OCC Inquest - Mrugala 2015

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Mrugala
Given Name(s): Krzysztof
Age: 34

Held at: 25 Morton Shulman Avenue, Toronto, Ontario
From: May 25
To: May 28, 2015
By: Dr. Robert Boyko, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Krzysztof Mrugala
Date and time of death: August 28, 2012, pronounced deceased at 10:00 a.m.
Place of death: Sunnybrook Health Science Centre, Toronto
Cause of death: Blunt impact head trauma
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 28 of May, 2015
Coroner's name: Dr. Robert Boyko
(Original signed by coroner)


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


Inquest into the death of:

Krzysztof Mrugala


Jury Recommendations

To V.H.L. Developments Inc.:

  1. Review immediately all supervisory roles, responsibility and training.
  2. Implement that the Site Supervisor review safe working procedures at the site of the work on a daily basis.

To the Ministry of Labour:

  1. Request that constructors and employers conduct an immediate review of all supervisory roles, responsibility and training.
  2. Require that any staff changes to supervision be reported to the ministry and that this change is communicated to constructors, employers, and workers on the job site.
  3. Consider requesting that constructors post the site supervisor’s identity on the job site with a photograph and contact information
  4. Hire more inspectors to increase frequency of inspections.
  5. Review allocation process of inspectors relative to concentration of job sites.
  6. Ban the consumption of alcohol on job sites.
  7. Implement inspection blitz campaign to include proper construction and dismantling of scaffolding.
  8. Implement inspection blitz campaign to include fall protection and prevention.

To the Ministry of Labour, Chief Prevention Officer, and the Infrastructure Health and Safety Association (IHSA):

  1. Restrict the use of cellular phones to appropriate and safe circumstances on all job sites.
  2. Educate constructors, employers, and workers on the impact and risks of alcohol on the job site, including but not limited to print campaign, digital media, and signage.
  3. Educate constructors, employers, and workers on the impact of residual alcohol in an individual’s body as it relates to impairment of their ability to work the next day.
  4. Develop a media campaign to reinforce for constructors, employers, and workers the accredited training on fall prevention and the proper usage of fall protection gear.
  5. Develop a media campaign for constructors, employers, and workers to reinforce the positive impact – decreasing accidents while increasing productivity - of properly implementing safety protocols.
  6. Develop a media campaign to educate constructors, employers, and workers on their role in the Internal Responsibility System, including how to anonymously report unsafe work conditions.
  7. Review processes to ensure that regulations according to the Ontario Occupational Health and Safety Act and training programs are implemented

To the Ministry of Training, Colleges and Universities, Ministry of Labour, and the Chief Prevention Officer:

  1. Provide accredited training for all constructors, employers, and workers who use scaffolds regarding construction, dismantling, and safe use of scaffolds.
  2. Emphasize, during scaffold training, that all scaffolding should be either fully installed or fully dismantled.
  3. Training in scaffold use should include a requirement for an inspection and tagging system to indicate that it is safe to use.
  4. Instruct all constructors, employers and workers to use scaffolding only when it is fully installed, tagged and recorded as being inspected by the site supervisor.
  5. Provide accredited training for all constructors, employers and workers regarding fall safety and fall prevention.