Office of the Chief CoronerReport for 2009-2011
Table of Contents
Message from the Chief Coroner 1Motto 2Values 2QualityAssurance2009-2011 3OrganizationalStructure 4Budgets 5Investigations 5Inquests 7Research 10DeathReviewCommittees 11CardiacDeathAdvisoryCommittee 12ConstructionFatalityReviewCommittee 12Technology(Modernization)Initiatives 13PublicSafetyInitiatives 15Awards 21SeniorStaff 22
Office of the Chief Coroner Report 2009-2011
Message from the Chief Coroner
Iampleasedtopresentthe2011AnnualReportoftheOfficeoftheChiefCoronerforOntario.Thisreportencapsulatestheactivitiesoftheofficefortheyears2009,2010and2011,aligningourannualreportingcyclewiththemostup-to-datestatistics.
Ourofficehasbeenengagedinanumberofexcitinginitiativesaimedatimprovingserviceandenhancingpublicsafety.TheinvestmentsoftheGovernmentofOntariohaveenabledustomoveforwardonanumberoftransformativeprojects:
• Withourpartner,InfrastructureOntario,wearebuildingastateoftheartforensicservicescomplexthatwillhousetheOfficeoftheChiefCoroner,theOntarioForensicPathologyServiceandtheCentreofForensicSciences.
• Weareimplementingarobustinformationmanagementsystemandrollingoutaprovince-widecoronerdispatchsystemthatwillgreatlyimprovecommunicationsandresponselevels.
• Telemedicine technology has been acquired to facilitate case conferencing at scenes in remote and northern locations–asignificantstepforwardindeliveringhighqualityservicetothepeopleofOntario.
OurguidingframeworkhasbeentherecommendationsmadebytheHonourableStephenT.Goudge,CommissioneroftheInquiryintoPediatricForensicPathologyinOntario.Thisinquiry,announcedonApril25,2007,wastheresultofaninvestigationcommissionedbyformerChiefCoronerDr.BarryMcLellanintoaseriesofautopsiesconductedbyDr.CharlesSmithbetween1981and2001.JusticeGoudge’sreportwasissuedinOctober2008andcontained169recommendations.
WhileeffortsareongoingtoenhanceOntario’sdeathinvestigationsystemthroughtheapplicationofnewtechnologyandbusinesspractices,determiningcauseandmannerofdeathandpreventingprematuredeathinOntariocontinuestobeourfocus.Iwouldliketorecognizethecommitmentofourstaffandtheapproximate300physician-coronerswhocarryouttheirdutiesandresponsibilitieseverydaywithcompassion.ThepeopleofOntarioandourjusticesystempartnersdeserveserviceofthehighestcalibreandwearededicatedtothatend.
IhopethatyoufindthelatestinformationonCanada’sbiggestandbusiestdeathinvestigationsystemuseful.Formoreinformationonoursystem,pleasevisitwww.ontario.ca/safety.
AndrewMcCallum,M.D.,FRCPCChief Coroner for Ontario
Office of the Chief Coroner Report 2009-20111
Office of the Chief Coroner Report 2009-20112
Motto
We speak for the dead to protect the living
TheOfficeoftheChiefCoronerforOntarioservesthelivingthroughhighqualitydeathinvestigationsandinqueststoensurethatnodeathwillbeoverlooked,concealedorignored.Thefindingsareusedtogeneraterecommendationstohelpimprovepublicsafetyandpreventdeathsinsimilarcircumstances.
Values
Who Are We?
TheactivitiesoftheOfficeoftheChiefCoronerfallunderthejurisdictionoftheCommunitySafetyDivisionoftheMinistryofCommunitySafetyandCorrectionalServices.TheministryiscommittedtoensuringthatOntario’scommunitiesaresupportedandprotectedbylawenforcementandpublicsafetysystemsthataresafe,secure,effective,efficientandaccountable.Thesesystemsincludeemergencymanagement,scientificinvestigations,coordinationoffiresafetyservicesandOntario’sdeathinvestigationsystem.
InOntario,deathinvestigationservicesareprovidedbytheOfficeoftheChiefCoronerandtheOntarioForensicPathologyService.TheOfficeoftheChiefCoronerworkscloselywiththeOntarioForensicPathologyServicetoensureacoordinatedandcollaborativeapproachtodeathinvestigationinthepublicinterestwiththegoalofprovidingservicesofthehighestcalibre.Otherdeathinvestigationpartnersincludepoliceservices,theCentreofForensicSciencesandtheOfficeoftheFireMarshal.
InOntario,coronersaremedicaldoctorswithspecializedtrainingintheprinciplesofdeathinvestigation.Coronersinvestigateapproximately17,000deathsperyearinaccordancewithsection10oftheCoronersAct.Theyinvestigateallunnaturaldeathssuchasthosewherefoulplay,suicide,accident,negligenceandmalpracticearesuspectedorallegedonafee-for-servicebasis.Thepurposeofadeathinvestigationunderthesecircumstancesistoanswerthefollowingquestions:
• Who the deceased was• Howthedeathoccurred(i.e.themedicalcauseofdeath)• When the death occurred• Where the death occurred and• Bywhatmeansthedeathoccurred(i.e.natural,suicide,accident,homicideorundetermined)• To determine whether or not an inquest is necessary; and• Tocollectandanalyzeinformationaboutthedeathinordertopreventfurtherdeathsinsimilarcircumstances.
Office of the Chief Coroner Report 2009-2011
3
Quality Assurance 2009-2011
OntarioisnotonlythelargestmedicolegaldeathjurisdictioninCanada,itisalsothelargestinNorthAmerica,andoneofthelargestintheworld.Thegoalofourqualityassuranceprogramistoensurethatdeathinvestigationservicesaredeliveredtothesamehighstandardacrossaprovincewhichisgeographicallyvastanddemographicallydiverse.AnypolicydevelopmentmusttakeintoaccountthatOntario’slandscaperangesfromhighurbandensitytoremoteandsparselypopulatedcommunities,andthatitspopulationisethnicallyandculturallydiverse.
