OCC Inquest - Harrison, Towie, Twiddy and Dunsmuir

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: Holly Harrison, Mari-Lee Towie, Benjamin Twiddy, Kevin Dunsmuir, Jennifer Dunsmuir, Robert Dunsmuir, Cameron Dunsmuir
Held at: Toronto, ON
From the: 29th of March, 2015
To the: 29th of April, 2016
By: Dr. David Evans, Coroner for Ontario
having been duly sworn/affiremed, have inquired into and determined the following:

Surname: Harrison
Given name(s): Holly
Age: 18
Date and time of death: April 29th 2012 at 2:08 a.m.
Place of death: Lakeridge Health Centre, 1 Hospital Court, Oshawa Ontario
Cause of death: Smoke inhalation
By what means: Accident

Surname: Towie
Given name(s): Marie-Lee
Age: 17
Date and time of death: April 29th 2012 at 1:07 a.m.
Place of death: 917 Dundas Street West, Whitby Ontario
Cause of death: Smoke inhalation
By what means: Accident

Surname: Twiddy
Given name(s): Benjamin
Age: 19
Date and time of death: April 29th 2012 at 1:31 a.m.
Place of death: Rouge Valley Hospital, 580 Harwood Ave South, Ajax, Ontario
Cause of death: Smoke inhalation
By what means: Accident

Surname: Dunsmuir
Given name(s): Kevin
Age: 55
Date and time of death: March 29th 2013 at 12:30 p.m.
Place of death: 72 Howard Ave. Sharon (East Gwilimbury) Ontario
Cause of death: Smoke inhalation
By what means: Accident

Surname: Dunsmuir
Given name(s): Jennifer
Age: 51
Date and time of death: March 29th 2013 at 12:30 p.m.
Place of death: 72 Howard Ave. Sharon (East Gwilimbury) Ontario
Cause of death: Smoke inhalation
By what means: Accident

Surname: Dunsmuir
Given name(s): Robert
Age: 19
Date and time of death: March 29th 2013 at 12:30 p.m.
Place of death: 72 Howard Ave. Sharon (East Gwilimbury) Ontario
Cause of death: Smoke inhalation
By what means: Accident

Surname: Dunsmuir
Given name(s): Cameron
Age: 16
Date and time of death: March 29th 2013 at 12:30 p.m.
Place of death: 72 Howard Ave. Sharon (East Gwilimbury) Ontario
Cause of death: Smoke inhalation
By what means: Accident

(original signed by Foreman and Jurors)


This verdict was received on the 29th of April, 2016
Coroner’s Name: Dr. David H. Evans
(original signed by Coroner)


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


Inquest into the deaths of:

Holly Harrison, Mari-Lee Towie, Benjamin Twiddy, Kevin Dunsmuir, Jennifer Dunsmuir, Robert Dunsmuir, Cameron Dunsmuir


Jury Recommendations

To the Office of the Fire Marshal and Emergency Management

  1. To consult with stakeholders to define the meaning of “public education” in section 2(1)(a) of the Fire Protection and Prevention Act through a Directive.
  2. To develop a public education program related to public fire safety in accessory apartments.
  3. To educate the public on its responsibility to maintain and not dismantle/vandalize smoke alarms. 
  4. To work with the Insurance Bureau of Canada and other stakeholders to increase insurance policy requirements for residential smoke alarms/smoke detectors and carbon monoxide detectors and to develop public service announcements to promote awareness of the importance of working smoke alarms/detectors and carbon monoxide detectors.
  5. To continue and expand the accessibility of all training resources to municipalities by providing standard curriculum e-learning, Train the Trainer packages, local training opportunities and teaching materials to municipalities to provide for consistent province wide training and standards.

To the Office of the Fire Marshal and Emergency Management and Municipal Fire Departments

  1. To consider incorporating lessons learned from East Gwillimbury and Whitby incidents into future course materials (with personal information and identifiers removed and without using the audio of the 911 calls), such as fire college symposia and training materials, including but not limited to suggestions for self-evacuation and/or self-preservation.
  2. Fire Inspectors to notify tenants of Landlord’s non-compliance via letter.
  3. Inspectors (fire or building) must have visual proof of compliance, e.g. confirming drywall installation for fire separation.  (Verbal confirmation by property owner is not sufficient). 
  4. Develop a provincial “red-flag” system which would trigger a re-inspection of properties with a history of non-compliance/conviction under the Fire Code.
  5. Canvass neighbourhood/community post fire to promote awareness of fire safety and prevention.

To the Office of the Fire Marshal and Emergency Management and Municipalities

  1. To continue and expand public education on the fact that upon discovery of smoke or fire every person must immediately get out and stay out of the building.
  2. As part of public education, promote awareness of different types and appropriate use of fire extinguishers. Included in this education, could be demonstrations and hands-on practice.

To Municipalities

  1. Consult with stakeholders to explore the installation of clearly visible house numbers.
  2. Work towards a provincially integrated computer software program to assist dispatching of 911 calls.

To the Ontario Association of Fire Chiefs

  1. Fire Departments to explore re-allocating their current resources, and/or utilizing resources from the suppression area, for fire prevention, public education and fire safety inspections in their municipalities. This could include a Home Visit Public Education program and literature that will provide occupants home fire safety information, such as the presence of smoke detectors, CO detectors, escape plans, vulnerable occupants (physical and cognitive disabilities), appliance  (e.g. dryer) safety, delivered by fire fighters as provided by the municipality.  Such programs may include a home inspection as determined by the municipality.  

