Ministry of the
Solicitor General

OCC Inquest - Hanjra 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Hanjra
Given name(s): Saifullah
Age: 40

Held at: Brampton
From: May 14, 2019
To: May 16, 2019
By: Dr. Robert Boyko
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Saifullah Hanjra
Date and time of death:  December 25, 2015 at 11:20 a.m.
Place of death: Trillium Health Partners, Mississauga Hospital - 100 Queensway West, Mississauga
Cause of death: Traumatic brain injury, due to fall from ladder
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on May 16, 2019
Coroner's name: Dr. Robert Boyko
(Original signed by coroner)


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


Inquest into the death of:

Saifullah​ Hanjra


Jury Recommendations

To the Ministry of Labour:

  1. Be it recommended that, the provincially mandated Working At Heights training be expanded to include training on working at elevations less than three metres, including, but not limited to, mandatory training for the safe use of ladders (including, but not limited to, principles of three-point contact and other balance-related considerations). Alternatively or concurrently, be it recommended that, a separate, ladder-specific training, be devised and implemented.
  2. Be it recommended that, as part of the aforementioned training, Regulation (213/91) be amended such that employees shall be prohibited from ascending and descending ladders with materials, tools, and so on, in their hand(s).
  3. Be it recommended that Regulation (213/91) be amended such that an employee ascending, working on or descending a ladder have at least one other employee with a direct line of sight to their work and within a reasonable distance, such that they may render assistance, if required.
  4. Be it recommended that Regulation (213/91) be amended such that a Risk Assessment, be completed for each individual applicable task, before the commencement of work on said task. The Risk Assessment shall be completed jointly by the employee(s) completing said task and their supervisor – and signed by both.
  5. Be it recommended that, a standard for the frequency and intensity of proactive site/workplace inspections be established, to further promote and educate regarding health and safety.

To the Infrastructure Health and Safety Association (IHSA):

  1. Be it recommended that the IHSA devise a Risk Assessment Template form, encompassing as full a spectrum as possible of workplace tasks that could potentially put an employee at increased risk, while being efficient enough such that employees and supervisors are not unreasonably burdened.
  2. Be it recommended that the IHSA increase the offline and online content available for employees and supervisors with regards to safe workplace operations, including using ladders.

To Nekison Engineering and Bondfield Construction:

  1. Be it recommended that each and every employee orientation include a review of the company’s Ladder Guidelines, along with any current and future ladder-related legislation.
  2. Be it recommended that all employees and supervisors are provided, at the time of their orientation to a jobsite, with a health and safety package from the employer(s), as well as any other applicable contractor(s) (for example, a primary contractor), containing all applicable documents for the jobsite in question.