OCC Inquest - Perry 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Perry
Given Name(s): Stephen
Age: 47

Held at: 155 Elm St., Sudbury
From: February 22
To: February 25, 2016
By: Dr. Ray Sawkiw, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Stephen Perry
Date and time of death: January 29, 2012 at 12:15 pm
Place of death: Coleman Mine, Levack, ON
Cause of death: Crushing injury to head and chest
By what means: Accident

(Original signed by: Foreperson and Jurors)


The verdict was received on the 25th of February, 2016
Coroner's name: Dr. Ray Sawkiw
(Original signed by coroner)


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


Inquest into the death of:

Stephen Perry


Jury Recommendations

  1. It is recommended to the Ontario Ministry of Labour that Regulations for Mines and Mining plants be amended to require each underground mine in Ontario to require an assessment by a ground control engineer specific to supporting faces in each mine. It is requested that this recommendation be dealt with through the MLRC subcommittee on ground control.
  2. It is recommended to the Ontario Ministry of Labour that they form an MLRC subcommittee on technology with the mandate of investigating technology such as but not limited to remote loading.
  3. It is recommended to the Ontario Ministry of Labour that Legislation be amended in regards to working alone. We strongly feel that the mere presence of a radio does not remove the dangers of working alone. This provision should be removed from legislation.
  4. It is recommended to all underground mines that a committee be established to examine potential options in improving underground emergency vehicles or the first aid stretchers so to allow for first aid work (e.g. CPR) and that the emergency vehicles be equipped with their own first aid kits pursuant to section 281.2 subsection (2) of the Occupational Health and Safety Act and Regulations for Mines and Mining Plants.
  5. It is recommended to the Ontario Ministry of Labour that Advanced level First Aid training for all supervisors at underground mines be obligatory and it is recommended that a Mine Rescue Worker be available on every shift.
  6. It is recommended to the Ontario Ministry of Labour and all mines that an AED (automated external defibrillator) be available at refuge stations and encourage more personnel to be trained.
  7. It is recommended to the Ontario Ministry of Labour and all mines establish a working group conduct a risk assessment with a view to improving lighting options for the ANFO  loader.
  8. It is recommended to the Ministry of Community Safety and Correctional Services that the inquest process be reviewed to shorten time frames between fatalities in mining and inquest start dates.
  9. It is recommended to all mines that all safety systems be reviewed to allow them to be more proactive.
  10. It is recommended to all mines that the communication systems be improved.