OCC Inquest - Penny 2015

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Penny
Given Name(s): Luke
Age: 26

Held at: Oshawa, Ontario
From: March 2
To: March 6, 2017
By: Dr. Michael Martin, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Luke Penny
Date and time of death: May 19, 2010
Place of death: 9680 Garrard Road, Brooklin, Ontario
Cause of death: Crush asphyxiation due to blunt force trauma with post-traumatic entrapment
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 6 of March, 2015
Coroner's name: Dr. Michael Martin
(Original signed by coroner)


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


Inquest into the death of:

Luke Penny


Jury Recommendations

  1. That the Ontario Ministries of Labour and of Trades, Colleges and Universities collaborate in the creation of educational materials and training dealing with working safely in trenches.
  2. That the Ontario Ministry of Municipal Affairs and Housing draft regulations calling for the marking of walls that are below grade, such as foundation walls, at the point below which further excavation should not be conducted without adequate shoring of the wall, as determined by an engineer.
  3. That the Ontario Ministry of Labour draft regulations governing when foundation walls should be braced as a result of excavation of earth away from the wall, so that workers on site can readily know when their working conditions meet minimum safety standards.
  4. That the Ministry of Municipal Affairs and Housing consider amending Part 9 of the Building Code to provide a definition of the term “surcharge” as well as a threshold as to when a certain degree of surcharge would require to be built in accordance with Part 4 of the Building Code.
  5. That the Ontario Ministry of Labour examine the current inspection schedule for Health and Safety and determine if more onsite inspections, both scheduled and unscheduled, of construction sites would be beneficial.
  6. That the Vulnerable Workers Taskforce, as created by the Ministry of Labour, examine the current level of mandatory safety training and consider developing a mandatory specialized training course in heath and safety aimed specifically at trades and construction workers.