In partnership with the urban Indigenous community, continue active membership on the Indigenous Child Welfare Collaboration Committee established in January 2018 to strengthen relationships, develop pathways and strategies for a coordinated approach to services and wraparound support for First Nations Inuit and Mtis children and families involved in child welfare services in Hamilton. However, if a coroner feels the investigation shows existing circumstances pose a risk of further deaths and that actions should be taken, the coroner is under a duty to make a report. The ministry should update all forms to remove the term North American Indian in favour of First Nations/Inuit/Mtis on any admission or information forms used with people in custody. The role of the coroner is to investigate sudden deaths that have been reported to them, and to hold inquests where appropriate. In partnership with representatives of bands and First Nation communities and affiliated Indigenous stakeholders, establish multisectoral, multidisciplinary roundtables at local, regional, and provincial levels accessible to community members and service providers to problem-solve regarding service to young people with complex needs. Issue an all correctional staff memo regarding use and availability of the Emergency (911) Rescue Knife as per Local Standard 3.5.20. 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. In jury inquests, the coroner directs the jury on matters of law and the jury decides the appropriate verdict . That bystander training be provided to police officers so that officers feel more comfortable addressing inappropriate behavior by colleagues. An inquest jury examining the cases of two Oji-Cree men has released 35 recommendations after a four-week hearing in Thunder Bay, Ont. 10am Neil Parsonage, aged 66, from Windsor, died 26/03/2022 in JRH; Tuesday 14 March Inquest to conclude. The coroner has a degree of discretion to call a jury in any case that is in the public interest, but a jury must be called if the death occurred in prison; in police custody; by accident, poisoning or any disease that requires other government departments to be notified; or when circumstances exist that might affect the health and safety of the BBC Radio Sussex. 'Short form' verdicts such as accident or misadventure; natural causes; suicide; and homicide make up the majority of all verdict conclusions. Openings. 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. In consultation with residential homes and child and youth mental health facilities like Lynwood, develop a common joint responsibility protocol governing the process, roles and responsibilities when it comes to searching for youth who have left congregate settings without permission. Held at: SudburyFrom:June 13To: June 16, 2022By:Dr.Geoffrey Bondhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Ronald LepageDate and time of death:April 6, 2017 at 9:12 p.m.Place of death:Health Sciences North, 41 Ramsey Lake RoadCause of death:blunt force/crush injury to abdomen and pelvisBy what means:accident, The verdict was received on June 16, 2022Coroner's name:Dr.Geoffrey Bond(Original signed by coroner), Surname:BlairGiven name(s):Delilah SophiaAge:30. Section 9: Giving Evidence As a witness you are not on trial, you are there to assist the court The Coroner decides which witnesses should attend, and in what order they are called. Date inquest concluded. 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. Training should be given to establish who should lead the call when dealing with a potentially violent incident or crisis. Held at:LondonFrom:November 21To:November 30, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Murray James DavisDate and time of death: August 17, 2017 8:00 a.m.Place of death:Elgin Middlesex Detention Centre, 711 Exeter Road, London, ONCause of death:Acute combined fentanyl and hydromorphone toxicityBy what means:accident, The verdict was received on November 30, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:AmaralGiven name(s):JoseAge:49. This team should be staffed by trained mental health professionals, crisis intervention professionals, and persons with lived experience. Consider conducting inquests in a timely manner, within 24 months from the incident date. Review the current Use of Force Model (2004) and related regulations, and consider incorporating the concept of de-escalation expressly (both in terminology and visual representation) into the Model as a response option and/or goal. 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). Explore the capability of the information management systems to track the deployment of alternative responses to assist a person in crisis and the outcomes. 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. . 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. the cost of transportation for survivors and service providers. 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. They contact the survivor to inform her of the offenders living situation, any conditions or limitations on his movement or activities, and what she should do in the event of a possible breach by the offender. Service providers provide one annual report for all funders across government to account for the funds received, articulate results and highlight key challenges, learnings, and accomplishments. Continue working with the ministrys partners to create educational materials that highlight the dangers associated with skid steer work and the risks of being struck by a skid steer. Nine jurors reached unanimous decisions on all but one of the 14 questions at the inquests into Britain's worst sporting disaster. Inquest Openings from 9:00am on Wednesday 1 March 2023 at Warrington Coroners Court, West Annexe, Town Hall, Sankey Street, Warrington, WA1 1UH : Salim Mahmud Khan Kevin Vincent Flanagan Carl. Sometimes a coroner uses a longer sentence describing the circumstances of the death, which is called a narrative verdict. Service models in the areas of substance use and abuse, general criminal behaviour, mental health, fathering, and culturally specific services. Try to find out: the date the. The Office of the Chief Coroner should consider conducting inquests within a timely manner, within 24 months from the incident date with the exception of extraordinary circumstances. The ministry should consult with the Ministry of the Attorney General to determine a process for obtaining summary information about upcoming court appearances for persons in custody and prospective length of time in custody, and rapidly provide this information to health care and programming staff. These solutions should be communicated to relevant staff and stakeholders in a timely manner. Prohibiting the use of skid steers in reverse unless it is operationally necessary. Ensure that all safety plans are written down and shared with Lynwood staff, the young persons guardian, and other members of a young persons circle of care where appropriate and consistent with privacy legislation and rights. The Ministry of Labour shall review and consider whether to amend. This includes: familiarity with the act and the regulations that apply to the work, ability to identify and address workplace hazards. Ensure that police officers can accurately identify their own, Continue implementation of the pilot enhanced de-escalation training developed by the Ontario Police College (. 