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Office of the Chief Coroner

Verdicts and Recommendations from Inquests

Updated to July 2008

A  B  C  D  E  F  G  H  J  K  L  M  N  O  P  R  S  T  V  W  Y

If you don't see the name you are looking for, please contact Katherine Stephen in the Office of the Chief Coroner.
Deceased Date
of Inquest		 Presiding Coroner Verdict Recommendations Summary of Inquest
ACRES, Bruce Willis June 23-24, 2004 Dr. A. McCallum   recommendations Accident. Farm tractor.
AL-AMIZI, Saad Oct. 29, 2004 Dr. G. Watt verdict no recommendations Accident. Custody. Morphine.
ALVES, Jose
LEON, Darren
 June 9-19, 2003 Dr. D. Schooling verdict recommendations Accident. Construction.
ANDERSON, Wayne W. March 17-19, 2008. Dr. W. Buckton verdict and recommendations   Natural. Custody. Sarnia Police.
ANWAR, Najib June 27, 2005 Dr. A. McCallum verdict & recommendations   Natural. Custody. Kingston Penitentiary.
APPLETON, Robert John P. May 22, 2008. Dr. R. Caskey verdict & recommendations   Natural. Custody. Warkworth Institution.
ASHLEY, William Nov. 7-24, 2005 Dr. R. Drake verdict   Accident. Construction. Gas line.

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B

BAKER, Cyril March 16-17, 2005 Dr. R. Chivers verdict & recommendations   Accident. Construction on highway.
BAKER, John Mansfield June 16-17, 2003 Dr. D. Cooke verdicts & recommendations   Natural. Custody. Warkworth Institution.
BALOG, Joseph Dec. 13-15, 2004 Dr. P. Savage verdict recommendations Accident. Custody. Central North Correctional Facility
BARBER, Mark April 25-25, 2007 Dr. J. Carlisle verdict recommendations Natural. Custody. Metro West Detention Centre.
BARBIERI, Nicola Feb. 9-10, 2004 Dr. R. Boyko verdict & recommendations   Accident. Construction.
BARKER, Jamie Bryant June 14, 2004 Dr. T. Wilson verdict & recommendations recommendations Accident. Construction. Drowning. Ambassador Bridge.
BARKER, Ronald Nov. 28, 2005 Dr. R. McILQUHAM verdict & recommendations   Suicide. Custody. Collins Bay Institution.
BARNES, Gerald November 26-27, 2007. Dr. R. Mann verdict & recommendations   Accident. Construction.
BARRETT,Kenneth Feb. 8-10, 2005 Dr. J.R. Swain verdict recommendations Accident. Construction.
BEERS, Craig
JENKINS, Judith
PIDGEON, Steven
STEVENSON, David
 Nov. 1-Dec. 2, 2004 Dr. W. Lucas verdict (BEERS)
verdict (JENKINS)
verdict (PIDGEON)
verdict (STEVENSON) 		recommendations Accident. Undetermined. Methadone.
BEGIN, Richard Jan. 20, 2005 Dr. E. Gardiner verdict recommendations / explanation Accident. Construction.
BEIRNES,Steven April 27-28, 2006 Dr. J. Deacon verdict   Suicide. Custody.
BELCOT, Donald Feb. 2-3, 2004 Dr. R. Chivers verdict   Natural. Custody. Hamilton Detention Centre
BELDMAN, David January 29 - February 7, 2008. Dr. J. Stanborough verdict and recommendations   Natural. Psychiatric facility.
BELL, George
EVANS, Donald
EVANS, Caroline (Joy)
McKAY, Vivian
OSTER, Cynthia		 Sept. 12-Nov. 16, 2005 Dr. B. Porter verdict (BELL, G.)
verdict (EVANS, D.)
verdict (EVANS, C.)
verdict (McKAY, V.)
verdict (OSTER, C.)		 recommendations Accident.Vehicle.
BENJAMIN, Troy April 6-13, 2005 Dr. W. Lucas verdict & recommendations explanation Natural. Custody. Peel Regional Police.
BENNETT, Clifford R. April 29, 2002 Dr. B. Bechard verdict & recommendations   Accident. Custody.
Collins Bay Penitentiary
BISSCHOPS, Robert, L. April 4-8, 2005 Dr. S. McRae verdict & recommendations   Accident. Custody. Sudbury Jail.
BLACK, Jermaine Kenneth Dec. 14-20, 2006 Dr. A. Lauwers verdict recommendations Natural. Custody.
BLAIR, James Fitz-Roy March 27 - April 5, 2006 Dr. D. Evans verdict recommendations Natural. Custody.
BLAIS, Denis Feb. 7-March 3, 2005 Dr. P. Clark verdict & recommendations   Suicide. Psychiatric institution.
BLAIS, Serge Oct. 7-8, 2004 Dr. R. Drake verdict & recommendations   Accident. Gravel Pit.
BLANCHETTE, Yvan May 4-6, 2005 Dr. B. Mainville verdict & recommendations   Accident. Custody. Millhaven Penetentiary.
BODEN, Wayne Dec. 20, 2006 Dr. R. McIlquham verdict   Natural. Custody.
BOLGER, John, C. Dec. 5-13, 2005 Dr. P. Savage verdict recommendations Suicide. Custody. OPP.
BONNEAU, Robert Feb. 12-13, 2007 Dr. J. Carlisle verdict recommendations Natural. Custody.
BOREA, Ernesto April 11-12, 2005 Dr. W. Ewen verdict & recommendations   Accident. Custody. Maplehurst Correctional Facility.
BOUCHARD, Keith February 20, 2008. Dr. L. McNaughton-Filion verdict and recommendations   Natural. Custody. Kingston Penitentiary.
BOWMAN, Scott March 31, 2003 Dr. P. Clark verdict & recommendations   Suicide. Custody. Belleville Police.
BOYD, David Feb. 24, 2004 Dr. A. Lauwers verdict & recommendations   Natural. Custody. Warkworth Penitentiary
BOZIC, Mikael Anthony Dec. 5-12, 2006 Dr. J. Ewen verdict   Natural. Custody.
BOZIC, Tijana Sep. 26 - Oct. 7, 2005 Dr. J. Edwards verdict   Accident. Traffic.
BREDESEN, David June 20-22, 2005 Dr. R. Boyko verdict recommendations Accident. Construction.
BUDGELL, Christine June 11-19, 2007 Dr. W. Lucas verdict recommendations Undetermined. Custody. Durham Regional Police.
BURNS, Jerome June 24-27, 2003 Dr. D. Legge verdict & recommendations   Accident. Mining.
BURTON, John May 3, 2006 Dr. P. Savage verdict   Natural. Custody.