Consistentwithourcommitmenttoquality,theOfficeoftheChiefCoronerembracesfourcorevalues:
Integrity:Werememberthatthepursuitoftruth,honestyandimpartialityarethecornerstonesofourwork.Responsiveness:Weembraceopportunities,changeandinnovation.Excellence: Weconstantlystrivetowardsbestpracticeandbestquality.Accountability:Werecognizetheimportanceofourworkandwillacceptresponsibilityforouractions.QualityassuranceactivitiesoftheOfficeoftheChiefCoroneroverthereportperiodcanbedividedintofourmajorareas:
1. Policies&proceduresunderwentsignificantreviewandrevisioninlightofamendmentstotheCoronersActandrecommendationsarisingfromtheInquiryintoPediatricForensicPathology.
2. Investigationsweremonitoredforadherencetopoliciesandproceduresandforidentifyingtrends.3. Thedevelopmentofanewinformationmanagementdatabase,amajorupdateofOntario’sdeath
investigationdatabase,offersmajoropportunitiesforfurtherimprovementofconsistency,completenessandtimelinessofdeathinvestigations.
4. Implementationofacomplaintstrackingsystemin2011.
Throughtheseendeavours,weareenhancingthequalityandefficiencyofourorganizationandweremaincommittedtoembracinginnovation,educationandexplorationtofurtheradvanceandpositionourofficeforthefuture.
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Organizational Structure
InadditiontoitsheadquartersinToronto,theOfficeoftheChiefCoronerhasanumberofregionalofficesthroughouttheprovince.EachofficeismanagedbyaRegionalSupervisingCoronerwithsupportfromadministrativestaff.Theregionsandtheirrespectivegeographicareasareoutlinedbelow:
Region OfficeLocation Boundaries
East Peterborough Haliburton,Hastings,KawarthaLakes,Northumberland,Peterborough,Renfrew
East Kingston Dundas,Glengary,Frontenac,Grenville,Lanark-Leeds,Lennox-Addington,Ottawa,Prescott,Russell,PrinceEdwardCounty,Stormont
West Hamilton Brant,Dufferin,Haldimand,Hamilton,Niagara,Norfolk,Waterloo
West London Bruce,Chatham-Kent,Elgin,Essex,Grey,Huron,Lambton,Middlesex,Oxford,Perth
North Thunder Bay Kenora,RainyRiver,ThunderBay
North Sudbury Algoma,Cochrane,Manitoulin,Nipissing,ParrySound,SudburyTimiskaming
Central Guelph Halton,Peel,Simcoe,Wellington
Central TorontoEast Toronto(eastofYongeStreet)
Central Toronto West Toronto(westofYongeStreet)
Central Brampton Durham,Muskoka,York
Budgets
*2008-09$36.1million*2009-10$33.1million*2010-11$34.8million
Note:Budgetexpendituresincludebutarenotlimitedto:FinancialsupportoftheOntarioForensicPathologyService,theProvincialForensicPathologyUnitinToronto,fiveRegionalPathologyUnitsacrossOntario,paymentstoapproximately300fee-for-serviceinvestigatingcoronersandpaymentstoapproximately170fee-for-servicepathologistswhoconductapproximately6000autopsiesperyearunderacoroner’swarrant.
Investigations
TheCoronersActisthelegislativeframeworkfordeathinvestigationinOntario.Sections10and15oftheActsetoutthecircumstancesinwhichadeathshouldbereportedtoacoroner,aswellasthepurposeofadeathinvestigation.TheOfficeoftheChiefCoronerinvestigatesapproximately20%ofalldeathsthatoccurwithintheprovinceonanannualbasis.
InOntario,coronersmustbelicensedmedicaldoctors.Thereareapproximately300coronersinOntariowhoconductanaverageof17,000deathinvestigationsannually.
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2011-2012 ($42.5 million)ODOE - Transportation, Administration, Inquests, Pathology/Medical Services,
Supplies & Equipment
Salaries/Wages/Benefits Transfer Payments Other Direct Operating Expenses (ODOE)
Salaries/Wages/Benefits 29%
Transfer Payments 4% Other Direct Operating
Expenses (ODOE) 67%
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Office of the Chief Coroner Report 2009-2011
Thetablesbelowshowthenumberofdeathsinvestigatedintheyears2009and2010,brokendownbymannerofdeath,regionandoffice.
2009 Manner of Death by Region and OfficeNatural Accident Suicide Homicide Undeter-
minedSkeletal Total
KingstonOffice-EastRegion 1700 368 135 17 54 7 2281
PeterboroughOffice-EastRegion
802 198 65 8 10 13 1096
HamiltonOffice-WestRegion 1303 594 193 18 63 35 2206
LondonOffice-WestRegion 1593 443 155 13 88 9 2301
SudburyOffice-NorthRegion 750 224 83 12 21 7 1097
ThunderBayOffice–NorthRegion
305 130 42 14 15 3 509
TorontoEastOffice–CentralRegion
1292 434 137 43 60 3 1969
TorontoWestOffice–CentralRegion
1132 301 118 24 49 4 1628
BramptonOffice-CentralRegion
1087 329 118 8 39 11 1592
GuelphOffice-CentralRegion 1447 481 186 25 77 31 2247
Total 11411 3500 1232 182 476 123 16926
2010 Manner of Death by Region and OfficeNatural Accident Suicide Homicide Undeter-
minedSkeletal Total
KingstonOffice-EastRegion 1566 377 121 15 29 10 2118
PeterboroughOffice-EastRegion
801 210 66 10 13 8 1108
HamiltonOffice-WestRegion 1167 593 160 19 55 48 2042
LondonOffice-WestRegion 1479 483 175 14 75 9 2235
SudburyOffice-NorthRegion 671 304 75 11 19 7 1087
ThunderBayOffice–NorthRegion
300 125 48 15 7 3 498
TorontoEastOffice–CentralRegion
1247 363 136 30 44 3 1823
TorontoWestOffice–CentralRegion
1231 327 111 40 58 4 1771
BramptonOffice-CentralRegion
1040 361 103 13 29 7 1553
GuelphOffice-CentralRegion 1359 512 174 11 78 46 2180
Total 10861 3655 1169 178 407 145 16415
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Inquests
Aninquestisapublichearingconductedbyacoronerwherethecircumstancesofadeatharepresentedtoajurybycallingwitnesses.TheevidenceispresentedbyaCrownAttorneywhoactsascounseltothecoroner.Partieswhohaveaninterestintheinquestmayalsoparticipatebyquestioningthewitnessesorbycallingwitnesseswhohaveevidencedeterminedtoberelevantbythecoroner.
