OCC Inquest - Badakhshan 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Badakhshan
Given Name(s): Farshad
Age: 31

Held at: Toronto
From: January 27
To: February 2, 2016
By: Dr. Robert Boyko, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Farshad Badakhshan
Date and time of death: May 22, 2014 at 23:55 hours
Place of death: 111 Disco Rd., Toronto, Ontario (Toronto West Detention Centre)
Cause of death: Hanging
By what means: Suicide

(Original signed by: Foreperson and Jurors)


The verdict was received on the 2nd of February, 2016
Coroner's name: Dr. Robert Boyko
(Original signed by coroner)


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


Inquest into the death of:

Farshad Badakhshan


Jury Recommendations

To: The Ministry of Community Safety and Correctional Services

  1. Implement a consistent use of alert codes as appears on the Offender Tracking Information System (OTIS) Unit Notification Cards across other inmate documentation such as, bed-board and log books.
  2. When an inmate asks to see a physician, details for the reason for the request shall be documented to allow for appropriate triage.
  3. That all correctional officers, regardless of part-time or full-time status, receive mandatory yearly re-certification/training in the area of suicide prevention.
  4. Consider implementing an additional staggered schedule for staff members during peak activity periods within the Special Needs Special Handling Unit.
  5. Consider implementing mandatory psychiatrist clearance before transfer from enhanced suicide watch status.