OCC Inquest - Brunt and Kendall 2017

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: Brunt, Adam and Snow, Kendall, Gary



Held at: 25 Morton Shulman Avenue, Toronto
From: May 9
To: May 25, 2017
By: Dr. William Lucas, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Brunt
Given name(s): Adam
Age: 30
Date and time of death: February 8, 2015
Place of death: Hanover and District Hospital, Hanover
Cause of death: Drowning
By what means: Accident

Surname: Kendall
Given name(s): Gary
Age: 51
Date and time of death: January 31, 2010
Place of death: Bluewater Health, Sarnia
Cause of death: Complications of cold water immersion
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 25 of May, 2017
Coroner's name: Dr. William Lucas
(Original signed by coroner)


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


Inquest into the deaths of:

Adam Brunt and Gary Kendall


Jury Recommendations

To the Province of Ontario, including the Ministry of Community Safety and Correctional Services, the Ministry of Advanced Education and Skills Development, the Ministry of Labour, and any other relevant Provincial Government Ministry or Agency:

  1. We encourage the Province of Ontario to consider placing in abeyance all training exercises for ice / cold water rescue in locations where any current is deemed to be "swift" (above one knot or such other level as may be deemed to constitute "swift" water) and thereby presents an increased level of risk. This should apply to both regulated and unregulated trainers, instructors and service providers.
  2. We encourage the Province of Ontario to consider keeping training for ice / cold water rescue training in "swift" water conditions in abeyance unless and until a committee of subject matter experts feels that the available equipment (personal protective equipment, as well as other equipment the committee deems necessary and appropriate), techniques, locations and standards are such that the training can be conducted in a manner that minimizes risk to a level deemed safe for training. We encourage the Province of Ontario to convene such a committee at intervals that are appropriate to review the issue and consider updates / changes to equipment, techniques, locations and standards.
  3. If at some point in the future a committee of subject matter experts should feel that available equipment (personal protective equipment, as well as any other equipment deemed necessary and appropriate), techniques and standards are such that ice / cold "swift" water rescue training can be conducted in a manner that minimizes safety risks to levels deemed safe for training, we encourage the Province of Ontario to consider designating the locations in the province where such training may take place. The locations should involve ice / cold “swift” water that presents the lowest risk while still providing value in training. We encourage random safety inspections by appropriately qualified individuals at the designated locations to ensure training exercises abide by the training standards.
  4. In the meantime, unless and until such time as a committee of subject matter experts determines that available equipment and techniques are such that ice / cold water rescue training can be conducted in "swift" water in a manner that minimizes safety risks, we encourage the Province of Ontario to create an approved training curriculum (including but not limited to content, design, delivery and evaluation), using National Fire Protection Association (NFPA) as the baseline standard, for separate courses relating to "swift" water rescue and ice / cold still water rescue. The program for each course should include skills that would be transferable to a real ice / cold "swift" water rescue situation. Appropriate people to develop such curricula might include (but not necessarily be limited to) staff from the Office of the Fire Marshal and Emergency Management (OFMEM), subject matter experts from the Ontario Professional Fire Fighters Association, Fire Fighters Association of Ontario, the Ontario Association of Fire Chiefs, and other experts on rescue techniques and safety, including Ontario Fire Service Section 21 advisory committee.
  5. If the Province of Ontario creates both "swift" water rescue and ice / cold still water rescue curricula, we encourage the province to take all necessary steps, including changes to legislation or regulations as required, to ensure that all trainers, instructors and service providers abide by the approved curriculum for each course, and that the courses take place only in appropriate or approved locations.
  6. In addition to Recommendations 4 and 5, we encourage the Province of Ontario to consider regulating the content, design, delivery and evaluation of the training provided, using NFPA as the baseline standards, for the various fire services roles within the scope of the definition of "fire protection services" in the Fire Protection and Prevention Act, 1997 to meet the minimum requirements set by the OFMEM. This would also include taking all necessary steps, including changes to legislation or regulations as required, to ensure that all trainers, instructors and service providers abide by the approved curriculum for each course.
  7. We encourage the Province of Ontario to consider creating a system whereby all trainers, instructors or providers of courses in "fire protection services", including ice / cold water rescue and "swift" water rescue (or any combination of those skills), are certified or otherwise deemed qualified to an appropriate standard. This includes instructors, trainers and providers in private services as well as government or regulated bodies.
  8. We encourage the Province of Ontario to create / maintain a list or data base of "fire protection services" courses which include approved trainers, instructors and service providers. This should be provided to each municipality to ensure that municipalities retain individuals or companies that have been properly certified and that are properly regulated. Information should include, but not be limited to safety records and records of complaints.
  9. We encourage the Province of Ontario to consider requiring a pre-training roles and responsibilities form that should include sign-off from each of the individual roles including, but not limited to, Lead Instructor, Incident Commander, Accountability Officer, Health and Safety Officer, and/or RIT Team, if necessary. This form should be completed prior to any training exercise related to "fire protection services".

