Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario

Surname: Smith
Given Name(s): Gerald
Age: 57

Held at: Napanee, Ontario
From: April 12
To: April 12, 2016
By: Dr. Shane Teper, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Gerald Smith
Date and time of death: December 4, 2013 at 12:35 a.m.
Place of death: Kingston General Hospital
Cause of death: Hypoxic ischemic encephalopathy complicating cardiorespiratory arrest due to hanging.
By what means: Suicide

(Original signed by: Foreperson and Jurors)

The verdict was received on April 12, 2016
Coroner's name: Dr. Shane Teper
(Original signed by coroner)

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

Inquest into the death of:

Jury Recommendations

Segregation units should not have beds with overhead rails.