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. Show entries 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. The death of Daniel Robert NELSON was drug related. This should emphasize the importance of open communication and positive relationships in carrying out police work, and conflict resolution tools. Study the feasibility of, and implement if feasible, justice sector participants having access to relevant findings made in family and civil law proceedings for use in criminal proceedings, including at bail and sentencing stages. Make the position of Missing Persons Coordinator a full-time permanent position, which to date has been part of a pilot project. The provision of medical care including the appropriate dispensing of medications to participants in the program, in recognition that participants may face barriers in accessing medical care and carrying out treatment plans independently. 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. 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. The ministry should develop guidance to determine criteria by which. Mandatory use of a signaller when operating a skid steer. Develop, establish, and provide regular training to, circumstances in which the policy is applicable, including when an individual would be considered potentially dangerous, involving a supervising officer in the planning of the arrest, when possible, completing an arrest decision tool, which may include a checklist of criteria, how to identify possible factors that could complicate an arrest, such as possible mental health issues, unpredictability, past incidents with police, and violent history, In support of the planning process, develop and provide guidance and training on circumstances where it may be appropriate to contact a subject to ask them to attend a police detachment for the purpose of effecting an arrest. support for the development of programs that are flexible and able to respond to a range of needs including chronic and acute needs in a range of health and well-being domains. Indigenous people must be able to access spiritual rights as well as programs with regularity and without unreasonable delay. Conduct a comprehensive, third-party audit of its health and safety system. The ministry should review and if necessary consider enhancing the mechanisms for ensuring that all staff receive their suicide awareness training in accordance with the timelines set out in policy. Consider providing cognitive behavioural therapy, and/or other evidence-informed clinical interventions, for inmates who may be at risk of suicide. When first addressing an employee in medical distress, a full body assessment (head to toe) must be completed. Consider additional fines/penalties for supervisors who are violating the regulations (importance of leading by example with workers). The summary should be placed at the front of each health care record and should list all serious medical diagnoses, including opioid use disorder. The following are few of the most commonly used inquest verdicts: Natural cause (this includes cases of fatal medical issues) Misadventure and/or accidents Industrial disease (you can get this as coroner's inquest for asbestosis that causes death) Unlawful killing Lawful killing (this includes cases of death by acts of war or self-defense) To the Ministry of the Solicitor General and Windsor Police Service, Surname:OgundipeGiven name(s):VictorAge:41. 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. Ensure that housing support personnel are aware of both the policing and community-based options available to respond to mental health crisis. 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. 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. In December a coroner . Strengthen annual education for Crowns regarding applications for Dangerous and Long-term Offender designations in high-risk, Commission a comprehensive, independent, and evidence-based review of the mandatory charging framework employed in Ontario, with a view to assessing its effect on, Review and amend, where appropriate, standard language templates for bail and probation conditions in, plan for removal or surrender of firearms and the Possession and Acquisition License (, possibility of a "firearm free home" condition, past disregard for conditions as a risk factor, When evaluating the suitability of a prospective surety in. This training should be designed and delivered by Indigenous people. 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. Consider including a case study focused on falling ice in excavations in future inspector training material. The mnistry should ensure that the Toronto South Detention Centre, and any other detention centres organized in the same manner, have an additional copy of the unit notification card kept on the unit for review by correctional officers while an inmate is absent due to court or other external location. State detention includes people in immigration detention centres. Efforts to improve public awareness of these options should be developed in consultation with content experts and community organizations that represent persons with lived experience. The ministry should prioritize the completion of its project to implement electronic health records for patients living in correctional facilities. To improve outcomes for First Nations children and youth, continue to work through the Child Welfare Redesign Strategy on potential further changes to the funding allocation and the funding model and approach to the child welfare service delivery model, including consideration of developing a prevention and reunification process that focuses on family preservation, family reunification, kinship preservation, family contact, assessment of child, youth and parent strengths and needs, parenting skills, home management and routine, infant care, and exploring and developing support networks.
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