OCC Inquest - Lopes 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Lopes
Given name(s): Antonio Manuel Simoes
Age: 58

Held at: 25 Morton Shulman Ave, Toronto, ON
From: Sept. 11
To: Sept. 12, 2017
By: Dr. John Carlisle, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Antonio Manuel Simoes Lopes
Date and time of death: Oct. 19, 2013 at 2:00 p.m.
Place of death: St. Michael's Hospital, 30 Bond Street, Toronto
Cause of death: Blunt force trauma to head and neck, including scalp laceration and fracture of the C4 vertebrae, attributed to a descent from height.
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 12 of Sept., 2017
Coroner's name: Dr. John Carlisle
(Original signed by coroner)


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


Inquest into the death of:

Antonio Manuel Simoes Lopes


Jury Recommendations

To the Ministry of Labour:

  1. Implement a requirement for training as it relates to scaffolding construction for all supervisors of scaffold construction.
  2. Establish a working group to more clearly define "training, knowledge and experience" required to supervise scaffolding construction.
  3. Establish a working group to consider the feasibility of standardized training that will be required by all "competent persons" who undertake to supervise the construction of scaffolding.
  4. Establish a study to consider implementing first aid training into the current mandatory training for Working at Heights under the Occupational Health and Safety Awareness and Training Program, or in the alternative, first aid training for anyone who works at construction sites which involve work at heights 2.4 metres above the ground.