OCC Inquest - Ysebert 2017

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Ysebert
Given name(s): Jeffrey
Age: 34

Held at: 860 William Street, Cobourg
From: Nov. 8
To: Nov. 9, 2017
By: Dr. Jennifer Tang, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jeffrey Raymond Ysebert
Date and time of death: January 11th, 2015 at 7:05 a.m.
Place of death: Peterborough Regional Health Centre
Cause of death: Acetaminophen hepatotoxicity
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on the 9 of Nov., 2017
Coroner's name: Dr. Jennifer Tang
(Original signed by coroner)


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


Inquest into the death of:

David Robert Hagen


Jury Recommendations

We, the jury, recommend to Correctional Services Canada:

  1. Any blister packs or bottles of acetaminophen distributed in the facility must have a warning label that states the maximum daily dose in accordance with the recommendations from Health Canada that doses above the recommended dose do not add to pain relief and that taking excessive doses creates serious risk without adding any benefit. The warning label should also include the consequences of overdose as stated by Health Canada (death and/or liver failure).
  2. Take into account the daily maximum (24 hours) dose of acetaminophen suggested by Health Canada when allocating tablets into blister packs, only providing the maximum dosage for a 24 hour period.
  3. Review Correctional Services Canada protocol surrounding hourly cell checks to ensure correctional officers are documenting accurate and detailed observations pertaining to inmates’ health and welfare (i.e. vomiting, physical condition), to ensure the safety and well-being of the inmate.

To the Ministry of Health and Correctional Services Canada:

  1. Review the wait times for inmates to be seen by health care professionals.