Coroners' inquest records - The National Archives blog Revise the use of force report form to require officers to document de-escalation techniques used. Did you find what you were looking for? 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. Inject a significant one-time investment into, Realign the approach to public funding provided to. Educate any worker who is to work for or on behalf of Green Star at a construction site where a skid steer is in use (including those who operate skid steers) regarding the risks and dangers associated with working on or near a skid steer and ensure that they are familiar with the aforementioned safety plan. [1] Held at: TorontoFrom:May 16To: June 3, 2022By:Dr.David Edenhaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Marc Diza EkambaDate and time of death:March 20, 2015 at 10:53 p.m.Place of death:3070 Queen Frederica Drive, Mississauga, OntarioCause of death:multiple gunshot woundsBy what means:homicide, The verdict was received on June 3, 2022Coroner's name:Dr.David Eden(Original signed by coroner), Surname:VeilletteGiven name(s):Jean HervAge:48. The Coroner's officer will usually inform interested parties to the Inquest who is to give evidence at the hearing. The Regulation would require that, in such circumstances: impermeable personal protective equipment to be used and there be a process for verifying or confirming the use of the required personal protective equipment before work is performed in the area, the flushing of cyanide-containing material from lines, titrations to ensure cyanide content in any debris or materials in the area is below a set threshold (, lock out and tag out procedures are to be developed and implemented, workers required or assigned to work in the area have received cyanide awareness training and proper removal of. Deaths reported to the coroner - Kent County Council The ministry should explore digital form tools that would ensure all required fields are completed. 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. Recommend training programs be reviewed on an ongoing basis to maximize employees comprehension of content. 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. 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. Tailboard meetings/forms must be completed. Report to the Thunder Bay Police Services Board on the above. Police services and police services boards shall consult with third-parties, including individuals from the Black community, Black advocacy community organizations, persons with lived experiences from peer-run organizations, and appropriate content experts, and: develop an objective methodology to measure and evaluate police service performance on use of force, take corrective action to address systemic discrimination, provide clear and transparent information to the public on biased and discriminatory use of force. Seek and allocate adequate funding and resources to implement these recommendations. Lakanal House Coroner Inquest | Lambeth Council 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. 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. 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. 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. In addition, the panel will identify priorities for funding from existing resources to support Indigenous welfare programs and First Nation communities. 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. Current inquests | East Sussex County Council The educational opportunities should be provided upon intake and at least once a month in a group setting, and the contact information for healthcare workers should be provided to persons in custody if they would like to get more information. Roger and Bradley Stockton crashed on the second lap of last year's final sidecar race. That where an individual dies in cells, all officers involved in the arrest or monitoring of the deceased be provided information about the cause of death, and training on symptoms that may be related to this cause of death, as soon as reasonably possible following the death. This should include funding for more dedicated officers who can conduct drug investigations and share information with appropriate. The ministry should seek funding to implement these recommendations. In most cases, no further action is required, and the death can be registered as normal. Change its name to one that better reflects its purpose. Explore developing and providing all police officers with additional de-escalation training. Please check the website on the day of the hearing. The action plan should be completed in consultation with the. Time of death could not be determined.Place of death: Wilno, OntarioCause of death: shotgun wound of the chest and neckBy what means: homicide, Surname: WarmerdamGiven name(s): NathalieAge: 48, Date and time of death: September 22, 2015. 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. Clear communication of the transfer of supervision; Clear communication of the scope of supervision; and. Conduct a review and consider the role of jailers, the level of supervision given to individuals in custody, and training given to staff in that role, and in particular: Review the level of staffing, and consider a policy that links the number of staff to the number of prisoners, similar to the Ontario Provincial Polices standard of using one guard for seven individuals in custody. . Said plan should include (but not be limited to): A mandatory mechanical safety review that each skid steer operator must complete each day, prior to commencing work. Encourage review and participation in all best practices regarding cyanide safety put forth in the international Cyanide Management Code. 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. Consideration of streaming short video clips or other helpful information via the television screens on each living unit should also be given. 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. Ensure collaboration between corrections and probation staff to improve rehabilitation and risk management services. The study would, in part, inquire into the following: The process to identify relevant findings and for sharing those findings with other justice participants. 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. 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. Establish a Royal Commission to review and recommend changes to the Criminal Justice system to make it more victim-centric, more responsive to root causes of crime and more adaptable as society evolves. Ensure that survivors and those assisting survivors have direct and timely communication with probation officers to assist in safety planning. Being accessible by clients voluntarily and via referral,and not just through the criminal justice system. Review the current Use of Force Model (2004) and related regulations, and consider de-emphasizing use of the term "force" and employing alternative terminology. 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. Explore and research the availability and efficacy of additional less-lethal use of force options for officers. Try to find out: the date the. The revisions should require correctional institutions to ensure that: one or more staff member is designated to develop a recovery plan when an inmate is removed from suicide watch, one or more staff member is designated to oversee the plan and ensure it is implemented, placement of inmates in recovery is reviewed with health care staff and this review is documented, The recovery plan is available for health care and operational staff. IV. Background: Annually, there are around 30,000 coroner's inquests held in England and Wales that conclude with a verdict. Develop a process, in consultation with the judiciary, to confirm that release conditions are properly documented. The ministry should analyze the data they collect to determine where there are gaps in service delivery of programs at particular institutions. Inquests - Derbyshire Live - Derby Telegraph Prepare an emergency response plan to use if a worker does come into contact with a hazard. It would also provide a primary point of communication for emergency response and medical personnel. Coroner's inquests - how they work and what it will involve 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. 