OCC Inquest - Woods 2017

Bureau du coroner en chef

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Woods
Given Name(s): Joseph Gerald
Age: 42

Held at: 5500 North Service Rd., Burlington, ON
From: January 17th
To: January 19th, 2017
By: Dr. James Kovacs, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Joseph Gerald Woods
Date and time of death: March 11, 2015 at 16:25 hours
Place of death: Milton District Hospital, 7030 Derry Road, Milton, Ontario
Cause of death: Hypoxic-ischemic encephalopathy
By what means: Suicide

(Original signed by: Foreperson)


The verdict was received on the 19 of January, 2017
Coroner's name: Dr. James Kovacs
(Original signed by coroner)


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


Inquest into the death of:

Joseph Gerald Woods


Jury Recommendations

To the Maplehurst Correctional Complex:

  1. That the practice of administering medication and the overall timing of the distribution of medications to inmates be reviewed, in consultation with a medical professional, with an aim to create a schedule for distribution that is the most medically appropriate in the circumstance.
  2. That each officer on duty in an area where inmates are housed be issued a radio and that they carry it with them at all times while on duty in that area.
  3. That Correctional Officers be reminded to adhere to the policy of checking on inmates at the indicated frequencies.
  4. Periodic audits be undertaken to confirm the accuracy of CO logbooks/observation sheets.
  5. An electronic system be implemented with swipe/tap cards outside each cell to ensure that inmates are checked upon at indicated frequencies, where each CO will have an individual identity card to ensure accuracy.
  6. That protocol be developed so the unit control module can ensure, upon receiving any radio alert to a hanging, that the "911 knife" will be delivered to the location as soon as possible.
  7. That consideration be given to reminding operational and medical staff of the importance of assessing the reasons for an inmate's non adherence to their prescribed medication schedule and identifying an action plan to address the identified problem in accordance with the Adherence to Medication and Treatment Plans Policy.
  8. Adhere to the policy of no torn or damaged correctional property in the cells, specifically the practice of clothing lines or anything resembling a clothing line.

To The Ministry of Community Safety and Correctional Services:

  1. That the Ministry of Community Safety and Correctional Services explore the possibility of implementing an electronic health care record system in Maplehurst to assist in improving overall access and accuracy.
  2. That consideration be given to hiring further additional nursing staff to reduce the inmate to nurse ratios especially during medication rounds.