The Ontario Provincial Police (OPP) should: The Ministry of the Solicitor General should: Surname:EkambaGiven name(s):Marc DizaAge:22. The Ontario Use of Force model should be renamed to accurately capture the intent and purpose of the model, which is a guide to police engagement with the public rather than to suggest that force is inherent in police interactions. Coroner's Officer. Work with Indigenous communities to support the creation of residential treatment options that are Indigenous-run and Indigenous-informed with Indigenous-specific programming. The Coroners' Courts Support Service (CCVS) is an independent voluntary organisation whose trained volunteers offer emotional support and practical help to bereaved families, witnesses and others. In addition, such education should be repeated quarterly. 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. The ministry should require all forms related to the admissions of inmates to be completed in full, including review and signature by a sergeant (or their designate). Revise the provincial Use of Force Model (2004) as soon as possible. emerging technologies, like an electro magnetic sensor to prevent a boom or crane from entering the prohibited zone (disabling controls). The ministry should collaborate with the London Middlesex Medical Officer of Health in developing its harm reduction strategies. Ensure the Corporate Health Care Unit completes an action plan directed at recruiting and retaining health care staff at the. 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. 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. Develop and implement a pilot project to explore the feasibility of dispatching crisis support workers to mental health service calls that do not require police involvement, similar to Peel Regional Police Mental Health Strategies. The ministry shall update policy so that phone calls by persons in custody are not referred to as a privilege. Clarify the definition of accident in sections 52 and 53 of the, Consider studying the effectiveness of Albertas. 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. This shall include adequate training and resources for all care providers and all staff within MAPs so that individuals with a likelihood of violent behaviour as a result of trauma are still able to receive care and services from the. The reviewers should work with the local health care team to identify gaps and find solutions. 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. Construction projects should be planned and organized so that no cellular phones or similar cellular devices shall be used on the worksite except in case of an emergency or where use is restricted to occur inside of a designate structure, stationary vehicle, or other designated area away from any area in which construction work is occurring or ongoing. In order to support fulsome assessment, information sharing within the child welfare system and ensuring a holistic approach to caring for children and young people, develop future amendments to. Within 6 months of the jurys verdict, strike a task force to review, report on, and initiate changes to: funding, accountabilities, and timely access to care for all community-based mental health services that receive funding from the Government of Ontario, available resources and supports for family members and/or caregivers of patients and community services receiving mental health services, how family members and/or caregivers and community services can provide support and/or information about patients when patient consent is not provided, address what information can be shared from family members and other stakeholders, align services and community agencies to better share information about individuals with mental health concerns in the community, Establish further study and review of the criteria and training associated with the, mandatory refresher training for emergency room physicians and psychiatrists in the province of Ontario on when and how to use the Form 1 options associated with mental health, the assessment of Box A and Box B criteria for psychiatric evaluation and involuntary detention, to determine how best to ensure collateral information from family members and relevant community services information can be included as part of the process for determining appropriate treatment options. The audit should be independent and should result in an action plan that must be submitted to the. In partnership and in consultation with First Nations, provide direct, sustainable, equitable, and adequate funding to First Nations for prevention services, cultural services, and Band Representative Services to service and support both on- and off-reserve First Nations children, youth and families involved in child welfare and in support of children and youth in need of mental health supports pursuant to a needs-based approach that meets substantive equality. The ministry shall treat people in custody on remand as presumed to be innocent. 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. NELSON, Daniel Robert. Ensure that health care transfer summaries are completed in compliance with provincial policies when inmates are transferred between institutions. The ministry should provide direct access to Naloxone spray for people in custody, including within locked cells. Legal Framework . If there is any information relating to suicidal behaviour or ideation, it must be flagged so any other society workers are immediately aware of that aspect of a particular young persons history. Where gaps exist, the ministry should explore and research means to increase actual programing at Detention and Correctional Centres: Analysis of data collection or research of Indigenous core or other programing should include identification of gaps, steps taken to resolve gaps, improvements and best practices; This analysis and research should be reported, maintained and disseminated to Ontario`s correctional Institutions, service providers and for use with consultation with First Nation, Metis and Inuit community; The ministry should consider evaluating and modifying their policies on allowing volunteers into the facility that have a criminal record. The ministry should create and implement a policy that requires the use of specific language by correctional officers and healthcare workers at each correctional facility which prioritizes humanizing people in custody by addressing them as patients, persons in custody and/or persons who use drugs. The ministry should engage with people with lived experience to develop enhanced supports for people in custody who witness a traumatic event. The ministry should conduct an Indigenous led study that consults with Indigenous community organizations and Indigenous healthcare providers to obtain information regarding Indigenous cultural and spiritual healing practices and use of Indigenous traditions known to assist in prevention of substance use, wellness and a means to address addictions in a culturally sound way. 