OCC Inquest - Cole 2015

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Cole
Given Name(s): Shawn Dwight
Age: 34

Held at: 25 Morton Shulman Avenue, Toronto, Ontario
From: March 23
To: April 2, 2015
By: Dr. Bonnie Burke, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Shawn Dwight Cole
Date and time of death: December 26, 2012 at 9:55 a.m.
Place of death: Toronto East Detention Centre at 55 Civic Road in Toronto, Ontario
Cause of death: Sudden unexpected death in epilepsy
By what means: Natural

(Original signed by: Foreperson)


The verdict was received on the 2 of April, 2015
Coroner's name: Dr. Bonnie Burke
(Original signed by coroner)


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


Inquest into the death of:

Shawn Dwight Cole


Jury Recommendations

To the Ministry of Community Safety and Correctional Services:

  1. To adopt and implement the use of Electronic Medical Records (EMR) in the healthcare units of detention centres across the Province of Ontario.
  2. To adopt the use of a comprehensive Cumulative Patient Profile (CPP) form acceptable to the College of Physicians and Surgeons of Ontario (CPSO). Current policy should be changed to replace the requirement to use the Health Condition List with the CPP form.
  3. To provide physicians in detention centres across the province with computer and internet access within healthcare units as soon as is practicable. The Ministry should consult with physicians about which technological tools meet both security and healthcare requirements.
  4. To train all full-time nursing staff on how to input healthcare alerts for inmates into the Offender Tracking Information System (OTIS). This training should communicate the importance of having up-to-date and complete healthcare alerts in OTIS to ensure the continuity of care within and between institutions.
  5. To undertake a review of the 'Unit Identification Card' to consider the inclusion of a separate and distinct 'Health Care Alerts' section, in which an inmate's healthcare related OTIS entries are highlighted for review by correctional officers. The Ministry should consider having a policy whereby 'Unit Identification Cards' containing a 'Health Care Alert' are reviewed by correctional officers in each unit at the start of each shift. Handwritten health-related updates to the 'Unit Identification Card' should be entered in OTIS at the first opportunity.
  6. To adopt a new policy requiring inmates with a known seizure disorder to be housed with a cellmate subject to security concerns.
  7. To undertake a review of current policies and procedures for obtaining inmate consent for the sharing of medical information between detention centres and other healthcare institutions. This should include discussion with the Ministry of Health regarding the timely and appropriate sharing of patient information between institutions.
  8. To consider the feasibility and frequency of education/training sessions on seizure disorders for both medical and correctional staff. This could include the involvement of volunteer organizations such as 'SUDEP Aware'.
  9. To consider a study on current and emerging chronic diseases among the inmate population in Ontario, in order to proactively direct future healthcare initiatives and policy around inmate care.
  10. To ensure the temperature in negative pressure cells meets current standards for housing inmates.
  11. To disseminate the jury recommendations from the Inquest to all nurses and physicians involved in providing healthcare to inmates in all detention centres operated by the ministry.