OCC Inquest - Torchia 2017
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given Name(s): Riccardo
Held at: 25 Morton Shulman Avenue, Toronto
From: April 10th
To: April 20th, 2017
By: Dr. David Evans, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Riccardo Torchia
Date and time of death: August 2nd, 2011, at 2:14 p.m.
Place of death: Near 6701 Hwy 7 West, Vaughan, Ontario
Cause of death: Multiple trauma due to motorcycle/truck collision
By what means: Accident
(Original signed by: Foreperson)
The verdict was received on the 20th of April, 2017
Coroner's name: Dr. David Evans
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
To the Ministry of Transportation:
- We encourage the ministry to take steps as soon as reasonably practical to introduce regulations that make it mandatory for drivers with all classes of commercial or truck licences to be re-examined at regular intervals, and provide proof that their vision still meets the standard required, in order to maintain their licence.
- We encourage the ministry to consult with experts to ensure these re-examination intervals are reasonable.
- We encourage the ministry to advise staff that when their computer system indicates that test results for visual acuity are required, they should ensure that an eye test or exam is conducted and not bypass the system, as this presents an opportunity to check eye health.
- The ministry should amend the Form required for drivers applying for a commercial or truck licence. The amendment should explore whether it is possible to insert the most recent driver’s licence photo (or other photo, if available) directly onto the form that must be completed by the health practitioner conducting the vision / medical examination.
- The ministry should continue to accept electronic medical and eye exam forms and no longer accept regular faxed or postal mailed copies in an effort to modernize the system, collect history and make it more efficient for practitioners to submit information, especially when the applicant does not meet the standard.
- The ministry should focus on training of staff and supervisors to verify the information on the form for vision standards or eye exams, review the information to ensure accuracy and make an attempt to verify the identity of the applicant.
- As a longer term strategy, the ministry should consider how to enhance identity verification (i.e. eye scan, fingerprint technology).
- The ministry should consider that only qualified practitioners (Optometrists and Ophthalmologists) administer the visual acuity portion of the exam to ensure the most accurate assessment and reduction of potential "cheating" by patients at a Family Doctor or Nurse Practitioner office that may employ older, less sophisticated eye exam testing approaches.
- The ministry should consider amending the driver's abstract to include all driving charges laid and not just convictions. The abstract period should also be expanded beyond 3 years history (i.e. last 5 or 10 years) with the goal to identify a pattern of poor driving experience.
To the College of Physicians and Surgeons, the College of Optometrists and the College of Nurses:
- We encourage the Colleges to consider requiring that health practitioners confirm identification using government issued photo identification of the person who is seeking completion of a Ministry of Transportation form for driver licencing rather than relying only on self-reporting.
- We encourage the Colleges to consider reminding health practitioners of the need to monitor patients to ensure they do not attempt to circumvent or “cheat” on the vision portion of any licencing examination (by looking through or around fingers that are supposed to cover one eye, for example).
- Colleges should train and remind health practitioners annually of the importance of sending completed forms required for driver licencing directly to the Ministry of Transportation from their office rather than relying on the patient to forward the form, particularly when the patient does not appear to meet Ministry vision standards required to obtain or maintain a licence.
To the Ministry of Community Safety and Correctional Services and the Ministry of the Attorney General:
- The ministries should consider whether it is feasible to require that all drivers involved in fatal motor vehicle collisions be subject to drug and alcohol testing.