OCC Inquest - MacKay 2017
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given Name(s): Jordy
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:
To Correctional Service Canada (CSC):
- When an inmate threatens self-harm he shall be put on increased monitoring such as modified suicide watch.
- Ensure dissemination of policies, procedures and/or directives to contracted medical staff in a timely manner.
- When an inmate is referred to multiple specialists, ensure direct communication between all parties.
- 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.