Ministry of the
Solicitor General

OCC Inquest - Fall 2019

Office of the Chief CoronerVerdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Fall
Given name(s): Michael
Age: 47

Held at: 4 Wellington Street, St. Thomas, Ontario
From: Sept. 23, 2019
To: Sept. 27, 2019
By: Dr. Elizabeth Urbantke
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Michael Fall
Date and time of death:  July 30, 2017 at 11:13 p.m.
Place of death: Elgin Middlesex Detention Centre, 711 Exeter Road, London, Ontario
Cause of death: Fentanyl toxicity
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on September 27, 2019
Coroner's name: Dr. Elizabeth Urbantke
(Original signed by coroner)


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


Inquest into the death of:

Michael Fall


Jury Recommendations

To the Ministry of the Solicitor General:

  1. Implement an electronic health record system to:
    1. facilitate continuity of care through improved communications among professionals and enable safe clinical decision making
    2. improve the ability to monitor health status, including substance use disorders and outcomes over time
    3. enhance appropriate utilization of services, including health-related programs
    4. collect data for future resource program planning, research or education
    5. conduct quality of care reviews
    6. develop an alert and notification system to ensure compliance with provincial standards of care
    7. enhance communication with community health providers
  2. Review the current counselling services and therapy offered to correctional officers and nursing staff who witness a death at a detention or correctional centre and implement the necessary changes to ensure it is providing access to adequate counselling services.

To the Elgin Middlesex Detention Centre:

  1. Implement a Direct Observation model in all other units at Elgin Middlesex Detention Centre, as piloted in Unit #4.
  2. Reinforce the policy requiring correctional officers to conduct night shift rounds of living units at “staggered” or irregular intervals.
  3. Ensure that at the beginning of every shift, a Sergeant or other designated person informs correctional staff about inmates recently found in possession of contraband drugs or suspected to be under the influence of contraband drugs. This should be done by written log sheet or document and read and initialed by each correctional officer on that shift.
  4. Develop a local policy to ensure that a social worker, counsellor or other appropriate staff member speaks to inmates who have witnessed a death at the institution as soon as practical following the death. Such inmates shall be offered trauma-informed services and, when requested, efforts will be made to find an outside service provider.
  5. Discontinue the practice assigning correctional officers to living units on “rotating” schedules. Replace this with a “platoon” model in which correctional officers are assigned to living units in teams and for periods of no less than six months at a time.
  6. Increase the number of correctional officers on night shifts to ensure that at least one officer is present on each unit at all times.
  7. Implement a policy that nursing staff responding to an emergency must be equipped with a radio and portable first response kit.
  8. Ensure that clocks on security cameras and equipment for monitoring security rounds are synchronized.
  9. Correctional officers should be provided intranasal naloxone to carry on their person.