous core programing with Indigenous leadership including First Nation, Metis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres. Possible outcomes include: natural causes; accident; suicide; unlawful or lawful killing; industrial disease and open verdicts (where there is insufficient evidence for any other verdict). Derbyshire Police. 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. To improve outcomes for First Nations children and youth, empower and seek to fund bands and First Nation communities and affiliated stakeholders (such as the Association of Native Child and Family Services Agencies of Ontario) to collect data and analyze data to determine whether, and to what extent, child welfare interventions and services are improving outcomes for children and youth. Ensure that police officers responding to a mental health crisis are aware that police have responded previously to incidents involving the same parties, and facilitate access for responding officers to significant information regarding previous calls. Ensure that suboxone film is covered by the Ontario Drug Benefit Formulary. We recommend that significant and automatic fines should be levied against any company/constructor that fails to ensure that a dedicated Signaller be assigned to Hydro-vac crews and/or any crane operation when working in the vicinity of overhead powerlines. The inquest heard from 278 witnesses and is estimated to have cost the taxpayer more than 6.5m. Implement the National Action Plan on Gender-based Violence in a timely manner. Ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the. Regular refresher training on mental health issues should be provided to all police officers who interact with the public. coroner's jury, a group summoned from a district to assist a coroner in determining the cause of a person's death. It is recommended that the Ministry of Labour, Training & Skills Development take steps to amend the. That the use of medically fragile flags be considered for the. 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. Physicians should be encouraged to communicate with a patients community health care providers when discontinuing or amending a prescription for an opioid medication, when consent is provided by the patient. The ministry should ensure that each institution: develops Indigenous specific programming which reflect the local Indigenous communities and agencies surrounding the institution; provides Indigenous persons in custody with access to Indigenous healing practices including Knowledge Keepers and Elders. Review and improve training to housing support personnel on cultural competency, anti-Black racism, implicit bias, mental health and its intersectional nature. In recognition of the important roles of family and Indigenous communities, offer to involve the family and the Indigenous community of a deceased Indigenous young person in the Pediatric Death Committee Review process where appropriate, having due regard to confidentiality concerns. Include coercive control, as defined in the. On the second day of an inquest at Dublin District Coroner's Court today, counsel for Mr Sweeney's family, Roger Murray SC, said the net effect of the patient being discharged from the high . The study would, in part, inquire into the following: The process to identify relevant findings and for sharing those findings with other justice participants. The Coroner is expected to open an inquest where there is reasonable suspicion that the deceased has died a violent or unnatural death, where the cause of death is unknown or if the deceased. Clarify and enhance the use of high-risk committees by: Strengthening provincial guidelines by identifying high-risk cases that should be referred to committee. The ability to respond immediately with risk management services in collaboration with. 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 (. The ministry shall consult with an expert in trauma-informed care to review the current care programs to provide specific suggestions for institutional changes to promote trauma informed practices within the detention centre. Institute a policy to mandate regular debriefs with officers involved with incidents that engage the Special Investigations Unit to ensure that supports are in place and the incident to be used as a learning tool so that future incidents can be prevented. Inform staff and affected personnel that resources are available to support them with respect to work related stress. Older verdicts and recommendations, and responses to recommendations are available by request by: You can also access verdicts and recommendations usingWestlaw Canada. Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training. 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. Consideration of streaming short video clips or other helpful information via the television screens on each living unit should also be given. Specifically: prioritize the Health Care Performance and Planning Units analysis of recruitment challenges for correctional health care staff. 42. risk assessment training with the most up-to-date research on tools and risk factors. Develop strategies on prescribing and dispensing medications in a manner that would assist with protecting patients from being coerced into diverting the medication to other inmates. Inform staff of the LivingWorks Start online training on suicide prevention and provide them with information to register. The coroner Sir John Goldring said he would accept a. Ensure that the Central East Correctional Centre (. Consider an appropriate role for community members or organizations as part of the missing person investigation, or in a debrief with the missing person once the investigation is concluded. Require emergency response personnel in plants using cyanide to be provided with basic first aid/. 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. All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. Training for new officers should be amended so that the question of the suspects mental health be as prominent in their considerations as the criminal activity they have committed. 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. The ministry should modify the Death of an Inmate Policy to consider the impact of delivering notice over a phone to family members. Held at:Town of MidlandFrom: October 17To: October 20, 2022By:Dr. Mary Beth Bourne, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Vikram DhindsaDate and time of death: January 18, 2017 at 5:12 a.m.Place of death:Unit 3 A Wing, Cell #16 Central North Correctional Centre 1501 Fuller Avenue, PenetanguisheneCause of death:hangingBy what means:suicide, The verdict was received on October 21, 2022Presiding officer's name:Dr. Mary Beth Bourne(Original signed by presiding officer). Refer to the mining legislative review committee the consideration of amendments to Ontario Regulation 854, Mines and Mining Plants (the Regulation) that would: Require the following precautions be taken should a worker perform maintenance work in an area in which the work may reasonably be expected to expose the worker to a material containing cyanide at concentrations that may endanger the worker. 