OCC Inquest - Mitchell 2015

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Mitchell
Given Name(s): Guy
Age: 38

Held at: Hamilton, Ontario
From: July 6
To: July 24, 2015
By: Dr. Jack Stanborough, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Guy Mitchell
Date and time of death: April 29, 2012 at 9:18 p.m.
Place of death: Brantford General Hospital – 200 Terrace Hill St., Brantford, Ontario, N3R 1G9
Cause of death: Drowning and hypothermia
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 24 day of July, 2015
Coroner's name: Dr. Jack Stanborough
(Original signed by coroner)


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


Inquest into the death of:

Guy Mitchell


Jury Recommendations

To the Ministry of Community and Social Services, the Ministry of the Attorney General, the Office of the Public Guardian and Trustee and the Province of Ontario:

  1. In order to ensure the safety, wellbeing and quality of life of vulnerable adults with developmental disabilities, within 6 months of the date of this verdict, establish a working group in consultation with Community Living Ontario; Host Family Coordinators Association; People First; Ontario Agencies Supporting Individuals with Special Needs (OASIS); Provincial Network on Developmental Services and other appropriate stakeholders (such as other provinces) to consider:
    1. the creation of distinct and separate adult protection legislation in Ontario, including a mandatory reporting obligation for all suspected cases of abuse or neglect
    2. the creation or establishment of a Provincial Advocate for the Protection of Adults with Developmental Disabilities
    3. the expansion of the role of Adult Protection Support Workers in the context of supporting persons placed home share settings
    4. revisions to the Substitute Decisions Act, 1992 to expand the role of the Official Guardian’s Office to assist in the decision-making process of an Adult with a developmental disability
    5. enhanced public awareness of the vulnerability and need for protection of adults with developmental disabilities.

To the Ministry of Community and Social Services:

