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In recognition of the fact that law enforcement agencies in the City of Thunder Bay lack the appropriate training, cultural competency, and resources to provide appropriate services to individuals suffering from alcohol/substance use disorder and/or chronic housing insecurity, work to ensure that community-based programs which provide outreach and services to such individuals are maintained and continued, including and not limited to: the Care Bus, operated by NorWest Community Health Centre, the WiiChiiHehWayWin street outreach initiative, operated by Matawa First Nations Management. 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. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. Continue to ensure that all young people in care have reasonable access to cell phones or other technologies they may need to communicate with their family, their First Nation and others important to them. For the purpose of assisting clinicians in directing patients to receive timely mental health services and promoting accountability of community mental health services, a direction requiring that all hospital and community-based mental health services that receive funding from the Government of Ontario: collect and publish monthly non-identifying data regarding: wait times for treatment (i.e., actual receipt of mental health services by mental health professionals as opposed to waiting times for intake) and patient volumes, days and hours of mental health services provided, provide the resources to allow hospitals and community-based mental health services to provide this data, increase mental health awareness and promotion of initiatives within communities to address the lack of familiarity of services and options available for persons and families dealing with mental health situations. When non-Indigenous service providers are providing care, the First Nation Mental Wellness Continuum Framework should be considered when developing and delivering services to Indigenous children in care. Increasing program availability and develop flexible options for, Recognize the specialized knowledge and expertise of, Address barriers and create opportunities and pathways to services for, Improve the coordination of services addressing substance use, mental health, child protection, and, As new services are funded, include aims and outcomes associated with building an underlying network of specialized services to address, Endeavour to minimize destabilizing factors for perpetrators of, Investigate and develop a common framework for risk assessment in. Review the current Use of Force Model (2004) and related regulations, and consider de-emphasizing use of the term "force" and employing alternative terminology. If the cause remains in doubt after a post mortem, an inquest will be held. A requirement that all skid steer operators regularly clean and clear debris from the windows of the skid steer to ensure maximum visibility. Isle of Man inquest hears of father and son's TT sidecar deaths In most cases, no further action is required, and the death can be registered as normal. For conductive energy weapons consider high visibility markings (colour) to differentiate them from firearms. Specifically, the the ministry should: ensure that all Native Inmate Liaison Officer/Indigenous Liaison Officer (, benefits, that include access to an employee assistance program, opportunities for support following traumatic incidents, create policy and direction that recognizes the role and function of. Encourage review and participation in all best practices regarding cyanide safety put forth in the international Cyanide Management Code. 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). That an accessible sobering centre with a locally developed model of care appropriate to meet the needs of Thunder Bay and surrounding communities be established. Misadventure is where someone doing something lawful unintentionally kills another. Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. The ministry should position equipment necessary for an emergency medical response close to living units. Coroners' Inquests - Province of British Columbia 05/09/2022. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers). All physician assistants and doctors are provided with a detailed orientation and training of the workplace in which they are being deployed. We recommend that locates in the vicinity of power lines should include underground, on grade, and above grade utilities or hazards, as well as current, voltage and distance from grade to the high-power line. Explore, with community mental health partners, the feasibility of extending the availability of Mobile Crisis Rapid Response Team (. Missoula coroner's inquest jury returns verdict in fatal officer The Toronto Police Service should explore the ability to use audio/visual capabilities to have short notice assistance from external professionals e.g. The ministry should conduct regular reviews to ensure its complement of nurses is sufficient to allow thorough assessments of each Inmate. 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 (. It is recommended that all mine and metallurgical sites where cyanide is present conduct periodic simulation exercises of cyanide exposure events as a means to promote preparedness by testing policies and plans, standard operating procedures, and personnel training. Provide additional guidance on how to assess the risk of ice on excavation walls. The ministry should ensure that healthcare and correctional staff at correctional facilities receive additional training about building rapport and resolving challenging encounters with persons in custody. Sudden death of woman after routine surgery linked to use of blood That access to electronic health records be provided to all paramedics in Ontario, and if such access is available, that Superior North. 10am Willow-Raye Du Plooy, aged 21, from Banbury, died 28/11/2021 in Bicester; Pre inquest review. Be staffed 24 hours a day and 7 days a week. NELSON, Daniel Robert. Regular refresher training on mental health issues should be provided to all police officers who interact with the public. Explore and research the availability and efficacy of additional less-lethal use of force options for officers. 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. Revise the provincial Use of Force Model (2004) as soon as possible. The ministry should ensure that spiritual elders, knowledge keepers, and helpers are provided honoraria or financial compensation for their important work delivering cultural programming and access to their spiritual rights. 