office of the chief coroner report for 2009-2011 · message from the chief coroner. i am pleased to...

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



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.


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.


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.


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%



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


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.



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


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.



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.


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.



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.


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.



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.


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).



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.


*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.



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.


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.



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


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 2009-2011 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


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]

office of the chief coroner report for 2009-2011 · message from the chief coroner. i am pleased to...

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