  1. In order to enhance and standardize the procedure for screening and approval of host families in Ontario, within 6 months of the date of this verdict, establish a working group in consultation with Community Living Ontario; Host Family Coordinators Association; Ontario Agencies Supporting Individuals with Special Needs (OASIS); Provincial Network on Developmental Services and other appropriate stakeholders to determine existing best practices and to consider:
    1. minimum standards for all host family residences and, in the case of rural properties, the requirement for the provision of surveys and inspection of properties and immediate surroundings to determine risks and hazards
    2. registration and agency licensing of host family residences
    3. standardized screening and vetting of applicants, including:
      1. pre-assessment standardized residence inspection
      2. standardized prohibition against “grandfathering” or transfer of responsibility without full compliance with application and screening process
      3. policy for reassessment of home environment after any significant life changing event
      4. mandatory completion of programs similar to those used to evaluate prospective foster and adoptive families i.e. PRIDE and SAFE
      5. demonstration of financial stability
      6. required CPR/First Aid training
      7. standardized contract including:
        • provisions that clearly outline conduct that will result in termination
        • prohibition against smoking in residences
        • mandatory respite as may be required by the service agency; and
        • provision in contract for unannounced visits at the discretion of the service agency.
    4. minimum standards for written policies and procedures relating to screening and approval of host family residences – to be reviewed annually.
  2. In order to ensure the safety, wellbeing and quality of life of vulnerable adults placed in host family residences and to standardize the procedure for inspections or home visits at host family residences, within 6 months of the date of this verdict, establish a working group in consultation with Community Living Ontario; People First; Host Family Coordinators Association; Ontario Agencies Supporting Individuals with Special Needs (OASIS); Provincial Network on Developmental Services and other appropriate stakeholders to determine existing best practices and to consider:
    1. monthly home visits as a mandatory minimum with a third party participant for home sharer to be present – must be completed within the calendar month with no makeups or doubling up
    2. appropriate training of service agency staff for monthly visits
    3. a standardized checklist for monthly visits to include inspection or confirmation of the following:
      1. adequate fresh water supply
      2. appropriate ambient temperature (heating and where applicable air/conditioning)
      3. functioning toilets
      4. adequate food supply
      5. appropriate living space/bedroom for home sharer
      6. where required, inspection of all rooms within the home including the home provider
      7. confirmation of payment of utilities, including hydroelectricity, water, natural gas/propane/oil supply
      8. continued confirmation of financial stability; and
      9. smoke detectors and carbon monoxide detectors in proper working order
      10. Home provider and Home Sharer (or guardian) to receive a copy of the inspection results.
    4. appropriate training of service agency staff for annual inspections
    5. a standardized checklist for annual inspections with detailed listing of areas to be inspected, including, but not limited to:
      1. inspection of furnace/heating, water and electrical systems done by qualified/certified persons, confirming proper operating condition
      2. inspection of wells/cisterns, including water testing where applicable
      3. confirmation of insurance.
    6. minimum standards for written policies and procedures relating to monthly visits and scheduled inspections – to be reviewed annually.
    7. Home provider and Home Sharer (or guardian) to receive a copy of the annual inspection results.
  3. In order to ensure the safety, wellbeing and quality of life of vulnerable adults placed in host family residences and to standardize the procedure to ensure that they are provided with the appropriate knowledge and opportunity to express any concerns that they may have regarding their residential placement, within 6 months of the date of this verdict, establish a working group in consultation with Community Living Ontario; People First; Host Family Coordinators Association; Ontario Agencies Supporting Individuals with Special Needs (OASIS); Provincial Network on Developmental Services and other stakeholders to determine existing best practices and to consider:
    1. monthly private meetings with the home sharer in the company of a peer, friend or family member, as chosen by the home sharer; and
    2. at all times, supported decision-making in the Person Centered Planning process.
  4. In order to enhance the understanding of service agency employees, Board members, and home providers in relation to the requirements as set out in the Quality Assurance Measures, Regulation 299/10 and to increase awareness and recognition of abuse or neglect of adults with developmental disabilities within a host family setting, within 6 months of the date of this verdict, establish a working group in consultation with Community Living Ontario; Ontario Agencies Supporting Individuals with Special Needs (OASIS); Provincial Network on Developmental Services and other appropriate stakeholders to determine existing best practices and to consider:
    1. the development of further standardized training materials to be provided to all service agencies
    2. the requirement for and frequency of refresher courses; and
    3. the inclusion of the scenario involving the death of Guy Mitchell as a case study in any training materials to serve as an example of the importance of recognizing and acting on signs and indicators of neglect.
  5. In order to assist service agencies in complying with the requirements as set out in the Quality Assurance Measures, Regulation 299/10 in relation to the education of the individuals that they serve regarding the recognition and reporting of abuse or neglect, within 6 months of the date of this verdict, establish a working group in consultation with Community Living Ontario; People First; Host Family Coordinators Association; Ontario Agencies Supporting Individuals with Special Needs (OASIS); the Provincial Network on Developmental Services and other stakeholders to determine existing best practices and to consider:
    1. the development of further standardized training materials to be provided to all service agencies; and
    2. the requirement for and frequency of further education sessions.
  6. In order to enhance information exchange within service agencies and to facilitate inspection of records by the Ministry of Community and Social Services, within 6 months of the date of this verdict, establish a working group in consultation with the Ontario Agencies Supporting Individuals with Special Needs (OASIS); the Provincial Network on Developmental Services and other appropriate stakeholders to determine existing best practices and to consider the development and use of standardized electronic forms for case notes and all internal reports, including reports relating to complaints received by the service agency.
  7. In order to ensure the safety, wellbeing and quality of life of all vulnerable adults with developmental disabilities, within 6 months of the date of this verdict, and in consultation with the Ontario Association of Chiefs of Police; Ontario Agencies Supporting Individuals with Special Needs (OASIS); the Provincial Network on Developmental Services; and other appropriate stakeholders, determine existing best practices and required amendments of the existing Regulation 299/10 to include the following reporting and investigative provisions:
    1. all instances of suspected abuse or neglect to be reported to the police by service agency
    2. timing of report to police
    3. clarification and reinforcement of the requirement for a Serious Occurrence Report for all incidents of suspected or witnessed abuse or neglect
    4. where instances of abuse or neglect do not constitute criminal conduct, report to be made by police to reporting agency and Regional Office of the Ministry of Community and Social Services
    5. upon receipt of report from local police agency, in consultation with service agency, Regional Office of the Ministry of Community and Social Services will initiate and provide the resources for further investigation of alleged abuse or neglect.
  8. In order to ensure timely communication to service agencies regarding the importance of recognition of risk factors associated with the abuse and neglect of vulnerable adults placed in host family residences:
    1. in all instances of death or serious bodily harm, communiqués shall be issued to all Developmental Services Ontario offices and funded service agencies within 30 days of the death or incident of serious bodily harm; and
    2. any recommendations relating to deaths of vulnerable adults placed in host family residences shall be distributed to all Developmental Services Ontario offices and funded service agencies within 30 days of the completion of a review or the receipt of a jury verdict.

