OCC Inquest - Crawford 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Crawford
Given Name(s): Christopher
Age: 33

Held at: 5 Ray Lawson Blvd.
From: May 30
To: June 1, 2016
By: Dr. Monique Moreau, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Christopher Crawford
Date and time of death: January 13, 2014 at 12:45 p.m.
Place of death: 2255 Erin Mills Parkway, Mississauga
Cause of death: Crush asphyxia
By what means: Accident

(Original signed by: Foreperson and Jurors)


The verdict was received on June 1, 2016
Coroner's name: Dr. Monique Moreau
(Original signed by coroner)


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


Inquest into the death of:

Christopher Crawford


Jury Recommendations

  1. Refer to Building Association - There must be an assigned and documented representative from the Constructor (i.e. supervisor or assistant supervisor) on every construction site for site safety at all times when work is being performed.
  2. Refer to Building Association - Improved communication, both verbal and written, through prescheduled or as required meetings with impacted trades complete with documented minutes distributed to interested parties in the most timely and efficient manner ie: electronic communications.
  3. Refer to Building Association - The improved use of CCTV cameras. This would be another tool to assist the construction supervisor in monitoring the ongoing construction activities on the worksite, and provide security benefits.
  4. Refer to Building Association - The Constructor must re-enforce in a non-intimidating manner the empowerment to stop work by every onsite worker for the safety of themselves, other workers or the public. Work stoppage can be done in person or by a posted onsite phone number at the discretion of the worker.
  5. Refer to Building Association - The “TIPS” hotline for the Ministry of Labour must be posted and available to all workers and the public to report anonymously any worksite safety concerns. The phone number must be toll free.
  6. Refer to Building Association and/or Ministry of Labour - The need for a third party safety compliance officer, or independent inspection, that provides unbiased reporting on safety infractions based on the Ministry of Labour Occupational Health and Safety Act, through unscheduled spot checks at a minimum of weekly inspections.
  7. Refer to Building Association - The use of work wear with the unique company logo that is easily identifiable from a reasonable distance, ie: hardhat or safety vest, to better differentiate trades on the worksite.
  8. Refer to Building Association - All deliveries, to include but not limited to equipment and materials and any new trades must check in at the construction office each new visit prior to entering the construction site.
  9. Refer to Professional Engineers Association - The construction practice for the use of shims at the base of any structural column must be changed to reflect one shim pack per anchor bolt per column base as an industry standard.
  10. Refer to Professional Engineers Association - Consideration must be given to the additional use of cross bracing or temporary cabling to provide additional support as required during the construction process.