OCC Inquest - MacKay 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: MacKay
Given Name(s): Jordy
Age: 31

Held at: 860 William Street, Cobourg, ON
From: March 9
To: March 10, 2017
By: Dr. Gordon Watt, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jordy MacKay
Date and time of death: August 16, 2015 at 2:48 p.m
Place of death: Warkworth Institution
Cause of death: Hanging
By what means: Suicide

(Original signed by: Foreperson and Jurors)


The verdict was received on March 10, 2017
Coroner's name: Dr. Gordon Watt
(Original signed by coroner)


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


Inquest into the death of:

Jordy MacKay


Jury Recommendations

To Correctional Service Canada (CSC):

  1. When an inmate threatens self-harm he shall be put on increased monitoring such as modified suicide watch.
  2. Ensure dissemination of policies, procedures and/or directives to contracted medical staff in a timely manner.
  3. When an inmate is referred to multiple specialists, ensure direct communication between all parties.
  4. Create an electronic record that shows an inmate’s history of threats of self-harm and actual self-harm that is accessible to all involved CSC staff.