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. It is recommended that the chief coroner take steps to expedite the hearing of coroners inquests, if feasible that they be held within three years. Consider adopting Femicide as one of the categories for manner of death. Increase hiring of Ministry of Labour, Training & Skills Development construction inspectors. To support and promote cultural safety for First Nations children and young people, the, To address the mental health needs of children and young people, the. We recommend that the frequency of required refresher courses/training for Constructors, Employers, Supervisors, and Workers, who work in proximity to overhead power lines. To ensure the safety of children in care, train staff to ensure that, to the extent a youths file is transferred from one staff member to another, all information relating to a young persons suicidal behaviour and ideation is clearly flagged in transfer discussions or communications between staff. Also in this section In addition, the panel will identify priorities for funding from existing resources to support Indigenous welfare programs and First Nation communities. An inquest is not a trial and does not assign blame or liability. The ministry should ensure that correctional officers investigate cell change requests immediately, and grant same immediately, where merited. There are no fees attached to this service. arrives at St. Pancras Coroner's Court for a hearing into the singer's . 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. 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. The verdict of the coroner's jury will fall into one of the following five categories: accident, natural, suicide, homicide and justifiable homicide. The provision of therapeutic care. Commission a study to examine the creation and implementation of a province-wide, civilian-led crisis intervention system to respond to persons in crisis, including mental health crisis. Evidence relating to the Five Incidents . The ministry should explore the use of a scoring metric to determine risk in areas such as mental health and violence, assessed first at Intake and re-evaluated on a continuous basis. Develop workable practices to improve contact and connection of individual young people with safe adults in their circle of care, to reduce circumstances where children are absent and their whereabouts are unknown. The hazard alert should identify cyanide, in all of its forms, as a potential workplace hazards. 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. If you are thinking about challenging a coroner's decision, it is important that you seek specialist advice as soon as possible. To ensure the safety and ongoing wellness of the children in its care, where a youth has disclosed suicidal behaviours or ideation, make best efforts to bring together all those involved in a youths circle of care to discuss and assess the youths situation and participate in safety planning for the youth (including the youths self-identified support, youths guardian, First Nation if applicable, medical team, supportive community members and family where appropriate). Consider providing cognitive behavioural therapy, and/or other evidence-informed clinical interventions, for inmates who may be at risk of suicide. Held at: North YorkFrom:July 18To: July 18, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Metti YonanDate and time of death: November 28, 2014 at 12:40 p.m.Place of death:Sunnybrook Hospital, 2075 Bayview Avenue, North YorkCause of death:blunt force crushing injuries to the torso that caused extensive internal hemorrhageBy what means:accident, The verdict was received on July 18, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner). The coroner Sir John Goldring said he would accept a. Consider extending the recommendations 10-22 to include all municipal police forces across Ontario. whether the missing person is an Indigenous youth. 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. Develop further therapeutic activity programming for youth that reflects a wide variety of interests. This unique intersection of Blackness and lived experience of mental health issues must be specifically addressed in any training on use of force, de-escalation, and police interaction with such persons. The content of such training to include: what cyanide is used for within the workplace and where it can be found, the method for identifying cyanide within the workplace, personal protective equipment and limitations associated with such equipment, the signs and symptoms of cyanide exposure, first aid / treatment procedures for people potentially exposed to cyanide. 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. Verdicts / Conclusions; Obtaining a death certificate; Preventing future deaths; Deaths under Investigation. Review, in consultation with stakeholders, the discretionary nature of inquests into the deaths of children in care and consider advocating for legislative change requiring said deaths to be the subject of mandatory inquests. 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. This will require consultation with and inclusion of a diverse group of Indigenous communities/agencies, in recognition of the fact that Indigenous cultures/traditions/ways of being are not monolithic and that Thunder Bay is home to Indigenous peoples from across the North who possess a spectrum of cultural values/languages/ways of being. Designate an employee to manage this plan, monitor the weather, ensure compliance with the plan and maintain records. This training should be designed and delivered by Indigenous people. The Coroner's Office can be contacted by email at coroners@cambridgeshire.gov.uk or by telephone on 0345 045 1364. Review current procedures and processes in respect of police response to persons who have a mental illness. 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. 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. Ensure that the Central East Correctional Centre (. 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. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. That care and services must be provided using a trauma informed approach to ensure that individuals who have suffered complex traumas are not excluded from the services that may assist them. The evaluation of the effectiveness of such training should include the participation of affected communities, including persons with lived experience from peer-run organizations. Held at:25 Morton Schulman Avenue, TorontoFrom:April 4To:April 7, 2022By:Dr.Robert Boykohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Fernando SantosDate and time of death: January 23, 2018 at 3:38 p.m.Place of death:1575 Lakeshore Road West, MississaugaCause of death:blunt force trauma of the torsoBy what means:accident, The verdict was received on April 7, 2022Coroner's name:Dr.Robert Boyko(Original signed by coroner), Surname:SaidiGiven name(s):BabakAge:43.