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Inquest Overview

Inquest: 20643, 2007-2009

Means of Death: Suicide

Recommendation Search Results Abstract

Click the magnifying glass icon below to view Inquest Recommendation Details and Responses.

Open 1. Completion of Admission Checklist should be as follows: a) Computerized admission checklist template to be completed by the A & D Officer. b) All fields must be completed before the form can be accepted into the system. c) Once accepted, a Read More...

Open 2. When a new alert has been posted the issuing institution must immediately contact the Operational Manager at the institution where the inmate or resident is being housed. All alerts placed on OTIS or a Youth OTIS will be displayed by a "pop-up" Read More...

Open 3. Commencing immediately all correctional staff (including medical staff and [Redacted]) are to be provided a fixed period of time per month to review ministerial policies, standing orders and any new changes or updates. Such time is to be considered Read More...

Open 4. The [Redacted] program be expended to every youth and adult correctional facility where the aboriginal population exceeds an annual average of 30% in that institution.

Open 5. When an inmate has been identified as a potential suicide risk, but has not been placed on suicide watch, health care staff should be required to attach memos to the face sheet alerting the staff to the potential risk and advise them to monitor the Read More...

Open 6. Within one year of today's date, in consultation with the Office of the Child and Family Service Advocacy, and subsequently the Provincial Advocate of Children and Youth, create provincial standards and policies for the transfer of youth pursuant to Read More...

Open 7. Within one year of today's date, following consultation with the Office of Child and Family Service Advocacy, and subsequently the Provincial Advocate for Children and Youth, create a protocol by which information is shared between an adult facility Read More...

Open 8. Within one year of today's date the Office of Child and Family Service Advocacy and subsequently the Provincial Advocate for Children and Youth should create a Deputy Advocate whose office and staff are located in [Redacted] Ontario.

Open 9. Every attempt should be made to ensure that all offenders, in particular those of Aboriginal descent, be placed in custody facilities in their home communities or as close to them as possible.

Open 10. Transfer of Young Offenders from youth facilities to adult facilities: a) Once an application for transfer to an adult facility has been requested the resident's Case Management Team should be contacted and involved in the initial process and the Read More...

Open 11. Secure Isolation a) Secure isolation should only be used for crisis management in cases where an individual is at imminent risk to cause themselves or another person serious bodily harm, or imminent risk to cause serious property damage. b) Read More...

Open 12. Due to the significant increase of residents suffering from serious mental illness, within 6 months of today's date the Ministry of Children and Youth Services shall provide additional funding to the Youth Correctional Facilities for the intense Read More...

Open 13. Within 6 months of today's date a policy should be created ensuring that shift briefings are conducted in such a manner that the inmates are supervised at all times (i.e. "shift-overlap').

Open 14. Within 6 months as of today's date the Ministry of Community Safety and Correctional Services shall provide additional funding to all [Redacted] Ontario maximum security district jails for the hiring of additional Correctional Officers in order to Read More...

Open 15. Within 12 months of today's date the upper bunks and cell doors in segregated areas should be redesigned for prevention of suicide by hanging (i.e. removal of crossbar on top bunk; solid plate on upper portion of cell door).

Open 16. Within 3 months of today's date the Ministry of Children and Youth Services should develop a policy directed to its managerial staff regarding young offenders who are subsequently charged as an adult while still a young offender sentence. This policy Read More...

Open 1. Completion of Admission Checklist should be as follows: a) Computerized admission checklist template to be completed by the A & D Officer. b) All fields must be completed before the form can be accepted into the system. c) Once accepted, a Read More...

Open 2. When a new alert has been posted the issuing institution must immediately contact the Operational Manager at the institution where the inmate or resident is being housed. All alerts placed on OTIS or a Youth OTIS will be displayed by a "pop-up" Read More...

Open 3. Commencing immediately all correctional staff (including medical staff and [Redacted]) are to be provided a fixed period of time per month to review ministerial policies, standing orders and any new changes or updates. Such time is to be considered Read More...

Open 4. The [Redacted] program be expended to every youth and adult correctional facility where the aboriginal population exceeds an annual average of 30% in that institution.

Open 5. When an inmate has been identified as a potential suicide risk, but has not been placed on suicide watch, health care staff should be required to attach memos to the face sheet alerting the staff to the potential risk and advise them to monitor the Read More...

Open 6. Within one year of today's date, in consultation with the Office of the Child and Family Service Advocacy, and subsequently the Provincial Advocate of Children and Youth, create provincial standards and policies for the transfer of youth pursuant to Read More...

Open 7. Within one year of today's date, following consultation with the Office of Child and Family Service Advocacy, and subsequently the Provincial Advocate for Children and Youth, create a protocol by which information is shared between an adult facility Read More...

Open 8. Within one year of today's date the Office of Child and Family Service Advocacy and subsequently the Provincial Advocate for Children and Youth should create a Deputy Advocate whose office and staff are located in [Redacted] Ontario.

Open 9. Every attempt should be made to ensure that all offenders, in particular those of Aboriginal descent, be placed in custody facilities in their home communities or as close to them as possible.

Open 10. Transfer of Young Offenders from youth facilities to adult facilities: a) Once an application for transfer to an adult facility has been requested the resident's Case Management Team should be contacted and involved in the initial process and the Read More...

Open 11. Secure Isolation a) Secure isolation should only be used for crisis management in cases where an individual is at imminent risk to cause themselves or another person serious bodily harm, or imminent risk to cause serious property damage. b) Read More...

Open 12. Due to the significant increase of residents suffering from serious mental illness, within 6 months of today's date the Ministry of Children and Youth Services shall provide additional funding to the Youth Correctional Facilities for the intense Read More...

Open 13. Within 6 months of today's date a policy should be created ensuring that shift briefings are conducted in such a manner that the inmates are supervised at all times (i.e. "shift-overlap').

Open 14. Within 6 months as of today's date the Ministry of Community Safety and Correctional Services shall provide additional funding to all [Redacted] Ontario maximum security district jails for the hiring of additional Correctional Officers in order to Read More...

Open 15. Within 12 months of today's date the upper bunks and cell doors in segregated areas should be redesigned for prevention of suicide by hanging (i.e. removal of crossbar on top bunk; solid plate on upper portion of cell door).

Open 16. Within 3 months of today's date the Ministry of Children and Youth Services should develop a policy directed to its managerial staff regarding young offenders who are subsequently charged as an adult while still a young offender sentence. This policy Read More...


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