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C

CAMERON, Charles I. June 24, 2003 Dr. B. Mainville verdict   Accident. Custody. Kingston Penitentiary. Excited Delirium.
CAMERON, James May 7, 2008. Dr. B. Mainville verdict and recommendations   Suicide. Custody. Kingston Penitentiary.
CAMPSALL, David W. B. April 21-23, 2008. Dr. A. McCallum verdict and recommendations   Accident. Custody. Quinte Detention Centre.
CANCAR, Filip May 12-14, 2008. Dr. D. Sedran verdict   Suicide. Custody. Toronto Police.
CARINGI, Enrico Oct. 3-5, 2006 Dr. J. Edwards verdict recommendations Accident. Construction
CARUSO, Joseph Jan. 30 - Feb. 9, 2006 Dr. J. Edwards verdict rrecommendations Natural. Custody.
CASA VERDE NURSING HOME
EL ROUBI, Ezzeldine
and
LOPEZ, Pedro		 Jan. 31-April 18, 2005 Dr. D. Evans verdict (EL ROUBI, E.)
verdict (LOPEZ, P.)		 recommendations Homicide. Nursing Home.
CASWELL, Moira Jan. 17-25, 2005 Dr. D. Eden verdict recommendations Accident. Snow grooming machine.
CATENA, Anthony June 16-18, 2003 Dr.W.D. Allin verdict recommendations Accident. Construction.
CHRISTOPHER-REID, O'Brien November 5 - December 14, 2007 Dr. J. Edwards verdict, recommendations and explanation   Homicide. Custody. Toronto Police. Mentally ill.
CHRISTOU, Nicholas September 11-13, 2007. Dr. D. Sedran verdict recommendations Accident. Construction.
CIPOLLONE, Vincenzo December 13, 2007. Dr. D. George verdict no recommendations Natural. Custody. Beaver Creek Institution.
CLEMENT, James and Ryan Feb. 28-March 3, 2005 Dr. D. Cooke verdict & recommendations   Accident. Construction. Electrocution.
COASTER, Kenneth March 16-18, 2005 Dr. D. Legge verdict recommendations Suicide. Custody. O.P.P.
COOPER, Tyler Sept. 19-27, 2005 Dr. D. Wolski verdict & recommendations   Accident. School Trip.
CORBETT, Ronald Robert Jan. 31, 2007 Dr. A. McCallum verdict   Natural. Custody.
CORRIGAN, John Nov. 8-9, 2004 Dr. J. Kovacs verdict recommendations Accident. Construction.
COUTTS, Burns June 26-30, 2006 Dr. G. Watt verdict & recommendations   Suicide. Custody. Ottawa Police.
COX, Edward July 14-16, 2003 Dr. K. Smith verdict recommendations Accident. Construction.
CRUPI, Carmelo January 31 - February 1, 2008. Dr. G. Watt verdict no recommendations Natural. Custody. Ottawa Police.
CUDDY, Kerri Nicole Dec. 13-16, 2004 Dr. W. Lucas verdict & recommendations   Suicide. Custody. Peel Regional Police.

