OCC inquest - Unkerskov-Chinnery
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given Name(s): Andreas
Held at: Hamilton, Ontario
From: March 7
To: March 14, 2016
By: Dr. William Lucas, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Andreas Unkerskov-Chinnery
Date and time of death: February 2, 2011 at 11:23 p.m.
Place of death: Hamilton General Hospital, Hamilton, Ontario
Cause of death: Perforating gunshot wound of abdomen
By what means: Homicide
(Original signed by: Foreperson and Jurors)
The verdict was received on the 14th of March, 2016
Coroner's name: Dr. William Lucas
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
To Minster of Health (Canada), the Minister of Justice (Canada) and the Ontario Ministry of Health and Long Term Care
- Use of cannabis products may have adverse mental health effects on vulnerable individuals, especially adolescents and young adults. If the legal status of cannabis products changes such that they become more widely available, governments should consider medical or other available evidence in order to determine an appropriate minimum age for possession or use of the products.
- Use of cannabis products may have adverse mental health effects on vulnerable individuals, especially adolescents and young adults. If the legal status of cannabis products changes such that they become more widely available, governments should consider regulating the potency of the products. If the different potencies are permitted, and medical or other available evidence warrants it, governments should consider requiring that warnings on packaging reflect that increased potency may increase associated risks.
- Use of cannabis may have adverse mental health effects on vulnerable individuals, especially adolescents and young adults. If the legal status of cannabis products changes such that they become more widely available, governments should consider requiring informative packaging warning consumers of the potential psychological or physical risks associated with use of the products, as is required for tobacco packaging.
- Use of cannabis products may have adverse mental health effects on vulnerable individuals, especially adolescents and young adults. If the legal status of cannabis products changes such that they become more widely available, governments should engage in public awareness campaigns to inform the public (with a special focus on adolescents and young adults) of the potential risks associated with consumption of those products.
To the Ministry of Health and Long Term Care and local Medical Officers of Health
- Consider developing and/or enhancing public awareness campaigns to educate the public, and particularly youth, about recognizing the early signs and symptoms of mental illness. Consider engaging young people in the development of this campaign that speaks directly to this audience. Campaign information should include resources available within the community that provide support and potential intervention to the persons needing them.
To the Ministry of Children and Youth Services
- Consider incorporating a psychological screening tool as part of the risks/needs assessment and case management plans with regards to youth involved in Ontario Youth Justice System.
- Direct supervisors of the probation officers who are delivering services within the meaning of the Youth Criminal Justice Act and under the Child and Family Services Act to ensure that those workers review and revise the case management plan if the youth is either non-compliant or not making progress and/or achieving the goals of the case management plan to see if the goals are appropriate to the needs of the young person and what other options can be pursued.
- Consider training and implementing Motivational Interviewing techniques for probation officers to utilize in their ongoing assessment and interactions with the youth in order to gain a better understanding of what is important to the individual and what motivates them to elicit behavioral changes. Ideally this technique should be used with individuals who have experienced developmental trauma (i.e. divorce, number of moves, number of schools) making them more vulnerable to crisis.
- Consider annual audits of risk/needs assessments and case management plans of the probation officer’s files to ensure compliance with the appropriate policies.
- Educate probation officers on the meaning and importance of the policy that requires Probation Officers to meet with young people in their own environment. If safety concerns preclude Probation Officers from attending at the residence of the young person, the Ministry should provide guidance on satisfactory alternatives including the creation of safe spaces for the workers to meet with youth outside of the probation offices.
To the Hamilton Police Services
- Increased and ongoing training for communications branch to ensure clear, effective and efficient information is relayed from dispatcher to police based on information provided from call taker.
- Review (capture) or study the use of force cases dealing with persons in crisis to identify future training opportunities for patrol officers and the communication branch.
- Make probation officers and youth aware of the Strategic Targeted Offenders Program (STOP) and the implications for the youth for whom they provide case management services.
- Consider enhancing the STOP program by investigating ways to further increase positive interactions between the youth and police officers.
- Explore ways to educate young people about the Crisis Outreach and Support Team (COAST) program and how to access the services of COAST.
- Consider investigating the use of wide angled lapel cameras for frontline officers in order to verify the event and gather more information about the interaction.
- Consider incorporating this case as a scenario learning tool at the Hamilton Police Service Training Facility in order to exercise and solidify officer skills in de-escalation.
- Consider scenario training in the area of disarming techniques involving an armed subject (non firearm related).