Ministry of the
Solicitor General

OCC Inquest - 911 Deaths 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: Matthew Robert Humeniuk, Michael Isaac Kritz, Stephanie Joelle Bertrand, Kathryn Missen
Held at: Sudbury and Ottawa
From: Oct. 15, 2018
To: Nov. 1, 2018
By: Dr. David Cameron, Coroner for Ontario
having been duly sworn/affiremed, have inquired into and determined the following:

Surname: Humeniuk
Given name(s): Matthew Robert
Age: 33
Date and time of death: June 30th, 2013
Place of death: Red Rock Point, Sudbury, Ontario
Cause of death: Blunt force head injuries
By what means: Accident

Surname: Kritz
Given name(s): Michael Isaac
Age: 34
Date and time of death: June 30th, 2013
Place of death: Red Rock Point, Sudbury, Ontario
Cause of death: Effects of fire
By what means: Accident

Surname: Bertrand
Given name(s): Stephanie Joelle  
Age: 25
Date and time of death: July 8h, 2013
Place of death: Health Sciences North, Sudbury, Ontario
Cause of death: Head injury
By what means: Accident

Surname: Missen
Given name(s): Kathryn
Age: 54
Date and time of death: September 3rd, 2014
Place of death: 689 Montcalm Street, Casselman, Ontario
Cause of death: Acute bronchial asthma
By what means: Natural causes

(original signed by Foreman and Jurors)


This verdict was received on Nov. 1, 2018
Coroner’s Name: Dr. David Cameron
(original signed by Coroner)


We, the jury, wish to make the following recommendations:


Inquest into the deaths of:

Matthew Robert Humeniuk, Michael Isaac Kritz, Stephanie Joelle Bertrand, Kathryn Missen


Jury Recommendations

To the Government of Ontario

Ontario should:
  1. Put in place an independent body to provide oversight to all 911 operations, keeping in mind regional differences and service levels, and its mandate should include, but not limited to:
  1. investigating, responding to, and resolving complaints
  2. conducting audits
  3. collecting data and conducting research
  4. conducting systemic reviews
  5. issuing an annual report, which should be publicly accessible and should include the meeting dates, times and agenda for each meeting held.
  1. Ensure timely access by families to all pertinent and comprehensive information related to deaths where 911 services are involved.
  2. Develop and conduct a public awareness campaign on the purpose of the 911 service, including alternative numbers for reaching police in non-emergency situations.
  3. Investigate methods to deter inappropriate and accidental (e.g. pocket dialing) use of the 911 service.
  4. Ensure that conclusions and recommendations of internal reviews conducted in relation to deaths where 911 services are involved are made public to ensure transparency, accountability, and accuracy.
  5. Ensure that private and public 911 communication centers, Police, Emergency Medical Services (EMS, Fire (career and volunteer), (collectively to be called “Emergency Services”), operate on the same or compatible computer aided dispatch (CAD) system by December 2023 to allow for immediate sharing of critical information among Emergency Services.
  6. Require that Ontario and all municipalities insure that their CAD systems have the capacity to:
  1. Utilize the re-bid feature to request caller location information;
  2. Allow operators to emphasize critical information; and
  3. Escalate alerts the greater the delay in dispatching the call (e.g. additional audible or visible alerts at five, ten, fifteen minutes).
  1. Require the Ministry of Health and Long Term Care, EMS, Police and Fire to establish an interoperable radio channel that would be available to all Emergency Services during a multi-agency response.
  2. Require that Ontario and all municipalities ensure that 911 services within their jurisdictions are appropriately staffed, including ensuring that supervisors of 911 call takers and dispatchers can focus on their supervisory duties without being diverted by routine call taking or dispatching duties.
  3. Require that supervisors of 911 call takers and dispatchers are trained on the equipment and software used by the personnel they are supervising.
  4. Require that Ontario and all municipalities provide appropriate supports for 911 call takers, dispatchers and supervisors, including supports for mental health and post-traumatic stress disorder.
  5. Require that Ontario and all municipalities identify appropriate emergency resources when dealing with a water rescue, including available police or fire boats, launch points, and personnel. This information should be available to all 911 call takers, dispatchers and supervisors through the CAD system.
  6. Require that Ontario and all municipalities ensure that 911 services within their jurisdictions establish a formal policy, accompanied by comprehensive training, to:
    1. permit callers who are unable to verbally communicate their needs to communicate through other means (e.g. silent 911 call procedure);
    2. permit front line Emergency Service responders to communicate directly with a caller where appropriate
    3. govern when a medical tiered response is engaged, including simultaneous notification
    4. ensure appropriate organizational accountability when there are unnecessary delays in dispatching 911 calls
    5. require 911 call takers and dispatchers to engage their supervisors prior to making decisions beyond their normal training (e.g. instructing a caller to light a signal fire)
    6. ensure that supervisors for Emergency Services have the capacity to communicate directly with each other
    7. ensure that front line Emergency Service responders have the capacity to communicate directly with other responders and dispatchers
    8. permit all 911 call takers, dispatchers and supervisors to request and receive updated location information from cellular providers
    9. identify and acknowledge critical information during radio communications (e.g. “Pan Pan Pan” and “Roger”)
    10. conduct an internal review where 911 services are involved in a death and concerns have been identified by family or staff, which must include consultations with staff during and following the review
    11. address whether and when the Bell Surveillance and Maintenance Centre is referred to in CAD and the implications of its inclusion
    12. conduct a debriefing with appropriate staff following a major 911 incident.
  7. Require that Ontario and all municipalities ensure that bi-directional real-time CAD data, and other data (such as maps), are available to police, fire and EMS first responders on mobile data terminals.
  8. Require that Ontario and all municipalities install a minimum of three direct telephone lines between and among 911 communications centres (the precise number of lines to be decided based on call volumes and other relevant factors).
  9. Work with Bell Canada to increase the number of participants that can be on the same emergency call above the current limit of three.
  10. Ensure active supervisors or designates of 911 call takers and dispatchers have the capacity to monitor CAD information at all times.
  11. Report to the Office of the Chief Coroner by no later than December 1, 2019, and annually for five years, in an open letter, regarding the progress made with respect to these recommendations.
  12. Investigate measures (including equipment and facilities) to assist 911 call takers, dispatchers and supervisors to effectively and comprehensively listen to information being communicated from callers and colleagues (e.g. when callers are hard to hear or understand).

To All Municipalities in Ontario that provide 911 services

All Municipalities that provide for 911 services in Ontario should:
  1. Take their own steps to enact any and all recommendations that apply to municipalities by December 2021, whether or not Ontario requires them to do so.
  2. Review current staffing formulas.
  3. Add clerical help to call centers.
  4. Review the suitability of 12-hour shift schedules.
  5. Use local resources (e.g. volunteer fire) to address response time delays.
  6. Install clearly marked signage to direct responders to local/rural volunteer fire stations;
  7. Ensure sufficient lighting (through permanent or portable means as appropriate) at launch points (e.g. docks, trail heads) to prevent delays to responders when leaving the launch point.
  8. Identify a mechanism to urgently engage a dispatcher on a call of a critical or uncertain nature (e.g. “hotshot”).