OCC Inquest - Lalonde 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Lalonde
Given Name(s): Nicholas
Age: 23

Held at: 20 Weber St. E., Kitchener
From: January 27th
To: January 29th, 2016
By: Dr. John Ewen, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Nicholas Lalonde
Date and time of death: October 11, 2013 at 12:43 hours
Place of death: 185 King Street, North, Waterloo, ON
Cause of death: Multiple blunt force injuries due to a fall from the 12th floor to the 8th floor; mast climber
By what means: Accident

(Original signed by: Foreperson and Jurors)


The verdict was received on the 29th of January, 2016
Coroner's name: Dr. John Ewen
(Original signed by coroner)


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


Inquest into the death of:

Nicholas Lalonde


Jury Recommendations

To the Ministry of Labour

  1. Ministry of Labour shall institute a policy whereby inspectors are required to include within their inspection / investigation a consideration of all prior contacts with the Ministry of Labour involving the workplace parties.
  2. Ministry of Labour shall arrange for the Inspection Compliance and Enforcement ("ICE") system to generate a report on a bi-weekly basis that would identify workplace parties with two or more field visits.
  3. In so far as "ICE" is a provincial system we recommend attempts be made to extend its database beyond Ontario into other provinces and territories as the construction industry does not limit itself to provincial borders.
  4. Ministry of Labour and the Ontario College of Trades shall explore a formal information sharing agreement to faciliate the regulation and certification of trades people.
  5. Ministry of Labour shall include a crane blitz and fall blitz within its inspection blitz program in the next fiscal year.
  6. Ministry of Labour shall conduct a public awareness campaign with respect to the dangers of all hazards, with a particular focus on fatalies.
  7. Ministry of Labour  shall include a component on crane operation, signalling and hazards and the legislation / regulations governing same in the Entry Level Construction Training.
  8. We recommend the above training exceed 8 hrs. and a follow up session within 6 months.
  9. Ministry of Labour shall increase, overall, the number of proactive construction site inspections it conducts.
  10. Ministry of Labour shall increase, overall, the number of inspectors it employs.
  11. Ministry of Labour shall mandate permanent visible anchors be installed and communicated to all construction workers, through verbal and documented instructions.
  12. The Ministry of Labour should mandate all construction companies post clearly the Ministry of  Labour's phone number and their ability to communicate any concerns at the job sire in confidence.

To Maison

  1. Develop a health and safety policy that includes clear, progressive discipline for  failure to follow that policy and / or any provisions of the Occupational Health and Safety Act and the regulations thereto.  Implement that policy forthwith upon commencement of your next project.
  2. Provide formal training to any site supervisor you employ in the areas of health and safety (including the Occupational Health and Safety Act and regulations) crane operation / signalling / rigging and fall protection with such training to be completed prior to the commencement of your next project.
  3. File with the Ministry of Labour along with their notice of a project a list of subcontractors.
  4. Create and provide a package for each subcontractor to provide a list of active on site workers listing up to date credentials.

To Central Construction

  1. Develop a health and safety policy that includes clear, progressive discipline for failure to follow that policy and / or any provisions of the Occupational Health and Safety Act and the regulations thereto.  Implement that policy forthwith upon commencement of your next project and thereafter.