Thejurymustanswerfivequestionsafterhearingfromthewitnessesandfromthepositionsofthepartieswithstanding.Thequestionsare:
• Whatistheidentityofthedeceased(who)?• Whatwasthedateofdeath(when)?• Whatwastheplaceofdeath(where)?• Whatwasthecauseofdeath(how)?• Whatwasthemannerofdeath(bywhatmeans-natural,accident,suicide,homicideorundetermined)?
Inquestsareheldinthepublicinterest;thepurposeistoinformthepublicfullyaboutadeath.Ifsomethingcanbelearnedfromthedeath,itishopedthejurywillmakerecommendationstopreventdeathsinsimilarcircumstances.Nooneisontrialataninquestandthejurycannotmakeanylegalfindingsorimplyanyresponsibilityorblame.Theinquestisintendedtomakethefactsofadeathpublicandtoidentify,ifpossible,howsimilardeathsmightbepreventedinthefuture.
Somedeathsrequireinquestsbylaw(mandatoryinquests).Otherdeathsmayidentifypublicsafetyconcernsthatarebestidentifiedthroughaninquest(discretionaryinquests).
RecommendationsfrominquestsaredistributedbytheChiefCoronertothosewhomaybeinapositiontoconsiderandimplementthem(e.g.agencies,employers,organizations,institutionsandgovernmentministries).
ThereisalonghistoryofpositivechangesthatimprovepublicsafetyforallcitizensofOntarioasaresultofinquestrecommendations.Theseincludechangesinareassuchashospitalprocedures,roadsafety,constructionworkplaces,howpoliceandthecourtshandleincidentsofdomesticviolence,changestolegislationrelatingtochildandfamilyservices,poolsafety,themedicaltreatmentofpatientsinpsychiatricfacilities,andworkplacesafety.
ThefollowingcasesillustratesometypesofdeathspubliclyexaminedthroughOntario’sinquestprocess:
Ricardo Wesley and Jamie Goodwin – 2009
Thismandatoryinquestwasconductedinthespringof2009inToronto,Ontario.OnJanuary8,2006,22-year-oldRicardoWesleyand20-year-oldJamieGoodwinweretakentothelocaljailinKashechewanFirstNationbyNishnawbe-AskiPoliceinanintoxicatedstate.Theywereplacedinseparatecells.Afirebrokeoutinthejailandeffortsbypolicetofreethemenwereunsuccessful.Therewasnomasterkeyavailabletounlockthecells,andbothmendiedaccidentallyduetosmokeinhalation.
Thisinquestlasted34daysandthejurymade86recommendationsaddressingfiresafetyandinspections,resources,legislation,policingpoliciesandprocedures,communityhealthandwellbeing,informationsharingandfunding.
Dustin King and Donna Bertrand – 2011
Thisdiscretionaryinquestwasconductedinthesummerof2011inBrockville,Ontario.
DustinKingwasa19-year-oldmanwholivedsporadicallywithfamilymembersbutalsostayedwithacquaintancesandfriendsinBrockville.Itwasatoneoftheseresidenceswhereheingestedalcohol,cocaineandOxyContinonNovember20,2008.Hewasdiscovereddeceasedthenextdayintheapartmentof41-year-oldacquaintanceDonnaBertrand.Hisdeathwasruledaccidentalduetoanoxycodoneoverdose. OnDecember2,2008,DonnaBertrandwasfounddeceasedatherhome.Shewasfoundtohavehadahistoryofsubstanceabuse,depressionandanxiety.Thecoroner’sinvestigationrevealedthatshewasbeingprescribedlargedosesofoxycodone.Herdeathwasruledasuicideduetomixeddrugtoxicity.
BothofthesedeathshighlightedthemagnitudeofopioidprescriptiondrugaddictioninOntario,aproblemofcrisisproportionsacrossNorthAmerica.Theinquestjury,throughthoughtfulandinformeddeliberations,offered48recommendationsthat,ifimplemented,couldpreventdeathsundersimilarcircumstances.ThisinquestwashighlightedintheBritishMedicalJournal.
Matthew Reid – 2010
Thisdiscretionaryinquestwasconductedinthewinterof2010inSt.Catharines,Ontario.
Three-year-oldMatthewReidwasinthecareofaChildren’sAidSocietyandhadbeenplacedinanaffiliatedfosterhome.Onthedaybeforehisdeath,a14-year-oldfemalewasplacedinthesamefosterhome.Thenextday,Matthewwasfoundwithnovitalsignsandresuscitativeeffortswereunsuccessful.Policechargedthe14-year-oldfemaleandshewaseventuallyfoundguiltyofsmotheringMatthewbyplacingapillowoverhisface.Matthew’sdeathwasruledahomicidecausedbysmothering.
Thejuryheardfrom30witnessesovera12-dayperiodandreturnedwith45recommendationsrelatedtoissuesaffectingyouth,fetalalcoholsyndrome,information-sharingamongChildren’sAidSocietiesandtheirpartners,andschoolboardpractices.ThisinquesthighlightedthenecessitytoprovidefulsomeinformationonchildreninthecareofChildren’sAidSocietiestoensureproperplacementandadequatelevelsofcare.
