OCC Inquest - Prindible 2016

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Prindible
Given Name(s): Lawrence William
Age: 51

Held at: Kawartha Lakes, ON
From: December 14
To: December 16 2016
By: Dr. Michael Martin, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Lawrence William Prindible
Date and time of death: Deccember 2, 2013, 00:24
Place of death: Central East Correctional Centre – 541 Highway 36, Ops Township, City of Kawartha Lakes
Cause of death: Hanging
By what means: Suicide

(Original signed by: Foreperson)


The verdict was received on the 16 of December, 2016
Coroner's name: Dr. Michael Martin
(Original signed by coroner)


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


Inquest into the death of:

Lawrence William Prindible


Jury Recommendations

To the Ministry of Community Safety and Correctional Services (MCSCS):

  1. That the Ministry of Community Safety and Correctional Services (MCSCS) should develop a clear protocol for the timely sharing of inmate medical / mental health information between relevant professionals within the institutions and with professionals contracted by the MCSCS to provide medical / mental health services to the inmates.  Further, that part of this protocol include the implementation of electronic medical records to provide more complete and timely transfer of such information.
  2. That the MCSCS amend the curriculum for the mandatory training on Suicide Awareness and Mental Health Issues to include a testing and formal individual evaluation component.  This is to ensure that the participants actually achieve the desired understanding of the course materials.
  3. That action be taken by the MCSCS to ensure compliance with the mandatory training for Suicide Awareness, Mental Health Issues, and First Aid / CPR / AED Use.  Individuals who have failed their training or whose training requirements have expired should be disciplined until their training is in compliance with the mandatory standards.
  4. That the MCSCS more generally, and the Central East Correctional Centre (CECC) specifically, establishes an accountability framework to ensure meaningful compliance with the pre-existing policies, procedures, and standing orders designed to ensure the physical and emotional well-being of inmates in segregation units.  Particular attention should be given to quality compliance with Institutional Services Policy and Procedures Manual, “Placement of Special Management Inmates”, 6.5 and Central East Correctional Centre, Standing Order, 4.20.6.  The accountability framework should include the implementation of random viewing of the video recordings by Superintendents and Upper Level Administration (not designates) to ensure that all staff are meaningfully completing their required tasks.
  5. That the MCSCS and the CECC immediately conduct a review of the services being provided to inmates in segregation with a view to assessing how the current segregation / protective custody housing options and staff resources are limiting the provision of effective services and compliance with current policies, procedures and standing orders.  Such a review should lead to recommendations for and implementation of concrete, practical changes to the organization and/or staffing of segregation units to ensure that service delivery does not continue to be compromised.
  6. That action be taken by the CECC to ensure that staff in all segregation units are complying with Standing Order 4.22.11 with respect to the use of the Emergency Rescue Knife. Further, that the Standing Order and practical implementation of the Order be amended to include the addition of a second Emergency Response Knife to each control module as a backup when the primary Emergency Knife is on the belt of the staff conducting the watch tour.
  7. That action be taken by the CECC to implement an order that watch tours in segregation units be conducted with two staff in each wing at all times. This is to ensure that in the event of a medical emergency the cell door can be immediately opened.
  8. That a protocol be developed by the CECC to assist with more effective communication regarding the nature of medical emergencies when possible. For example, the use of a coding system like in hospitals.
  9. That the MCSCS review the above three recommendations to ensure that similar systems are in place in other institutions.
  10. That the CECC place a portable defibrillator / AED device in an easily carried kit / bag, along with other basic first aid supplies, in the control module for each pod in the facility. Further, that the MCSCS conduct a review of the placement of portable defibrillator / AED devices and emergency kits in all of its facilities to ensure that they are quickly and easily accessible in the event of life threatening medical emergency.
  11. That the MCSCS amend the curriculum for mandatory training programs on First Aid / CPR / Use of AED for all institutional staff, in every position, in every institution, to include hands on response drills to the calling of emergency codes. This is to ensure that staff can be more organized and efficient when an emergency is actually occurring.