OCC Inquest - George 2015

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: George
Given Name(s): Alex John Boniface
Age: 33

Held at: Wikwemikong, Ontario
From: June 1
To: June 2, 2015
By: Dr. Shelagh McRae, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Alex John Boniface George
Date and time of death: September 14, 2013 at 2:20 p.m.
Place of death: Wikwemikong Unceded Indian Reserve No. 26
Cause of death: Mechanical asphyxia from being buried in a trench collapse
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 2 of June, 2015
Coroner's name: Dr. Shelagh McRae
(Original signed by coroner)


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


Inquest into the death of:

Alex John Boniface George


Jury Recommendations

  1. To the Wikwemikong Band Council it is recommended that in the interest of worker’s safety in the Wikwemikong Unceded Indian reserve N0. 26 that they shall implement an occupational health and safety policy within the Wikwemikong Gchi-Naaknigewin of June 2014.
  2. The Housing Director of the Wikwemikong Band Council regularly enters into contracts concerning construction projects within the boundaries of Wikwemikong Unceded Indian Reserve No.26. We recommend that the Band consider implementing a policy that all construction contracts include a term or clause that specifically requires the contractor to confirm workers shall be provided the necessary safety training and equipment for the specific nature of the work to be done.
  3. We recommend to the Wikwemikong Band Council that when considering what safety training and equipment is necessary for a contractor to provide to workers, the Housing Director for Wikwemikong should consider that the contractor use both national and provincial safety legislation and regulations, which apply to the construction project.
  4. To the Wikwemikong Band Council and Housing Director it is recommended that they will ensure that appropriate safety equipment, that has been inspected on a regular basis and meets CSA standards, for each construction job has been provided by the contractors. For example: cages or physical barricades within trenches, shoring materials, ladders, shovels, external barricades and first aid.
  5. We recommend with the approval of the Wikwemikong Band Council that Provincial safety legislation requires that construction projects of a certain size, value or type be reported to or registered with the provincial Ministry of Labour. Such reporting means that the project may become the subject of a safety inspection by Ministry officials. We recommend that Wikwemikong Band Council consider allowing such inspections on occasion, as the knowledge, training and experience of Ministry inspectors may help promote and ensure safer workplace.
  6. To the Wikwemikong Band Council and Housing Director it is recommended that all construction projects have a Construction Supervisor on site for the safety of all workers.
  7. To the Wikwemikong Band Council it is recommended that they collaborate with the Ministry of Labour to ensure that all employees are fully trained in the safety of trenching and all construction practices.
  8. We recommend to the Housing Director and Wikwemikong Band Council that construction contracts be revised and updated to reflect current safety standards, and that contractors sign an oath of worker health and safety.
  9. It is recommended that site plans be accessible to an on site supervisor and that metal stakes be securely located to mark underground pipes such as water and sewer.
  10. It is recommended to the Wikwemikong Band Council with the collaboration of the Ministry of Labour that training be provided to a band member(s) on the Ontario Occupational Health and Safety Standards and that this person enforce safety guidelines and that on-going training be enacted.
  11. If the Wikwemikong Band Council and the provincial Ministry of Labour are able to negotiate a protocol that allows inspection of construction projects on Wikwemikong Unceded Reserve No.26, we recommend that the protocol also include the understanding as to what will happen if concerns for worker safety are identified, and the Wikwemikong band member trained by the Ministry of Labour will be responsible for follow up or further inspection to ensure that the issue is corrected to improve worker safety.
  12. We recommend that all first response vehicles be equipped with additional safety equipment such as a shovel, collapsible ladder and ropes.