Ministry of the
Solicitor General

OCC Inquest - Cerqueira 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Cerqueira
Given name(s): William Ribeiro
Age: 41

Held at: Toronto
From: Nov. 21, 2018
To: Nov. 29, 2018
By: Dr. Steven Bodley
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: William Ribeiro Cerqueira
Date and time of death: April 3, 2015
Place of death: 100 Adelaide Street West, Toronto
Cause of death: Blunt Force Trauma of the Torso
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on Nov. 29, 2018
Coroner's name: Dr. Steven Bodley
(Original signed by coroner)


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


Inquest into the death of:

William Ribeiro Cerqueira


Jury Recommendations

To the Ministry of Labour, Office of the Chief Prevention Officer:

  1. Consider conducting an awareness campaign with respect to fall hazards associated with working at heights, every two years, with an educational blitz in multiple languages focused around the National Day of Mourning.
  2. Consider whether any such awareness campaign should include elements such as mandatory training, the internal responsibility system, statistics and testimonials around fall-related deaths and injury, the importance of communication regarding safety issues among all participants: workers, supervisors, employers and constructors, and provide the opportunity for family members to participate as key stakeholders who have been directly impacted by fall-related deaths and injuries.
  3. Consider mandatory health and safety training for supervisors (as defined by the Occupational Health and Safety Act) every two years.
  4. Consider requiring employers to send any identified unofficial supervisors, which would include anyone that has authority over other workers, to mandatory training (including Basic Supervisor Awareness and Working at Heights) or face actions by the Ministry of Labour.
  5. Consider conducting a cross-jurisdictional (e.g. across Canada, the United States, global) best practices review of similar industries (e.g. firefighting) involving working at heights training.
  6. Consider whether this review of working at heights training should include:
  1. The use of visual, physical, oral and auditory (e.g. call and response) checks when fall protection devices are being used;
  2. Addressing the dangers of complacency while working at heights;
  3. Meaningful statistics and video testimonials around fall-related deaths and injuries in Ontario;
  4. Developing annual key performance indicators related to fall protection.
  1. Consider review of the efficacy of training around the Internal Responsibility System with a view to improving elements as it relates to workers not only keeping the workplace safe and healthy, but keeping each other safe and healthy.
  2. Consider requiring mandatory interactive demonstration on-site as a part of toolbox talks covering the proper wearing and storing of fall protection equipment, and choosing of anchor points.
  3. Consider developing requirements within the Occupational Health and Safety Act for the proper storage of fall protection devices on construction sites.

To the Labourer’s International Union of North America (LiUNA):

  1. Consider the provision of grief counseling to workers in the event of workplace death incidents.

To  Hardrock Forming Company Ltd:

  1. As unforeseen hazards are identified by workers and supervisors, consider continually updating the Job Hazards Analysis to formalize the appropriate safety controls and informing the work crews of these new changes in the pre-job safety instructions (PSI) and toolbox talks.