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Office of the Chief Coroner Report 2009-2011
Thefollowingchartsdepictthetypesofinquestsheldfrom2009to2011:
2009 2010 2011
Total number of Inquests 72 58 34
Mandatory Inquests 71 56 28
(%ofTotal#ofInquests) 99% 97% 82%
Custody 49 33 17
68% 57% 50%
Construction 18 18 10
25% 31% 29%
Mining 4 5 1
6% 9% 3%
DiscretionaryInquests 1 2 6
(%ofTotal#ofInquests) 1% 3% 18%
No.ofRecommendations 354 282 355
Total number of days 216 189 205
Average number of days 3 3.3 6
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Research
TheOfficeoftheChiefCoronerisactiveinresearchandispleasedtopartnerwithotherorganizationsandgovernmentministriestoenhancepublicsafety.Belowaresomeexamplesofsomeoftheimportantworkthatourofficehasrecentlyparticipatedin:
Canadian Agricultural Injury Reporting Program
DatafromourCoronersInformationSystemdatabase(CIS)wasusedforresearchintofarming-relateddeathsinOntarioaspartofanationwidestudy.Thedatacollectedwasusedtohelpinformthedevelopmentofinjurypreventioncampaignsandpolicies.
Sunnybrook Health Sciences Centre and the University of Toronto Department of Psychiatry
Areviewof30yearsofsuicidedeathdatafromtheOfficeoftheChiefCoronerwasusedtoconductastudyintotherelationshipbetweensuicideandweatheracrossOntario.Theintentofthisstudywastobetterunderstandinwhatwayseasonalclimateandweathervariablesinfluencesuicide,andtoapplythisknowledgetofuturesuicidepreventionstrategies.Thisstudymayalsohaveimportantimplicationsforpublicpolicyandtheallocationofmentalhealthresources.
Institute for Safe Medication Practices Canada (ISMP Canada)
ISMPCanadaandtheOfficeoftheChiefCoronerworkcollaborativelytoreducepreventableharmrelatedtomedicationuse.ThiscollaborationhasinvolvedthesharingofdatafromOCCcasefilesindeathsrelatedtomedicationerrors.ISMPCanadaappliesthisdatatoitsworkwiththehealthcarecommunity;regulatoryagenciesandpolicymakers;provincial,national,andinternationalpatientsafetyorganizations;thepharmaceuticalindustryandthepublictopromotesafemedicationpractices.
The Electrical Safety Authority (ESA)
TheESAistheorganizationresponsibleforimprovingelectricalsafetyinOntario.TheESAexaminesallelectricalfatalitydataprovidedbytheOfficeoftheChiefCoronertoimproveitsabilitytoreduceelectrical-relatedfatalities.
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Office of the Chief Coroner Report 2009-2011
Death Review Committees
TheOfficeoftheChiefCoroneroverseessixexpertdeathreviewcommittees.Themembershipofeachcommitteeincludesindividualsrepresentingarangeofrelevantfields,whoprovideadviceandexpertiseforinvestigationsandreviewsconductedbytheOfficeoftheChiefCoroner.Thecommitteesinclude:
• TheDomesticViolenceDeathReviewCommittee• TheMaternalandPerinatalDeathReviewCommittee• TheGeriatricandLong-TermCareReviewCommittee• ThePatientSafetyReviewCommittee• ThePaediatricDeathReviewCommittee• TheDeathsunderFiveCommittee
Theobjectivesofthesecommitteesareto:
• Offerexpertopiniononcauseandmannerofdeath.• Identifythepresenceorabsenceofsystemicissueswhichmayrequirefollow-upbytheInvestigating,Regional
orChiefCoroner.• Identifytheneedtorefertootherappropriatebodiesforfurtherinvestigationand/oraction,when
appropriate.• Stimulateeducationalactivitiesthroughtherecognitionofsystemicissues.• Promoteresearchwhereappropriate.• UndertakerandomordirectedreviewswhenrequestedbytheChair.• AdvisetheChiefCoronerofcasesthatmayfurtherpublicsafetyifexaminedthroughtheinquestprocess.
Thecommitteesofferspecializedknowledgeandexpertiseincomplexdeathinvestigationswithinspecificsubjectmatterareas.Theyutilizetheservicesofknowledgeableandexperiencedindividualsrepresentingavarietyofmedical,social,legalandacademicdisciplines.Theyprovideathorough,comprehensiveanddiversereviewofthecircumstancesandfactssurroundingthedeath(s).Theydonotmakedecisionsregardingstandardsofcare,butmayidentifyissuesrelatingtostandardsofcare,andmayrecommendthattheChiefCoronerconsiderareferraltoaregulatorybodyforfurtherexamination.
Membersofexpertdeathreviewcommitteesreceivemodestcompensationbaseduponattendanceatcommitteemeetingsandpreparationofdeathreviewreports.Committeesmeetthreeto10timesperyear,dependingonthevolumeandurgencyofcasestobereviewed.
Thecommitteespreparereportsthatcontaintheirfindingsoneachcasereviewed.Inthecourseoftheinvestigation,thefindingsmaybesharedwithotherinterestedpartiesinanefforttogeneratemeaningfuldialogueandsystemicchange,ifappropriate.Thefindingsmayalsobesharedwithfamilymembersofthedeceasedindividualswhoarethesubjectsofreviews.
Thecommitteespreparetheirownannualreports.Tolearnmoreaboutcommitteesand/ortoobtaincopiesoftheirreports,seewww.ontario.ca/coronersreports.
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Cardiac Death Advisory Committee
TheCardiacDeathAdvisoryCommitteewasestablishedinSeptember2010toreviewtheresultsofinvestigationsintosuddenandunexpecteddeathsofpeople40yearsofageandunderwho,intheabsenceofadefinitivecauseofdeath,mayhavediedofacardiacevent.
Thegoalsofthiscommitteeincludedetermininghowtoidentifyriskfactorsanddevelopingrecommendationstoeducate,interveneandassistpreventioneffortsamongthoseinfieldswhomayhavecontactwithyoungpeoplewhoareatrisk.
Themembersofthecommitteeincludefitnessphysiologyexperts,cliniciansandcardiacarrhythmiaspecialists.
Areviewofcaseshasbeenundertakenandapaperonthefindingsisbeingpreparedforpublication.Theresultswilldirectfurtherresearchactivitiesinthisarea.
Construction Fatality Review Committee
Thiscommitteewasformallyestablishedin2010.ItsgoalistoincreasethelevelofsafetyonconstructionsitesinOntariothroughearlyidentificationofhazardsintheworkplace.
