OCC Inquest - Glognoli 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Glognoli
Given Name(s): Massimiliano
Age: 35

Held at: Brampton, Ontario
From: June 13
To: June 15, 2016
By: Dr. S. Teper, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Massimiliano Glognoli
Date and time of death: November 3, 2014 at 16:08 hours
Place of death: Credit Valley Hospital, Mississauga
Cause of death: Multiple trauma
By what means: Accident

(Original signed by: Foreperson and Jurors)


The verdict was received on June 15, 2016
Coroner's name: Dr. S. Teper
(Original signed by coroner)


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


Inquest into the death of:

Massimiliano Glognoli


Jury Recommendations

To the Ministry of Labour:

  1. Subject to other budgetary requirements, increase the number of Health and Safety Inspectors employed by the ministry, allocating according to the number of new projects in a given area, rather than by postal code.
  2. Increase the minimum requirement in the OHSA for site inspections conducted by the site supervisor and/or health and safety representative from weekly to documented daily inspections.
  3. Institute mandatory entry-level training currently in development scheduled after April 2017; but highly recommend implementation to be expedited.
  4. Whenever there is a requirement to post OHSA requirements or regulations on site, include in the posting the scheduled fines for violations of those requirements or regulations.
  5. Recommend automatic fines should be applied to all issued orders and fine amount should reflect the severity of the infraction. Said collected fines, wherever possible, should be directed to training and development.

To the Ministry of Labour, contractors and subcontractors:

  1. A guardrail construction course and certification be implemented to ensure that all guardrails are up to code; and anyone working on constructing or manipulating guardrails provides evidence of certification.
  2. All relevant certifications must be valid and readily available on site for inspection.
  3. All temporary power connections should be checked and approved by the on-site health and safety representative to ensure all connections and cables are fastened and secured to prevent accidental disconnection from power source.