To the Ontario Association of Fire Chiefs and the Ontario Association of Chiefs of Police

  1. To encourage collaboration between fire departments and police services in the area of training with a view to ensuring a safe and efficient response to structure fires and the preservation and collection of fire investigation related evidence.

To the Ministry of Education

  1. To consult with the Office of the Fire Marshal and Emergency Management and develop fire safety curriculum for high school students and young adults leaving home for the first time and their parents focusing on fire safety and fire prevention skills, including safe cooking, smoke alarms, the need for a means of egress and having and practicing an emergency exit plan in case of fire.
  2. To make available to the School Boards the OFMEM burn room videos and “No Time To Spare” video to raise awareness of how fast and deadly the by-products of fire can be (e.g. smoke).
  3. Explore opportunities to work with fire prevention and detection officers, as part of the mandatory volunteer hours curriculum for high school students. For example, students could work together to find ways to promote fire safety amongst their peers, e.g.”Cop Lights Bling”.  A video produced by the RCMP to raise awareness of moving over when cruisers lights are on.

To the Ministry of Community Safety and Correctional Services

  1. To make a Regulation, pursuant to clause 78(1)(k) of the Fire Protection and Prevention Act, requiring mandatory certification and training, to recognized industry standards, for all personnel (as defined in the Fire Protection and Prevention Act) whose primary job function is to perform:  1) fire inspections,  2) public education, and/or 3) communications (call-taking / dispatch).
  2. To work with the Technical Standards and Safety Association (TSSA) to promote the installation of Carbon Monoxide detectors through HVAC technicians who install gas fired appliances.
  3. To amend section 9.8 of the Fire Code to address interior finishes of the means of egress in accessory apartments with only one means of escape and, in particular, require that such finishes have a maximum flame spread rating of 150.
    For example:
    9.8.3.2 (2). Where a dwelling unit is served by one means of escape conforming to Sentence (1), the flame spread rating of interior wall and ceiling finishes adjacent to stairs within the dwelling unit leading to the means of escape shall not exceed 150.
    9.8.3.3. (3). Where a dwelling unit is served by one means of escape conforming to Sentence (1), or (2) the flame spread rating of interior wall and ceiling finishes adjacent to stairs within the dwelling unit leading to the means of escape shall not exceed 150.
  4. Legislation and or code be created pursuant to the FPPA that mandates that a municipality clearly and understandably educate the residents of the community on the fire protection services provided by the municipality.  This shall be done on fire department/municipal web pages, and printed literature produced by the municipality. This information should indicate whether fire protection is being provided by full time fire fighters, volunteer fire fighters or a combination of the two and their respective hours of operation. 

To the Ontario Safety League

  1. To liaise with existing fire safety agencies and councils, such as the Office of the Fire Marshal and Emergency Management’s Public Fire Safety Council, to address the issues of fire safety campaigns, programs and education curriculums. Refer to recommendation # 11.

To the Ontario Safety League and the Office of the Ontario Fire Marshal and Emergency Management

  1. Explore the idea of using transit services advertising as a method of raising fire safety awareness, e.g. “seconds count” and “get out, stay out”.

To the Media:

  1. Ask the media to assist in raising awareness around fire safety including the importance of early detection through smoke alarms and the “get out, stay out” message. The public needs to be aware that the fire department may not be able to effect a rescue and therefore needs to be more vigilant with regard to fire prevention and fire detection to ensure their own safety.

To The Ministry of Municipal Affairs and Housing, the Office of the Fire Marshal and Emergency Management and the Ontario Association of Fire Chiefs

  1. To consult with stakeholders, research and promote the installation of sprinklers as a component of fire and life safety in all newly constructed residential homes with the appropriate amendment under the Ontario Building Code.
  2. To consult with stakeholders to research and promote two forms of egress for accessory apartments with the appropriate amendment under the Ontario Building Code.
  3. Consult with the Real Estate Board and other stakeholders to explore the ability to list locations of fire halls and level of service they provide to prospective homeowners, e.g. location of schools. 
  4. When a building permit has been granted for renovations or retro-fit, a fire inspection must be completed, as well as a building inspection.
  5. Regulation be passed pursuant to the Fire Protection and Prevention Act mandating that municipalities provide information on tax assessments indicating the level of fire protection provided to individual property owners. This information should indicate whether fire protection is being provided by full time fire fighters, volunteer fire fighters or a combination of the two and their respective hours of operation. 
  6. Consider communicating any changes to the fire code regarding dwelling units to property owners through the property tax assessment form.

To The Office of the Chief Coroner

  1. The Office of the Chief Coroner shall request that all organizations and institutions receiving these recommendations provide reports updating their responses within a year of receipt. To inform the public of the contents of these reports, the Office of the Chief Coroner shall convene a press conference a year from the date that the recommendations were sent out to the recipient parties. Copies of the reports shall be forwarded to the jurors who will be invited to attend the press conference. All recommendations to be reviewed annually for the next two years with public reports filed providing an update on the status of the jury's final recommendations.