OCC Inquest - Benoit 2017

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Benoit
Given Name(s): Michael
Age: 45

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:

Michael Benoit


Jury Recommendations

To the Ministry of Community Safety and Correctional Services (MCSCS):

  1. MCSCS should explore the feasibility of implementing an electronic health record system for all Correctional Institutions throughout the Province of Ontario. 
  2. MCSCS should in future anchor point audits, consider the upper bunk mattress as a potential anchor point.
  3. 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.
  4. MCSCS should encourage medical staff peforming admissions to enquire whether a delay in obtaining prescribed medications could adversely affect the inmate.