Thecommitteefocusesonimprovingthequalityofinformationavailablefordeathinvestigations,theefficiencyofinquests,theusefulnessofrecommendationsfrominquestsintoaccidentaldeathsonconstructionsitesandthelikelihoodofthoserecommendationsbeingimplemented.
Theobjectivesofthecommitteeare:
• Tostudythecircumstancesofeventsleadingtodeath(s).Toofferopiniononthepreventionofsimilaroccurrences.
• Toidentifythepresenceorabsenceofsystemicissuesorhazardswhichrequirefurtherinvestigationorfollow-upbytheOfficeoftheChiefCoroner.
• Tostimulateeducationalactivitiesthroughtherecognitionofsystemicissuesandhazardsintheconstructionindustry.
• Toassistinidentifyingexpertstotestifyatinquests.
In2010,seventeenconstruction-relatedworkplacedeathswerereviewed.Whereappropriate,informationrelatingtopotentialissuesandrelevantexpertswasrelayedtotheRegionalSupervisingCoronertoassistwithinquestpreparation.
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Office of the Chief Coroner Report 2009-2011
Technology (Modernization) Initiatives
TheOCCandOFPSareinvestinginanewinformationmanagementsystemandrelatedtechnologies.
Telemedicine
TheOCCandOFPSrecognizedaneedforvideoandtelecommunicationamongheadoffice,regionalcoroners’offices,ForensicPathologyUnits,remoteandnortherncommunityhospitalsandpolice.Thisnewcapabilityenhancescasemanagementandservicequality,facilitatesteachinganddecreasestheneedtotransportbodiesacrosssignificantdistances.Itenablescoronersandpathologiststovirtuallyattenddifficult-to-reachlocationsandobserveandcollaborateoncases.Thistechnologyproducesfurthercostssavingsbyreducingtravelforattendanceatmeetings.
Videoconferencingequipmentincludes:
• RemotescenecamerastobeusedbytheOntarioProvincialPolicewhichstreamsreal-timevideoimagesfromremotescenesinNorthernOntarioacrossasecurejusticevideonetwork(viaWiFiorsatelliteuplink)
• Standardofficevideoconferencingequipmenttoenhancepeer-to-peerconsultation• Morguecartstoallowpathologiststosharevideoimagesforconsultationandteaching.
TheOCCandOFPStelemedicineprojectwona2011ShowcaseOntarioMeritAwardinthecategoryofInnovation.
Provincial Coroner Dispatch
Currently,whenadeathoccursinOntario,thereisnosinglemechanismtoassesstheneedforadeathinvestigationundertheCoronersActortonotifyaninvestigatingcoroner.Webelieveacommunicationsystemideallyshouldprovidereal-timeinformationtoguidedeploymentofcoronersandallowsystemmanagement.Theexistingsystemdidnotservethisrole.
TheOCCandOFPSexploredanumberofoptionsforaprovince-widecoronerdispatchprocess.Asaresult,theTorontoCoronerDispatchlocatedattheheadquartersoftheOCCandOFPSisexpandingitsscopetoprovideservicetotheentireprovince.Thiscentralizeddispatchservicewillallowcreationofadeathinvestigationrecordatthetimeofinitialcontact,astandardprocessforcoronerdispatchandaccessibilitytodetailsofdeathinvestigationsacrosstheprovince.Thissystemisexpectedtobefullyimplementedbythesummerof2012.
TheProvincialCoronerDispatchProjectwona2011ShowcaseOntarioMeritAwardinthecategoryofServiceExcellence.
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Death Investigation Information System
TheDeathInvestigationSystemTechnology(DIST)willcombineandsignificantlyenhancethefunctionalityandfeaturescurrentlyavailableinthepresentCoronersInformationSystemandPathologyInformationManagementSystem.DISTwillincorporatealldatafromtheOCCandOFPSintoanintegratedinformationmanagementsystemthatspanstheentiredeathinvestigationsystem.
Afullprocurementprocessresultedintheengagementofavendor,andtheimplementationiswellunderway,withfullroll-outexpectedinearly2013.Coupledwiththenewintegrateddispatchsystem,theDISTwillofferreal-timemanagementofthesystem,enhancedqualityassurancefeatures,appropriateandsecureinformationsharingandoptimalefficiency.
Forensic Services and Coroner’s Complex
ConstructionofthenewForensicServicesandCoroner’sComplex(FSCC)atKeeleStreetandWilsonAvenueinDownsviewcommencedinAugust2010.ThiswillbethefutureheadquartersoftheOCC,OFPSandtheCentreofForensicSciences(CFS).CarillionSecureSolutions,thecontractor,hasmadesignificantprogresswiththestructureofthebuilding.Equipmentandfurnitureprocurementandtransitionplanningareunderwaywithrelocationexpectedinearly2013.Thenewfacilitywillbethelargest,moststate-of-the-artfacilityofitskindintheworld,bringingtogetherallaspectsofforensicscienceandmedicine.
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Office of the Chief Coroner Report 2009-2011
Public Safety Initiatives
Reviews
Youth Suicides in Pikangikum First Nation
InSeptember2011,theOCCreleasedacomprehensivereviewof16on-reserveyouthsuicidedeathsinPikangikumFirstNationfrom2006to2008.Thisreviewwasinitiatedafterobservingthedevastatingimpactthedeathsofchildren10to19yearsoldwerehavingonthecommunity.Theobjectivesofthereviewwereto:
• Examinethecircumstancesofeachyouthsuicide.• Collectandanalyzeinformationaboutthedeaths.• Makerecommendationsdirectedtowardtheavoidanceofdeathinsimilarcircumstancesorrespectingany
othermatterarisingoutofthereview.
LedbyDeputyChiefCoronerDr.BertLauwers,themultidisciplinaryreviewcommencedinMarch2010.Itincludedtheassistanceofseveralparties,includinghealthcareprofessionals,theProvincialAdvocateforChildrenandYouth,andchildwelfareproviders.Atotalof100recommendationswereofferedtohelppreventyouthsuicide,notonlyinPikangikumFirstNationbutincommunitiesacrossOntario.Therecommendationstargetededucation,policing,childwelfare,healthcare,and,inparticular,thecreationofsuicidepreventionstrategies.