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. Immediately institute a provincial implementation committee dedicated to ensuring that the recommendations from this Inquest are comprehensively considered, and any responses are fully reported and published. Time of death could not be determined.Place of death: Foymount, OntarioCause of death: shotgun wound of the chest and neckBy what means: homicide, The verdict was received on June 28, 2022Presiding officers name: Leslie Reaume(Original signed by presiding officer). Provide frequent training to all workers to familiarize them with the hot weather plan/heat response plan and the dangers of working in high heat environments. In order to promote, protect, and prioritize worker health and safety, road-resurfacing contracts should be reviewed with attention to how time limits on construction work and limits on allowable lane closures are established. After 11 years, Diana the verdict: killed by a combination of Henri Mandate that all police service officers receive annual implicit bias and cultural competency training to address stereotyping of Black people, and the existing research on anti-Black racism in policing. To support ongoing consultation, communication, and transparency between the Society and the bands and First Nations communities of the children and youth it serves, the Society shall reach out to those bands and First Nation communities and offer to develop a communication protocol and offer to initiate quarterly reviews regarding all children receiving services from the Society. risk assessment training with the most up-to-date research on tools and risk factors. The ministry shall implement a policy requiring the inclusion of a letter describing what is contained in the return of property of an individual that has died in custody. We, the jury, wish to make the following recommendations: Surname:MacDougallGiven name(s):Quinn EmmersonAge:19. Compensation should include: cost of medicines or supplies required to facilitate service. 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. The ministry should ensure that Naloxone spray devices deployed in areas accessible to people in custody are positioned in a manner that correctional staff on security rounds may determine that a device has been used or removed. Court listings are held in the Avon Coroner's Court, Old Weston Road, Flax Bourton, Bristol BS48 1UL At this time Jury inquests are being held at Ashton Court Mansion House, Ashton Court Estate, Long Ashton, Bristol, BS41 9JN These listings are subject to change. Ensure existing policy and guidelines require probation officers to follow through on enforcement of non-compliance by requiring delivery and documentation of clear instructions regarding expectations to supervised offenders in a way that allows for direct and progressive enforcement decisions. The ministry should deliver alerts to persons in custody on an urgent basis regarding new and emerging threats from novel street drugs. The summary should be placed at the front of each health care record and should list all serious medical diagnoses, including opioid use disorder. Implement regular reviews to ensure the accuracy and reliability of the information in the records management system available to officers. Explore developing and providing all police officers with additional de-escalation training. Designated funding for transportation for those receiving, Funding to ensure mental health supports for. The ministry shall ensure that wherever a serious mental illness is suspected or identified through mental health screening, that the person in custody will not be placed in conditions of segregation. 2021 coroner's inquests' verdicts and recommendations Explore adding the term Femicide and its definition to the, Consider amendments to the Dangerous Offender provisions of the, Undertake an analysis of the application of s. 264 of the. 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. Consider the circumstances of all police-related inquests as training scenarios. The Solicitor General of Ontario should expedite the approval of updates to the Ontario Use of Force Model. The protocol should address: the circumstances in which a missing persons report should be filed, the information to be provided as part of that report, the residential homes responsibilities prior, during, and after filing a report (including conducting a property search where appropriate). What permissible uses could be made of the documents and findings in a criminal proceeding. Specifically: Implement the Corporate Health Care provincial committee to conduct in-depth health care reviews of sentinel events, including deaths, in a timely manner. Ensure that security patrols are completed during shift changeovers. The appropriateness of essential services being provided by private, for-profit partners. In consultation with civil society child rights experts and Indigenous rights experts, undertake a Child Rights Impact Assessment with respect to all proposed regulations made under and amendments to the. An inquest jury examining the cases of two Oji-Cree men has released 35 recommendations after a four-week hearing in Thunder Bay, Ont. Inquest Livestream - Province of British Columbia Coroners' appointments . The ability to respond immediately with risk management services in collaboration with. Inquest hears criticism of retired teacher's care Specifically: increase salaries and benefits for nursing staff at provincial correctional centres to ensure they are competitive with other nursing professional opportunities. Tel: 1-877-991-9959. Implement more rigorous and thorough assessment of potential and current employees. Inquest jury finds 'undetermined' cause in Oji-Cree man's death in 13 January 2022 Following a change in the law in 2013, the coroner now gives a 'determination' on the cause of death. 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, from Crewe, crashed on the second lap of the sidecar race on . What is an 'investigation'? 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. When a community prescription for an opioid medication is discontinued or amended by a. Hazard alerts should be distributed in a timely manner after a health and safety concern is made evident. You can also access verdicts and recommendations using Westlaw Canada. When the coroner's jury could not determine a cause of death, an "_" will appear in the verdict category. What Does a Coroner's Conclusion of Neglect mean? 