OCC Inquest - Dunn 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Dunn
Given Name(s): Joseph Charles "Todd"
Age: 43

Held at: Toronto, Ontario
From: May 2
To: May 5, 2016
By: Dr. David Eden, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Joseph Charles "Todd" Dunn
Date and time of death: September 27, 2014 at 5:40 p.m.
Place of death: Greater Niagara General Hospital, Niagara Falls, Ontario
Cause of death: Anoxic brain injury due to hanging
By what means: Suicide

(Original signed by: Foreperson and Jurors)


The verdict was received on May 5, 2016
Coroner's name: Dr. David Eden
(Original signed by coroner)


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


Inquest into the death of:

Joseph Charles "Todd" Dunn

Jury Recommendations

To the Ministry of Community Safety and Corrections and Canadian Border Services Agency:

  1. To continue to ensure that appropriate medical information is consistently shared in a timely manner upon the admission of detainees into custody.
  2. Both the Canada Border Services Agency and the Ministry of Community Safety and Correctional Services should collaboratively continue to ensure that, when any new information comes to light or a change in risk occurs which is potentially relevant to the risk of suicide of a detainee, that information is promptly shared between the Canada Border Services Agency and the Ministry of Community Safety and Correctional Services in a consistent and clearly defined manner.

To Immigration and Refugee Board of Canada:

  1. That the Immigration and Refugee Review Board have an independent and objective representative to meet with the detainee following the hearing to ensure his/her comprehension of the findings, if not represented by counsel.
  2. To ensure an independent representative complete a formal assessment of the stress level  and suicide risk of the detainee and to immediately communicate that assessment to the relevant care givers.