Inresponsetothereport,Dr.LauwerswasinvitedbytheHonourableDavidC.Onley,LieutenantGovernorofOntario,toattendawitnessingeventandcross-culturaldialoguewiththeTruthandReconciliationCommissionofCanada.Thisevent,heldinSeptember2011,sawthegatheringofresidentialschoolsurvivors,FirstNationseldersandanumberofotherprominentCanadians.
Retirement Home Investigations
InOctober2011,theOCCreleasedtheresultsofaninvestigationintothedeathsofresidentsoftheInTouchRetirementHomeinTorontothatoccurredbetweenFebruaryandDecember2010.Becausethefirstthreedeaths(betweenFebruaryandJuly2010)werenotinitiallyreportedtotheOCC,theinvestigationofthosedeathswaslimitedtomedicalrecords.AfourthdeaththatoccurredinDecember2010wasreported,andapost-mortemexaminationwasconducted.Concernsincludedthelivingconditionsattheretirementhome,thequalityandavailabilityofmeals,thecareprovidedbystaff,allegationsoffinancialimproprietybythehome’smanagement,and,inatleastonecase,allegationsoffrankneglectandstarvation.
LedbyRegionalSupervisingCoronersDr.DanCassandDr.JamesEdwards,theinvestigationsrevealednoevidenceofabuseorneglect.However,anumberofissueswereidentifiedrelatedtoresidentsofretirementhomes.Theseissuesincluded:
1. Thelackofanestablishedcomplaintmechanismwherebyresidents,substitutedecisionmakersormembersofthepubliccouldregisteracomplaintregardingthecareprovidedataretirementhomeandbeassuredofanimpartialinvestigation.
2. Thelackofrequirementsformedicalassessmentandreassessmentofresidentsofretirementhomes,toensurethatasaresident’scareneedsescalatetheirneedscanbeadequatelymetintheretirementhome.
3. Thelackofaprocesswherebyresidents(ortheirsubstitutedecisionmakers)arepresentedwithoptionswhentheresident’scareneedsgrowtoexceedthecapabilityoftheretirementhome,includingreferraltotheCommunityCareAccessCentreforapplicationtoalong-termcarehome.
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TheRetirementHomesAct(RHA)receivedRoyalAssentinJune2010,whiletheOCCinvestigationwasunderway.Thislegislationcontainedprovisionstoaddresstheidentifiedconcerns.Therefore,norecommendationsweremadeandnofurtheractionwastakenbytheOCC.
Drowning Review
InJune2011,theOCCreleasedareviewofaccidentaldrowningdeathsfromMaytoSeptember2010.TheOCCundertookthisreviewasaresultofaperceivedsurgeinthenumberofdrowningdeathsinOntario.Thepurposeofthereviewwastoidentifycommonfactorsthatmayhaveplayedaroleinthedeathsand,ifnecessary,makerecom-mendationstopreventsimilardeaths.
LedbyDeputyChiefCoronerDr.BertLauwers,thereviewteamexamined89accidentaldrowningdeathsandmade12recommendations.Highlightsofthereportincluded:
• ThenumberofaccidentaldrowningdeathsinOntariohasbeensteadilydecliningovertheyears.• Whiletherewasnosurgeinthenumberofdeathsoverallduringthetimeperiodstudied,therewasa260%
increaseindrowningdeathsinchildrenyoungerthanfive.Thirteenofthe89(15%)deathsinthisreviewwerechildrenlessthanfiveyearsold.
• Drowningislargelyamale-relatedphenomenon.Seventy-sixof89(85%)deathsweremale.• 71of89(80%)ofthedeathsoccurredinpersonsyoungerthanfiveorbetween15-64yearsold.• 55of66(83%)ofthedeathsrelatedtoswimmingoccurredwhentheairtemperaturewashigherthan21˚C.• 22of23(96%)ofthoseoperatingboatswhodrownedwerenotwearinglifejacketsorpersonalflotation
devices.• Alcoholwasacontributingfactorin39of58(67%)ofthedrowningdeathsbetween15-64yearsofage.
Overall,39of89(44%)ofdrowningdeathswerealcoholrelated.• In2010,forthosewhoseswimmingstatuswasknown,24of60(40%)werenon-swimmers.• 20of59(34%)ofthedrowningvictimswhoseplaceofbirthwasknownwerenotborninCanada.
Joint Initiatives
Opioid Working Groups
Inresponsetoaconsistentincreaseinopioid-relatedfatalities,ourofficewasinvitedtoparticipateontwoexpertworkingcommitteesthatweretaskedwithstudyingtheissuessurroundingthedispensingofopioidprescriptions,illegaltraffickingandabuse.DeputyChiefCoronerDr.BertLauwersjoinedtheMinistryofHealthandLong-TermCare’sNarcoticAdvisoryPanelandtheOpioidPublicPolicyProjecthostedbytheCollegeofPhysiciansandSurgeonsin2010.Bothmulti-disciplinarycommitteesgeneratedreportswithrecommendationstargetinglegislation,education,awarenessandenforcement.
TheOCCisactivelyinvolvedwithnationalstakeholdersinanefforttoaddressthissignificantadditionissuewhichwashighlightedbytheDustinKingandDonnaBertrandInquestin2011(page8).
Office of the Chief Coroner Report 2009-201116
Office of the Chief Coroner Report 2009-2011
Narcotic-Related Death Statistics in Ontario
Investigative Initiatives
Newborn Screening Protocol
Therearemanymetabolicdisordersthatcancausesuddenandunexpecteddeathinyoungchildren.Inanefforttoreducethemorbidityandmortalityassociatedwiththeserarediseases,bloodspotsamplesfromallnewbornsinOntarioarescreenedforatotalof31disorders.ThistestingiscompletedthroughNewbornScreeningOntario(NSO).Aspartofanyinvestigationintothedeathofachildundertheageoffive,OntariocoronersmustobtaintheNSOresultsandprovidethemtotheexaminingpathologist.