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 In December a coroner . What do different Coroner's Conclusions mean? - Enable Law Held at:TorontoFrom: September 6To: September 9, 2022By: Dr. Mary Beth Bourne, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Jacob GordonDate and time of death: November 24th, 2015 at 10:23 a.m.Place of death:Mackenzie Richmond Hill Hospital, 10 Trench Street, Richmond HillCause of death:electrocutionBy what means:accident, The verdict was received on September 9, 2022Presiding officer's name: Dr. Mary Beth Bourne(Original signed by presiding officer), Surname: MahoneyGiven name(s): MatthewAge:33. The action plan should be completed in consultation with the. These reviews should analyze relevant health care files and assess quality of care. [22] In this inquest the Coroner has examined the approach to be adopted in historical investigations of this nature. The ministry shall support the National Inquiry into Missing and Murdered Indigenous Women and Girls' Call to Justice 14.6 as it applies to provincial corrections services. Date inquest concluded. Reconvene one year following the verdict to discuss the progress in implementing these recommendations. That sufficient staff be hired and maintained to allow for constant visual monitoring of the living units and to adequately and immediately intervene in any circumstances of drugs or other contraband being found. 2020 coroner's inquests' verdicts and recommendations The death of Daniel Robert NELSON was drug related. 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. To ensure open and full communication, data collection, knowledge, and relationship-building regarding the children, youth, and families transferred to ongoing service, consider implementing a one care team per family system with consideration to the file loads of workers. Consideration should be given to two-way information sharing including of case notes, and opportunities to order treatment in institutions for those with existing probation orders who are on remand. Deaths reported to the coroner - Kent County Council The ministry should engage in community consultation on the development of Indigenous core programming with Indigenous leadership including First Nation, Mtis, Inuit communities and organizations, including health organizations that are both rural/remote and in urban centres. Revise the use of force report form to require officers to document de-escalation techniques used. Continue ongoing quality assessments to drive continuous improvement of standard operating procedures and protocols, documentation, and best practices with mental health services: to review and audit core services within Windsor Regional Hospital annually to ensure compliance to standards are met and keeping pace with community demands proactively. Improve public awareness of both policing and non-policing community-based crisis responses to mental health crisis. Require cyanide distribution lines be painted purple for identification and dye be added to cyanide solutions during mixing to make it red/purple in colour. 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 Toronto Police Service should consider the use of dedicated negotiators. These programs must also consider service coordination when a young person transitions to a new community to avoid the young person being placed on a waiting list to receive assistance. Legal Framework . The ministry should embrace an evidence-based approach to harm reduction in a manner that protects the mental and physical health of persons in custody. In addition, such education should be repeated quarterly. Isle of Man Government - Coroner's Officer Ensure that any arrest planning course delivered by the, Develop a mandatory training course for sergeants delivered by the, Provide dedicated mandatory mental health training as part of the annual block training delivered to officers through the, Ensure, where there are no legal impediments to doing so, that debriefs are held for involved officers after every major arrest, event, or unique policing scenario to gain insight on lessons learned, and that such lessons are shared with other. 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. They will make whatever inquiries are necessary to find out the cause of death, this includes ordering a post-mortem examination, obtaining witness statements and medical records, or holding an inquest. To the Ministry of the Solicitor General and Windsor Police Service, Surname:OgundipeGiven name(s):VictorAge:41. 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. That the Thunder Bay Police Service Board retain an expert consultant for the purposes of providing an independent assessment of the level of staffing required of the Thunder Bay Police Service. This includes: familiarity with the act and the regulations that apply to the work, ability to identify and address workplace hazards. They must be treated as such, including refraining from using the term offender. Coroner's jury | law | Britannica 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. Ensure that police officers can accurately identify their own, Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (. It is recommended that the Chief Prevention Officer of the. Programs are funded at a level that anticipates an increased stream of referrals. The ministry should conduct a comprehensive and ongoing process of engagement with patients in its custody in the development of healthcare strategy, policy and delivery. Regularly consult with bands and First Nation communities and Indigenous stakeholders on program implementation and service delivery for new and existing initiatives; and report back within a reasonable period of time. This increase shall: Not come as an alternative to the creation of a sobering centre, in recognition of the fact that these institutions would provide different services. The 74,160 records in this database were extracted from the Cook County Coroner's Inquest Records. An approach that is not one-size-fits-all. The Toronto Police Service should review research and studies in regard to use of non-lethal tools to incapacitate a subject in possession of a firearm. The ministry should ensure that all correctional officers and nurses have full access to medical and mental health records, and previous incarcerations, where permitted by law. Consider applying other ministry resources to support health care staff recruitment at the, Monitor how often inmates on suicide watch at the, Ensure that if any inmates on suicide watch at the, Provide an anonymized public report on the number of inmates on suicide watch at the.