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. To have a better experience, you need to: Review the Office of the Chief Coroners 2022 inquests verdicts and recommendations. That officers and jailers continue to be trained on an ongoing basis to seek out and record answers from the arrested person about their medical condition. Consider providing cognitive behavioural therapy, and/or other evidence-informed clinical interventions, for inmates who may be at risk of suicide. They must be treated as such, including refraining from using the term offender. The ministry should conduct regular reviews to ensure its complement of nurses is sufficient to allow thorough assessments of each Inmate. 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. The ministry should investigate how security is assessed concerning spiritual elders, knowledge keepers, and traditional teachers. Develop and deliver training for constables and sergeants on interpersonal skills, emotional intelligence, leadership, and team building. Seek and allocate adequate funding and resources to implement the above recommendations. At the end of an inquest, the Coroner will read out a formal verdict to record: the identity of the deceased; how the death happened ; . However, unlike other court processes, the Coroner's inquest is an inquiry and not a trial. We recommend that all construction projects that utilize booms or cranes in proximity to overhead power lines, be required to make a written request to the owner of the power lines, to facilitate compliance with sections 187 and 188 of Regulation 213/91 for Construction Projects. It should be clear that it is broadly accessible and not limited to a particular kind of relationship. Held at:SudburyFrom: August 29To: September 2, 2022By: Dr. David Cameron, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Richard Raymond PigeauDate and time of death: October 20, 2015 at 12:06 p.m.Place of death:3259 Skead Road, Skead, ON, P0M 2Y0 1660 Level, 1660-021 RampCause of death:crush-type blunt force injuries to torsoBy what means:accident, The verdict was received on September 2, 2022Presiding officer's name: Dr. David Cameron(Original signed by presiding officer), Surname: GordonGiven name(s): JacobAge:24. The ministry should develop guidance to determine criteria by which. In conjunction with recommendation number12, the ministry should abandon the use of the title, Native Inmate Liaison Officer, and move toward the exclusive use of the title, Indigenous Liaison Officer.. To ensure that First Nations children benefit from their legal entitlements under, In the spirit of recommendations made in the past in other settings, including those in the, residential treatment resources for Indigenous communities, service coordination for children with complex trauma and complex needs to ensure safety, continuity of care, and the avoidance of long wait lists. System approaches, collaboration and communication. We, the jury, wish to make the following recommendations: Surname:MacDougallGiven name(s):Quinn EmmersonAge:19. Firearm risks, including the links between firearm ownership and, Opportunities for communities, friends, and families to play a role in the prevention and reporting of, Provide specialized and enhanced training of police officers with a goal of developing an, Establish a province-wide 24/7 hotline for men who need support to prevent them from engaging in, Provide services aimed at addressing perpetrators of. These supports should account for the social barriers to accessing such supports within a custodial environment. Prioritizing the development of cross-agency and cross-system collaborative services. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. Consideration should be given to disseminating information through alternative methods where cellular service is not consistently available. When will a death be reported to the Coroner? Assess the feasibility and impact of establishing a mental health advocate role (or enhancing the abilities of social workers) to be the point person helping patients and families coordinate mental health services: this advocate assists with scheduling follow-up sessions after appointments; check-ins, and visits; support after medication changes; recommends community services; collecting collateral information from relevant parties, based on demand and proper funding, this advocate will be required to manage multiple concurrent cases effectively within a framework of flagging and following up with the highest-risk outpatients, consistently offer a family meeting within 48-72 hours of hospital admission, regardless of the patients status in hospital, to collect collateral information, documented offer of a meeting with family members or support team occurs prior to discharge from hospital to ensure a patient with mental health issues has support, provide mental health services 24 hours a day to better assist communities by expanding self-help services to those in need through online, hybrid, or in-person supports, The Ministry of the Solicitor General (ministry) should review the Offender Tracking Information System. Implement recommendation #5 from the inquest into the deaths of Arun Rajendiran, Darrel Tavernier and Stephen Kelly. Nine jurors reached unanimous decisions on all but one of the 14 questions at the inquests into Britain's worst sporting disaster. Inquests should be completed within 24 months from the incident date unless the circumstances warrant additional time. The Ministry of Labour shall review and consider whether to amend. Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission. The role of the coroner is to investigate sudden deaths that have been reported to them, and to hold inquests where appropriate. Take all reasonable measures to ensure workers are educated, understand and avoid the hazard. A-Z of records. If you are planning to attend an Inquest listed below, could you please either phone - 01823 359271 - or email - coroner@somerset.gov.uk It helps to have an indication of attendance in advance to ensure that we continue to comply with fire regulations and health and safety matters which apply to the court building. That the Board create a process for regular review of board policy to determine which policies need to be updated or created. To the Ministry of the Solicitor General and Windsor Police Service, Surname:OgundipeGiven name(s):VictorAge:41. Responsibility for conducting a debrief/return interview with the youth, and in particular with youth who habitually leave such facilities without permission, including whether such interviews may be best performed by other community groups or organizations such as Justice for Children and Youth. The training should address: understanding how emotional prejudice impacts decision making, tactics/solutions for mitigating the harmful impact of stereotyping on health and criminal justice outcomes, That both services consult with Indigenous Nations, Provincial Territorial Organizations (. Held at: Toronto, virtuallyFrom: August 22To: August 26, 2022By: Dr. Bonnie Goldberg, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Alexander PeterWettlauferDate and time of death: March 14, 2016 at 1:21 a.m.Place of death:Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, TorontoCause of death:gunshot wounds to chestBy what means:undetermined, The verdict was received on August 26, 2022Presiding officer's name: Dr. Bonnie Goldberg(Original signed by presiding officer), Surname: PigeauGiven name(s): RichardAge:54. BBC Radio Sussex. In addition, the panel will identify priorities for funding from existing resources to support Indigenous welfare programs and First Nation communities. Please note inquests can be changed at the last minute, please check before attending. Explore the capability of the information management systems to accurately capture the number of calls for service which are initially reported and dispatched as another type of call but are later assessed by the responding officers to be a call which has a significant person in crisis component. In the case of high risk and dangerous subjects, consider the application of Situation Mission Execution Administration Command & Communication (, Where there is an existing threat assessment on file, provide contact information so that. Provide direct, sustainable, equitable, and adequate joint funding from the named Ministries and Government of Canada to First Nations, off-reserve Indigenous service providers, and non-Indigenous service providers serving off-reserve First Nations children, youth and families to increase the capacity for collaboration in the provision of child welfare and mental health services. It simply aims to gather information in order to answer these questions. Amend section 232(1) of the Construction Regulations to: Clarify that the walls of an excavation shall be stripped of ice that may slide, roll or fall upon a worker. Provide training to workers on the signs and symptoms of heat stress and heat stroke, how to prevent heat-related illness and first aid steps to be taken should a worker believe they or their co-worker are showing signs of such illness. Require primary actors involved in a major incident to conduct a formal de-brief and write a report identifying lessons learned and recommendations for improvement, if appropriate. In compliance with its by-laws, the Board will create terms of reference for its governance committee and make the terms of reference public. 08:52, 2 MAR 2023. The Toronto Police Service should continue to build a diverse. There is still an open verdict on Berezovsky's death, which could mean the UK is unwilling to get to the truth. Advise all workers that they should report health and safety concerns to their health and safety representative, joint health and safety committee, to Fermars Health and Safety Department, or directly to the. Held at:HamiltonFrom: September 26To: October 21, 2022By: Jennifer Scott, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Devon Russell James Freeman (Muskaabo)Date and time of death: April 12, 2018 (October 7, 2017 April 12, 2018)Place of death:831 Collinson Rd, FlamboroughCause of death:hanging by ligtureBy what means:suicide, The verdict was received on October 21, 2022Presiding officer's name:Jennifer Scott(Original signed by presiding officer). It is recommended that the Chief Prevention Officer of the. Explore the capability of the information management systems to track the deployment of alternative responses to assist a person in crisis and the outcomes. Coroner's Officer. Consideration should be given to the United Kingdoms Domestic Abuse Commissioner model in developing the mandate of the Commission. Mandatory use of a signaller when operating a skid steer. These reviews should analyze relevant health care files and assess quality of care. 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. 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. Develop health and safety materials and for all workers and train workers, including temporary workers, on health and safety protocols prior to them undertaking any work. Prior to commencing work, survey worksites where high temperatures are a concern and ensure that every reasonable precaution is taken to protect workers from heat stress and heat related illnesses. Review the mandate of Probation Services to prioritize: Require that probation officers, in a timely manner, ensure: There is an up-to-date risk assessment in the file. Coroner's inquests are held in cases of sudden, unexplained or suspicious deaths. The ministry should review the suicide awareness training to ensure that it includes a robust individual evaluation component for comprehension of the course materials. What documents from civil and family law proceedings should be shared with justice sector participants, and how to facilitate sharing of such documents. The ministry should ensure mental health nurses are available on call 24 hours a day, seven days a week, to see any Inmates waiting for them as soon as possible to allow all assessments to be completed in a timely fashion regardless of whether any given Inmate has temporarily left the institution for court. . 4:33 p.m. - April 28, 2022. Provide professional education and training for justice system personnel on. The ministry should advocate for total compensation offered to nurses and healthcare staff be competitive with that in non-correctional settings. The ministry should ensure and enforce through training that all correctional staff ensure that any important information, including historical information, is entered into. In partnership with childrens mental health residential service providers, develop and effectively fund programs that are responsive to the needs of hard-to-serve young people presenting with high-risk behaviors such as aggression or suicidal ideation and other complex needs. That the Thunder Bay Police Service ensure that the Reconciliation training currently being undertaken by the service is not a one-time training course, but rather provided as continuous training over the course of an officers career and that the police service consult with Indigenous Nations. The ministry should explore implementation of harm reduction strategies similar to those used at supervised consumption sites.
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