To the Hamilton Regional Office of the Ministry of Community and Social Services, in consultation with CONTACT Hamilton; CHOICES; all service agencies providing services to adults with developmental disabilities in Hamilton; the Hamilton Police Service; Hamilton Public Health: the Children’s Aid Society of Hamilton, the Catholic Children’s Aid Society; and the Hamilton Burlington Society for the Prevention of Cruelty to Animals:

  1. In order to ensure the safety, wellbeing and quality of life of vulnerable adults with developmental disabilities and to ensure the timely exchange of information relating to the recognition of neglect, abuse and mistreatment of vulnerable adults, within 3 months of this verdict, each organization shall conduct an internal debriefing to discuss the outcome of this inquest, the recommendations of this jury; and best practices in relation to the reporting of suspected abuse or neglect and the need for follow-up with the appropriate community partners.

To the Regional Offices of the Ministry of Community and Social Services, all service agencies providing services to adults with developmental disabilities; the Police Services; Public Health: the Children’s Aid Society, the Catholic Children’s Aid Society; and the Society for the Prevention of Cruelty to Animals:

  1. In order to increase public awareness of the vulnerability of adults with developmental disabilities and to engage the community in strategies that will assist in recognizing potential neglect and abuse and the need for prevention of neglect and abuse, within 3 months develop a local media campaign, including a public forum, that:
    1. highlights the prevalence of neglect and abuse of adults with developmental disabilities
    2. highlights the health and social issues associated with adults with developmental disabilities
    3. highlights the subject of this inquest through a discussion of the various roles and responsibilities of community partners and members of the community in recognizing and reporting abuse and neglect of adults with developmental disabilities
    4. highlights the resources available in the community to address and report issues relating to the abuse and neglect of adults with developmental disabilities
    5. highlights current misconceptions relating to adults with developmental disabilities
    6. highlights signs of neglect and abuse of adults with developmental disabilities, and
    7. makes available statistics regarding the incidence of neglect and abuse of adults with developmental disabilities.
  2. In order to ensure the safety, wellbeing and quality of life of vulnerable adults with developmental disabilities, within 6 months of the date of this verdict, establish a working group to facilitate the preparation of a local protocol that:
    1. outlines the process for cross-training between service agencies, Police Services, Children’s Aid Societies, SPCA and other stakeholders
    2. promotes a collaborative and cooperative response to issues relating to the abuse or neglect of adults with developmental disabilities with attention to best practice guidelines and the most effective use of existing community resources
    3. facilitates and supports effective communication between service providers and other community partners
    4. recognizes the particular and specialized areas of expertise of each of the community partners
    5. clarifies the respective roles, responsibilities and practices of the community partners in relation to incidents involving suspected or alleged abuse or neglect of adults with developmental disabilities, and
    6. provides guidelines for response to reports or incidents involving suspected or alleged abuse of adults with developmental disabilities and ensures effective, respectful and appropriate service delivery.

To the Hamilton Regional Office of the Ministry of Community and Social Services, in consultation with CONTACT Hamilton; CHOICES; all service agencies providing services to adults with developmental disabilities in Hamilton:

  1. Pending provincial standardization of procedures and training relating to the host family program, within 3 months of the date of this verdict, establish a working group to prepare a Regional Operational Procedure Handbook, and share the development process and resulting handbook between relevant agencies outside the Hamilton area, that addresses:
    1. application and approval process for family home providers
    2. placement process
    3. monthly reports utilizing standardize electronic forms
    4. annual service reviews/inspections utilizing standardized electronic forms
    5. program administration
    6. record keeping requirements
    7. abuse prevention, identification and reporting
    8. individual support plans
    9. process for peer review between agencies

To the Hamilton Police Service:

  1. In order to enhance awareness of all personnel (including civilians) of existing regulations regarding the reporting and investigation of suspected abuse or neglect of adults with developmental disabilities, conduct block training that outlines the requirements pursuant to Regulation 299/10; the requirements as set out in Hamilton Police Service Policy and Procedure 4.1.20, "Senior and Vulnerable Adult Abuse" and the requirement to report investigative conclusions to the appropriate agency for follow-up.
  2. In order to ensure the appropriate assignment of investigations related to suspected incidents involving adults with developmental disabilities within a home share setting, in consultation with other police agencies and the Ministry of Community and Social Services, amend Section B.3.1.a, B.6.3, and B.7.3 of Hamilton Police Service Policy and Procedure 4.1.20, "Senior and Vulnerable Adult Abuse", to include "host family or home share residence".

To the City of Hamilton:

  1. Consider a by-law that requires the proper securing of the opening of any cistern/well on any property such that it is not accessible without removal of a security feature. The by-law should also include a provision that prohibits companies contracted to fill cisterns from doing so unless they are properly secured, as required by the by-law.