OCC Inquest - Benoit 2017
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given Name(s): Michael
Held at: 25 Morton Shulman Avenue, Toronto, ON
From: March 20th
To: March 27th, 2017
By: Dr. Roger Skinner, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Michael Benoit
Date and time of death: February 12, 2015 at 3:52 a.m.
Place of death: St. Joseph's Health Center (30 The Queensway, Toronto, ON)
Cause of death: Hanging
By what means: Suicide
(Original signed by: Foreperson)
The verdict was received on the 27 of March, 2017
Coroner's name: Dr. Roger Skinner
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
To the Ministry of Community Safety and Correctional Services (MCSCS):
- MCSCS should explore the feasibility of implementing an electronic health record system for all Correctional Institutions throughout the Province of Ontario.
- MCSCS should in future anchor point audits, consider the upper bunk mattress as a potential anchor point.
- MCSCS should reinforce through training the mandatory expectation regarding completion of all medical screening questions and the use of the comments section for documentation of other observations.
- MCSCS should encourage medical staff peforming admissions to enquire whether a delay in obtaining prescribed medications could adversely affect the inmate.