To the Province of Ontario, including the Ministry of Municipal Affairs and Housing:

  1. We encourage the Province of Ontario to communicate with all municipal governments advising them to consider reviewing their "establishing and regulating by-laws" for firefighting services as they relate to ice / cold 'swift" water rescue services (if they have such conditions within their jurisdiction), and to consult with their local Fire Chief about the training that may be made available or mandated in relations to those services. The review and consultation should take into account the Recommendations arising from the inquest into the deaths of Gary Kendall and Adam Brunt.

To the Province of Ontario, including the Office of the Fire Marshal and Emergency Management:

  1. We encourage the OFMEM to communicate with all fire services in the Province of Ontario to suggest that they review their "establishing and regulating by-laws" regarding ice / cold "swift" water rescue (if they have such responsibilities), to consult with their municipality about the level of service to be provided and to review the training related to that service. The review and consultation should take into account the Recommendations of the inquest into the deaths of Gary Kendall and Adam Brunt.
  2. We encourage the Province of Ontario to develop and maintain statistical records relating to circumstances of water and ice rescue / recovery attempts from across the province, including any injuries or deaths which occur during training. The Province of Ontario, through the OFMEM or another designated entity, should collect this information from local fire departments on an annual basis, and make it available to the public free of charge.

To the Province of Ontario, including the Ministry of Labour, the Ministry of Advanced Education and Skills Development and any other relevant provincial Government Ministry or Agency:

  1. We encourage the Province of Ontario, with the OFMEM and the Ministry of Advanced Education and Skills Development (MAESD), engage with stakeholders to consider what Technical Rescuer Courses (NFPA 1006), if any, may be appropriate to be taught to pre-service students and firefighters at registered Private Career Colleges (PCC), Colleges of Applied Arts and Technology (CAAT) and other training entities reviewed and approved by the OFMEM.
  2. We encourage the Province of Ontario to ensure that individuals who are not workers will be protected in a manner similar to that of workers when taking single or multi-skill courses, including ice / cold water rescue or “swift” water rescue training (or any combination of those skills). This may be achieved through the Ministry of Labour, the MAESD and any other relevant Government Ministry or Agency working collaboratively to ensure health and safety is integrated into the curriculum for ice / cold water rescue and “swift” water rescue training (or any combination of those skills) provided at registered PCC, CAAT, and other OFMEM endorsed training facilities. Amendments to legislation and / or regulations should be considered, if necessary, to achieve the desired health and safety protection, and to ensure the same level of health and safety protection is required from privately run providers.

To all recipients of these Recommendations:

  1. We encourage all named recipients of the Recommendations arising from the inquest into the deaths of Gary Kendall and Adam Brunt to respond to the Office of the Chief Coroner to report on progress in considering and / or implementing these Recommendations over the next 3 years. Report dates requested would be no later than December 31 / 2017, June 30 / 2018, December 31 / 2018, June 30 / 2019, December 31 / 2019 and June 30 / 2020. Any recipient of a Recommendation that provides a final response to a particular Recommendation (final response meaning that it has been implemented, or will not be implemented, as opposed to it still being under consideration or review) need not send further reporting letters about that particular Recommendation to the Office of the Chief Coroner after the date of that final response, even if it is prior to June 30 / 2020.