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D

DaROSA, Henry Aug. 18-19, 2003 Dr. D. Legge verdict & recommendations   Accident. Construction.
DASILVA, TImothy May 27-28, 2008. Dr. D. Schooling verdict & recommendations   Accident. Construction.
DAVIDSON, William March 23, 2005 Dr. A. McCallum verdict & recommendations   Accident. Custody. O.P.P.
DAVIS, Jonathan Nov. 3-4, 2004 Dr. R. Sawkiw verdict & recommendations   Accident. Mining.
DEBOER, Klaas
VANREES, Michael
 Dec 9-11, 2002 Dr. P. Savage verdict recommendations Accident. Construction. Trench cave in.
DEFIGUEIREDO, N. Feb. 16-18, 2004 Dr. D. Huyer verdict recommendations Accident. Construction.
DEOL, Baljit Singh April 22-29, 2003 Dr. A. Lauwers verdict & recommendations   Natural. Custody. Millbrook Correctional Centre.
DiCARO, Salvatore Oct. 6-7 2003 Dr. W. Lucas verdict recommendations Accident. Construction.
Di PASQUALE, Diego Jan. 27, 2003 Dr. B. Mainville verdict no recommendations Natural. Custody. Kingston Penitentiary.
DIPLOCK, Drew Feb. 28, 2005 Dr. D. Wolski verdict & recommendations   Suicide. Custody. Brantford Jail.
DOKIS, Kelly June 16-19, 2003 Dr. C. Rathwell verdict recommendations Accident. Construction. Electrocution
DOLEJS, Alois Oct. 30, 2006 Dr. B. Bechard verdict no recommendations Natural. Custody.
DUBOIS, Raymond July 9-13, 2007 Dr. D. Mutrie verdict & recommendations   Suicide. Custody. Thunder Bay Jail.
DUKIC, Bryan March 25-28, 2008. Dr. C. Fedoruk verdict & recommendations   Accident. Custody. Windsor Police.
DUPONT, Lori
DANIEL, Marc		 September 24 - December 11,2007. Dr. A. McCallum verdict and recommendations   Homicide. Suicide. Discretionary. Workplace violence. Domestic violence.
DWYER, David Oct. 27, 2004 Dr. McIlquham verdict & recommendations   Natural. Custody. Kingston Penitentiary.