4.1 It is recommended that employers, constructors, supervisors ensure that any hazard identified in risk assessments be relayed to workers together with the associated level of risk. Work with the Infrastructure Health and Safety Association to develop guidance material for employers and constructors on how to address the hazard of falling ice. Develop methods to evaluate the effectiveness of mental health, de-escalation and anti-racism training. The Office of the Chief Coroner posts verdicts and recommendations for all inquests for the current and previous year. PDF Inquests - a Factsheet for Families Ensure that the Central East Correctional Centre (. 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. 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. 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. This includes education of workers, availability and maintenance of rescue equipment (. Improve mental health awareness of housing support personnel, and in particular, concerning the recognition of mental health crisis. The ministry should ensure that correctional management, including regional directors and other senior ministry decision makers, staff and healthcare providers at correctional facilities receive additional Indigenous cultural safety training. The reviewers should work with the local health care team to identify gaps and find solutions. 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. TT sidecar driver had passenger's dog tag - inquest. Coroner's verdict in inquest into the deaths of TT sidecar racers The ministry should abandon its zero-tolerance policy with respect to both the use of street drugs and the diversion of prescribed drugs, recognizing that this policy stigmatizes and punishes people for behaviours that stem from underlying medical issues. 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. In December a coroner . 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. 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). For young people in care, engage with any outside service provider at the intake stage to set clear lines of responsibility regarding communication of information regarding the young person to those in the youths circle of care, including communication of self-harm attempts and leaving the property without permission. 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. 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. 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. If none already exists, explore with community mental health partners, the feasibility of establishing and adequately resourcing joint mental health-police response teams to assist with person in crisis calls for service. Be staffed 24 hours a day and 7 days a week. The coroner | Oxfordshire County Council It also ruled Don Mamakwa's death in 2014 had an . EASTWOOD, Claire Louise. The inquest heard from 278 witnesses and is estimated to have cost the taxpayer more than 6.5m. Consider amending the mandatory 24-hour reporting to police of children and young people who leave a licensed facility without permission. 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 that healthcare and correctional staff at correctional facilities receive additional training about building rapport and resolving challenging encounters with persons in custody. The Ministry of Labour shall review and consider whether to amend. 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. Consider reviewing the mandatory frequency of refresher courses for Suspended Access Equipment Training. Name of deceased. Mandatory use of a signaller when operating a skid steer. 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. 05/09/2022. These outcome measures should be supported by key performance indicators (. To use any such collected information to assess the effectiveness of the deployed alternative responses, to identify the potential for the improvement of future responses and outcomes, and to support any request for additional resources. Work towards creating (including if necessary by making a request to the, developing a strategic plan; including review and potential amendments to missing persons investigations (, use of civilian support workers, civilians in duties not required for a sworn officer related to, maintenance and development of community partnerships and, in particular, the Indigenous community, partnerships with youth institutions and, in particular, child and youth mental health facilities, Review and revise the risk assessment process and policies that govern whether a missing person is classified as Level 1 or Level 2, as well as whether an urgent search is required. What permissible uses could be made of the documents and findings in a criminal proceeding. Such a program should: operate only upon the consent of each individual participant, be managed in partnership between a sobering centre, managed alcohol facility and community care teams, include a system by which first responders can contact case managers/care team members to: inform them that an individual in their care has been in contact with first responders (emergency medical services (, In recognition of the seriousness of alcohol/substance use disorder (. An an inquest is purely a fact-finding hearing; nobody is on trial. Held at:Toronto (virtual)From: December 6To: December 9, 2022By:Mr. Etienne Esquega, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Jose AmaralDate and time of death: November 25, 2015 at 2:40 a.m.Place of death:Musselwhite MineCause of death:blunt force trauma to head and neckBy what means:accident, The verdict was received on December 9, 2022Presiding officer's name:Mr. Etienne Esquega(Original signed by presiding officer), Surname:MilletteGiven name(s):Denis Stanley JosephAge:52. 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. Held at:virtual inquestFrom: September 26To: October 7, 2022By: Murray Segal, Presiding Officer for Ontariohaving been duly sworn/affirmed, have inquired into and determined the following: Name of deceased:Victor OgundipeDate and time of death: January 26, 2017,10:14 p.m.Place of death:36 Queen Street East, TorontoCause of death:a) Hemoperitoneum, due to b) rupture of liver, due to c) blunt force injury to abdomen.By what means:accident, The verdict was received on October 7, 2022Presiding officer's name:Murray Segal(Original signed by presiding officer), Surname:FreemanGiven name(s):Devon Russell James (Muskaabo)Age:16. The committee should include senior members of relevant ministries central to, Require that all justice system participants who work with, Explore incorporating restorative justice and community-based approaches in dealing with appropriate. The ministry should develop training for correctional officers on strategies to work constructively with Indigenous men in custody, similar to the Biidaaban Kwewok and Biidaaban Niniwok Beginnings for Indigenous Women and Men training. The ministry should include a notation of any outstanding mental health assessments on the front of the unit notification cards. 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. Where possible and financially feasible, connect young people with external resources that could provide additional opportunities, including but not limited to sport, land-based learning, culture, art, and other pursuits that will assist in developing a forward pathway. 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).