OCC Inquest - Chatelain 2018
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given name(s): Richard
Held at: Napanee
From: Nov. 21, 2018
To: Nov. 21, 2018
By: Dr. Geoffrey Bond
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Richard Chatelain
Date and time of death: May 14, 2015 at 8:27 a.m.
Place of death: Bath Institution Regional Treatment Centre
Cause of death: Undetermined
By what means: Undetermined
(Original signed by: Foreperson)
The verdict was received on Nov. 21, 2018
Coroner's name: Dr. Geoffrey Bond
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
- All Regional Treatment Centre personnel interacting with inmates should have training to observe and document indicators of changing mental and physical conditions.
- A daily documentation of active medical problems will allow staff to fully assess their management and implications.
- Each Regional Treatment Centre inmate case with a complex medical history should have a review by a multi-disciplinary medical panel on a periodic basis. This will ensure comprehensive and proactive ongoing treatment rather than only a reactive response to specific concerns and complaints.