OCC Inquest - Garry 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Garry
Given Name(s): Shane
Age: 46

Held at: 25 Morton Shulman Avenue, Toronto, Ontario
From: May 24
To: May 30, 2016
By: Dr. Bonnie Burke, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Shane Garry
Date and time of death: February 7, 2014 at 9:04 p.m.
Place of death: Toronto East Detention Centre, 55 Civic Road, Toronto, Ontario
Cause of death: Nuchal hanging
By what means: Suicide

(Original signed by: Foreperson and Jurors)


The verdict was received on May 30, 2016
Coroner's name: Dr. Bonnie Burke
(Original signed by coroner)


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


Inquest into the death of:

Shane Garry


Jury Recommendations

  1. The Ministry of Community Safety and Correctional Services (MCSCS) shall reinforce to all correctional staff at the Toronto East Detention Centre the mandatory procedures in Standing Order 5.5.5, or its current equivalent, specifically:
    5.5.5 Any staff having information that an inmate has the potential to be suicidal shall, as soon as possible, verbally advise the charge nurse and the Operational Manager. The inmate shall be escorted to the Health Care Unit for assessment without delay and shall remain under constant supervision until health care staff sees him. An Occurrence Report shall be submitted to the Operational Manager who will then complete a "Compatibility" form. A copy of that Occurrence Report shall be forwarded to the Health Care Unit for inclusion on the inmate's Health Care Record.
  2. MCSCS shall adopt and implement the use of an Electronic Medical Record system in the healthcare unit at the Toronto East Detention Centre.
  3. MCSCS shall include the next court date of inmates as a requirement in the development of an Electronic Medical Record system.
  4. MCSCS shall, in the interim, while an Electronic Medical Record system is being implemented, adopt the use of a comprehensive Cumulative Patient Profile and discontinue the use of the Health Conditions List.
  5. MCSCS shall disseminate all recommendations from this inquest, and all relevant prior inquests, relating to inmate deaths at the Toronto East Detention Centre, to all correctional and healthcare staff at the Toronto East Detention Centre.
  6. MCSCS shall ensure that all staff receive their ongoing and regularly scheduled education/training on suicide awareness at the Toronto East Detention Centre.
  7. MCSCS shall reinforce that Occurrence Reports indicating suicide risks are discussed at the daily morning department head meeting in the Toronto East Detention Centre.