Asuccessfulpilotprojectwasundertakenin2009tointroduceprovince-widemetabolictestingofpost-mortembloodandbilesamplesbyNSO,andinJuly2010NSObecamethesoleproviderofmetabolictestingtotheOntarioForensicPathologyService(replacingalaboratoryservicebasedintheUnitedStates).NSO’spost-mortemtestingismorecomprehensiveandisagreatexampleofhowtheOfficeoftheChiefCoronerworkscooperativelywithotherorganizationstocontinuallyimprovedeathinvestigationsforthepeopleofOntario.
FormoreinformationontheNSO,pleasevisithttp://www.newbornscreening.on.ca.
Office of the Chief Coroner Report 2009-201117
*incomplete data
Public Safety Alerts
Therapeutic Air Mattress Alert
InFebruary2011,theOCCissuedapublicsafetyalerttoallOntarianstotheuncommonbutsignificantriskswhichmaybeassociatedwiththeuseoftherapeuticairmattresses.Therapeuticairmattressesarecurrentlyusedinhospitalsandlong-termcarefacilitiestopreventbedsores.Theseairmattressespartiallydeflateandinflateinaprogrammedsequencetorelievepressureontheskin.However,ourinvestigationsrevealedthatincertain,albeituncommon,circumstances,thepatientcanbecometrappedbetweenthemattressandthebedrailsorbedframe.
InMay2009,anelderlypatientinalong-termcarefacilitydiedafterbecomingwedgedbetweentheairmattressandthebedframe.Acoroner’sinvestigationrevealedthattheseairmattressesaresoldwithoutframes;theyareusedinconjunctionwithothermanufacturers’equipment.
Thecoroner’sinvestigationinvolvedanexaminationoftheequipmentbyanengineerwhodeterminedthattheseairmattressesshouldbeassessedforcompatibilitywithbedframesasgapsmaybepresentthatcouldposeentrapmentdangerstopatients,aswasthecaseintheMay2009death.
InMarch2010,theOCCissuedfiverecommendationsthatweredisseminatedtoanumberofstakeholdersforthepurposeofeducatingthemaboutthehazardsassociatedwiththeseairmattresses,inordertopreventsimilardeaths.Twofurtherdeathsinvolvingentrapmentbetweenbedrailsandinflatablemattressesresultedintheofficeissuingareminderin2011throughapublicsafetyalert,sothatbothprofessionalcaregiversandlovedoneswouldbeawareofthehazard.
Carbon Monoxide Alert
InMarch2009,theOCCissuedapublicsafetyalertremindingOntariansofthedangersassociatedwithcarbonmonoxide.Thealertwaspromptedbythefindingsofaninvestigationintothesuddendeathfromcarbonmonoxidepoisoningofan84-year-oldwomaninherhomeinSudbury.Thesourceofthecarbonmonoxidewasdeterminedtobethewoman’sfuel-burningboilersystem.
Carbonmonoxideisanodourless,colourlessgas,producedbytheincompleteburningofanyfuel,whichcancausedeathevenatlowconcentrations.Theboiler,muchlikemostfuel-burningappliances,waspassivelyvented,meaningitdrewairfrominsidethehouseanddischargedexhaustoutsidethroughachimney.
WiththeassistanceoftheTechnicalStandardsandSafetyAuthority(TSSA),theOCClearnedthattheownerhadrecentlyreplacedseveralwindowsandexteriordoorsinordertomakeherhomemoreenergyefficient.Further,itwasconfirmedthattherewerenomechanicaldefectsevidentintheboilersystem,andthatitwasoriginallyinstalledandventedaccordingtocodeandoperatingspecifications.Despitethis,theairflowhadreversed,causingcarbonmonoxidefumestoenterthehome.
Mostfuel-burningfurnaces,boilersandhotwaterheatersconsumelargequantitiesofairfrominsidethehouse,andexhaustittotheoutside.Thehousemustthereforebeadequatelyventedsothatthisaircanbereplaced,otherwisechimneyflowmayreverseandfumesmayenterthehome.Anyrenovationstoahomewhichmakeitmoreairtight,suchasnewdoorsorwindows,mayrequiretheadditionofventingtoensureadequateairflowtothefurnace,boiler,orhotwaterheater.
Office of the Chief Coroner Report 2009-201118
Office of the Chief Coroner Report 2009-2011
Choking Alert
InAugust2011,astheresultofthedeathofatoddlerduetochoking,theOCCissuedapublicsafetyalertremindingOntariansoftheimportanceofteachingchildrensafeeatinghabitsaswellasremindingthemofchokinghazards.
Whilemostpeoplearegenerallywellawareofthedangerthatobjectssuchasballoons,batteries,coinsandsmalltoyswithremovablepartsposetochildren,foodissometimesnotrecognizedasahazard.Youngerchildren,especiallythoseundertheageoffour,areparticularlyvulnerableastheyarestilldevelopingsafeeatinghabits,havesmallairways,havepoorchewingandswallowingandoftendon’tunderstandthedangersassociatedwithconsumingfood.
Thefollowingareexamplesofsomeofthefoodsthatshouldbeavoidedwhenchildrenarefouryearsofageandunder:
• Hotdogsandsausages• Grapes• Hardorrubberycandies• Rawcarrots,peasandcelery• Nuts• Seeds(watermelon,sunflower)• Popcorn,especiallywhentheremaybeunpoppedkernels• Fruitwithpits• Hardfruits(apples,pears)
Withchildrenundertheageoffour,foodsshouldbecutintosmallerpiecestominimizetheriskofanairwayobstruction.Foodssuchasgrapesandhotdogsareofparticularconcernsotheseshouldbecutlengthwiseintosmallerpieces.
Learningtoeatsafelyisalifeskill.Parentsandcaregiversofchildrenareremindedofthefollowingtipswhenteachingchildrentoeatsafely:
• Childrenshouldsitquietlywheneating-runningorjumpingmayincreasetheriskofairwayobstruction.• Teachchildrentotakesmallbitesandchewthoroughlybeforeswallowing.• Talkingandlaughingshouldalwaysbeavoidedwhenthereisfoodinachild’smouth.• Parentsandcaregiversareencouragedtotakeabasiccardiaclifesupportorlifesavingcourse.Coursesare
offeredbyorganizationssuchastheHeartandStrokeFoundation,theCanadianRedCross,theLifesavingSociety,andSt.JohnAmbulance.
