OCC Inquest - Iskandar 2017

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Iskandar
Given Name(s): Sarmad
Age: 21

Held at: 25 Morton Shulman Avenue, Toronto
From: February 27
To: March 3, 2017
By: Dr. Monique Moreau, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Sarmad Iskandar
Date and time of death: 23rd day of June 2014 at 14:57 hours
Place of death: 65 St. Mary Street, Toronto
Cause of death: Blunt force injury
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 3 of March, 2017
Coroner's name: Dr. Monique Moreau
(Original signed by coroner)


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


Inquest into the death of:

Sarmad Iskandar


Jury Recommendations

To Ministry of Labour:

  1. Recommend revision of Part IX Offences and Penalties of the Occupational Health and Safety Act  R.S.O. 1990 Chapter 0.1to reflect the economic realities within the Ontario construction industry in 2017.
  2. Recommend that the Ministry of Labour implement a proactive inspection protocol which includes mandatory inspections based on a number of factors, including but not limited to: number of workers on site, cost of project, size of project and incident history of site and construction company.
  3. Recommend revision of  Section 10.1 of the Working at Heights Training Program Standard to clarify that the written test must be in a language appropriate to the learner. Course attendees should complete the written test without help of translator.  Each individual's  written test should be evaluated by the class instructor prior to discussion of the test answers.
  4. Recommend the development and implementation of standardized independent safety inspections based on the risk profile of the construction project, including but not limited to: number of workers on site, phase of construction and cost and size of project.
  5. Recommend that for all construction projects, each trade with a minimum of five workers on site should have a designated supervisor on site at all times. This would be in addition to the construction company’s on-site supervisor.
  6. Recommend the use of ‘Guardrail Removal Permits’ including on-site supervisor sign-off at the end of each day when guard rail use is required by regulation.
  7. Recommend that a ‘Stop Work Order’ be issued in all fatality cases on construction projects to ensure sufficient time for all evidence to be collected and the affected areas to be deemed safe before resumption of work.
  8. Recommend on-site orientation sessions should include a practical demonstration of fall protection methods and equipment appropriate to that site.