OCC Inquest - Serra 2016

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Serra
Given Name(s): Giuseppe
Age: 40

Held at: 245 Windsor Ave., Windsor
From: August 15
To: August 19, 2016
By: Dr. Curtis Fedoruk, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Giuseppe Serra
Date and time of death: June 17, 2014 at 15:45 hours
Place of death: Tunnel 7 of the Herb Gray Parkway, Windsor, Ontario
Cause of death: Severe blunt force chest trauma
By what means: Accident

(Original signed by: Foreperson and Jurors)


The verdict was received on August 19, 2016
Coroner's name: Dr. Curtis Fedoruk
(Original signed by coroner)


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


Inquest into the death of:

Giuseppe Serra


Jury Recommendations

To the Chief Prevention Officer of the Ministry of Labour:

  1. Direct the current Formwork Working Group to consider implementing standards to mandate that an appropriate number and type of fasteners remain in place to ensure that forms remain upright until they are securely rigged to a hoisting device and to ensure that such fasteners are clearly identified.
  2. Consider whether Construction Regulation 213/91 of the Occupational Health and Safety Act should be amended to require that employers have written procedures for the erection and dismantling of forms, formwork, falsework and reshoring used on a jobsite and ensure that workers are trained in said procedures. Further the regulation should require that such written procedures accompany design drawings.
  3. Implement the Construction Hazard Awareness Training standards and regulations currently under review by the Ministry of Labour as soon as is practical to ensure that all workers receive mandatory hazard awareness training on construction sites.
  4. Consider an amendment to Construction Regulation 213/91 of the Occupational Health and Safety Act, that designates a specific worker be assigned to the process of removal of the fasteners prior to rigging to a hoisting device, and that the Supervisor identify to other workers on site who the designated worker is.  In the event that the designated worker changes, this information is to be communicated to the workers on site.
  5. Consider an amendment to the Construction Regulation 213/91 of the Occupational Health and Safety Act, that requires an employer make reasonable efforts to ensure that written information including work instruction, policies and procedures be provided to the workers in a language that they understand and comprehend.

To the Chief Prevention Officer of the Ministry of Labour, the Infrastructure Health and Safety Association and the Ministry of Advanced Education and Skills Development (formerly the Ministry of Training, Colleges and Universities).

  1. Implement mandatory training and refresher courses for all workers for high risk activities on construction sites.