Accidental Asphyxia – Food Bolus of Children 0 to 19 Years Old
AgeGroup 1999to20090to4YearsOld 16
5to9YearsOld 2
10to14YearsOld 2
15to19YearsOld 3
Total 23
Tolearnmoreaboutchokinghazardsandprevention,pleasevisitwww.kidshealth.orgorwww.safekidscanada.ca.
Office of the Chief Coroner Report 2009-201119
All-Terrain Vehicles Alert
Inthesummerof2011,a10-year-oldboywaskilledwhileridinganadultall-terrainvehicle(ATV)aloneinNorthernOntario,Inresponse,theOCCissuedapublicsafetyalertremindingOntariansofthedangersthesevehiclesposetochildrenundertheageof16.
AnumberofmedicalstudieshavefoundthatdriversandridersofATVs,particularlychildren,havehighratesofinjuryanddeathcomparedtootheroff-roadvehicletypes.Full-sizeATVsarelarge,heavy,andpowerfulmachinesthatrequirestrength,balance,dexterity,andjudgmentwhichchildrenhavenotyetdeveloped.Childrenareatriskofdrivingtoofastordrivingontounevenground,losingcontrolofthemachine,andbeingthrownfromthevehicleorcrushedinarollover.Theresultinggriefforthefamilyisunimaginable. Acoroner’sinquestin2005examinedthedeathofaseven-year-oldboywhodiedwhiledrivinganATV.Recom-mendationsatthattimeincludedmandatoryapprovedsafetytraining,increasedpubliceducationregardingthesafeoperationofATVs,andpermissiontodriveanATVonapprovedtrailsonlyfromage12-16.Therecommenda-tionsareequallyapplicabletoday.
AllATVdriversshouldcompletearidersafetycourseintheirareaorthroughtheCanadaSafetyCouncil,andparents,childrenandteensshouldbeawareoftheriskofinjuryordeathwhenridinganATV,especiallyintheabsenceofadultsupervision.
Thesearepreventabledeaths.TherecommendationfromtheOCCisthatchildrenundertheageof16shouldnotoperateATVsintendedforadults.
Office of the Chief Coroner Report 2009-201120
Office of the Chief Coroner Report 2009-2011
Awards
Ovations
TheOvationAwardishandedoutbytheMinistryofCommunitySafetyandCorrectionalServicesonanannualbasisinthecategoriesof:Innovation,OutstandingAchievement,Leadership,Partnerships&Greening.PastrecipientsincludethefollowingstaffmembersfromtheOfficeoftheChiefCoronerand/ortheOntarioForensicPathologyService:
• MarionMooreandKathySullivanoftheGuelphRegionalOfficereceivedanawardforOutstandingAchievementin2008.
• DorisHildebrandt:2010OvationAwardforOutstandingAchievementforherworkanddedicationtothePediatricDeathReviewCommitteeandrelatedresearchprojectswiththeHospitalforSickChildren.
• 2011ShowcaseOntarioAwardsofExcellence:Dr.DavidEden,Ann-CarolHargreaves,Dr.DirkHuyer,Dr.MichaelPickupandJeffArnold
2categories:Innovation–TelemedicineServiceExcellence–ComputerAidedDispatchSystemPilot
• Dr.BonitaPorter:VotedoneofCanada’sMostPowerfulWomenintheProfessionalCategorybytheWomen’sExecutiveNetworkin2008.Shereceiveda2008OvationawardintheLeadershipCategory
• Dr.WilliamLucas:MinistryPandemicPlan–2007OvationawardinthePartnershipCategory
Accolades
AwardedtouniformandcivilianmembersoftheOPPwhomakeoutstandingcontributionstotheorganization.
• ProjectResolveInitiative:2009AccoladeawardinthePartnershipCategory–TanyaHatton,KathyMcKague
andJeffArnold
Office of the Chief Coroner Report 2009-201121
Dr. Andrew McCallum, MD, FRCPCChief Coroner for Ontario
Dr. David Eden, MDRegional Supervising Coroner - Operations
Dr. Bonita Porter, B.Sc., Phm., M.Sc., MD, CCFPDeputy Chief Coroner - Inquests
Dr. Dan Cass, B.Sc, MD, FRCP(C)Regional Supervising Coroner – Toronto West Region
Senior Staff
Office of the Chief Coroner Report 2009-201122
Office of the Chief Coroner Report 2009-2011
Office of the Chief Coroner Report 2009-2011 Office of the Chief Coroner Report 2009-201123
Dr. Craig F. Muir MD, FRCSC, FACSRegional Supervising Coroner – North Region
Dr. James Edwards MDRegional Supervising Coroner – Central Region
Dr. Peter Clark MDRegional Supervising Coroner – East RegionPeterborough Office
Dr. Dirk Huyer MDRegional Supervising Coroner – Central RegionGuelph Office
Senior Staff
Dr. William Lucas MD, CCFPRegional Supervising Coroner – Central Region
Dr. Rick Mann MD, CCFP, FCFPRegional Supervising Coroner – West RegionLondon Office
Dr. Roger Skinner MD, CCFP(EM)Regional Supervising Coroner – East RegionKingston Office
Dr. Jack Stanborough MD, CCFP(EM), FCFPRegional Supervising Coroner – West RegionHamilton Office
Senior Staff
Office of the Chief Coroner Report 2009-201124
Dr. Michael B. Wilson MD, B.A.Sc., CCFP, FCFPRegional Supervising Coroner – North
Dr. A.E. Lauwers MD, CCFP, FCFP Deputy Chief Coroner – Investigations
Senior Staff
Office of the Chief Coroner Report 2009-2011 Office of the Chief Coroner Report 2009-201125
Contact
OfficeoftheChiefCoroner26GrenvilleStreetTorontoONM7A2G9Telephone:416-314-4000ortoll-free1-877-991-9959
Email:[email protected]