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E

EADIE, Randolph Nov. 28-29, 2005 Dr. W. George verdict & recommendations   Accident. Construction
EARLEY, Stephen November 7, 2007 Dr. B. Mainville verdict no recommendations Suicide. Custody. Joyceville Institution.
EFFORD, David June 20-12, 2005 Dr. P. Clark verdict recommendations Accident. Construction.
EGYPT, Leonard June 26-27, 2006 Dr. D. Giddens verdict   Natural. Custody.
ELLIOT, Jeffrey Thomas Sept. 13-24, 2004 Dr. P. Savage verdict & recommendations   Accident. Custody. Penetanguishene.
ELSIDDIQ, Gasim S. May 14, 2007 Dr. M. Reingold verdict recommendations Natural. Custody. Metro West Detention Centre.
ENGLISH, Robert May 31, 2007 Dr. B. Bechard verdict   Natural. Custody. St. Lawrence Valley Correctional Centre
EVANS, Michael Nov. 10, 2003-Jan. 20, 2004 Dr. R. Isaac verdict recommendations Accident. Construction.

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F

FAIRSERVICE, Terry April 4-6, 2005 Dr. D. Legge verdict   Accident. Mining.
FARMER, James June 7-9, 2004 Dr. W. Buckton verdict recommendations Suicide. Custody. Windsor Jail.
FARROWS-SHELLEY, William April 21-22, 2008. Dr. P. Clark verdict and recommendations   Natural. Custody. Warkworth Institution.
FAUSTINI, Paolo April 4-6, 2005 Dr. D. Wolksi verdict & recommendations   Accident. Construction.
FERNANDES, Joseph F. December 17-18, 2007 Dr. D. Schooling verdict and recommendations   Natural. Custody. Maplehurst Correctional Facility.
FERRON, Gilles Jan. 28, 2004 Dr. R. McIlquham verdict & recommendations   Natural. Custody. Kingston Penetentiary.
FLEXMAN, Andrew July 25, 2006 Dr. B. Bechared verdict no recommendations Accident. Construction.
FOBISTER, Geronimo Oct. 18-29, 2004 Dr. J. Hammett verdict recommendations Homicide. Custody. Standoff with police.
FRANCIS, Peter Jan. 29 - Feb. 7, 2007 Dr. J. Edwards verdict recommendations Homicide. Custody. Toronto Police shooting.
FRANCISCO, Armindo DeJesus Sept. 8-10, 2003 Dr. D. Huyer verdict recommendations Accident. Construction.
FRIVALT, George Russell December 17-19,2007. Dr. R. SKinner verdict & recommendations   Accident. Custody. Owen Sound Jail.
FRUSTIK, Peter Andrew June 12, 2003 Dr. B. Bechard verdict no recommendations Homicide. Custody. Collins Bay Penitentiary

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G

G, R (youth) May 4-7, 2004 Dr. K. Acheson verdict recommendations Accident. Custody. Youth.
GAGNE, Robert J. November 13-16, 2007. Dr. D. Schooling verdict and recommendations   Suicide. Custody. Maplehurst Correctional Facility.
GAREL, Elliot May 11, 2006 Dr. P. Savage verdict no recommendations Natural. Custody. Oakridges Mental Health Centre.
GRAHAM, Mark Norman June 3-July 2, 2002 Dr. K. Acheson verdict recommendations Undetermined. Police Shooting. South Simcoe Police.
GREENBIRD, Willard Albert April 13, 2004 Dr. J. Ewan verdict recommendations Natural. Custody. Maplehurst.
GRGAS, Mate May 22-23, 2007. Dr. S. Teper verdict and recommendations   Accident. Construction.
GROZELLE, Joseph Theodore March 19 - April 26, 2007 Dr. D. Eden verdict & recommendations verdict and recommendations Undetermined. Discretionary. Military College.

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H

HACKETT, Kenneth Feb. 10, 2004 Dr. T. Wilson verdict & recommendations   Accident. Construction.
HADLEY, Gillian
HADLEY, Ralph		 Oct. 22, 2001-Feb. 8, 2002 Dr. B. Porter verdict (GH)
verdict (RH)		 recommendations Homicide. Suicide. Domestic violence.
HAILE-SELASSIE, Girma Haile February 26-27, 2008. Dr. J. Kovacs verdict and recommendations   Accident. Construction.
HAINEAULT, Gladys Ann July 22, 1998 Dr. T. Gillmore verdict recommendations Natural. Custody. Toronto West Detention Centre.
HANNAN, Michael March 29-April 1, 2005 Dr. J. Ewen verdict recommendations Accident. Occupational.
HATT, Wade Lamont Oct. 30 - Nov. 4, 2006 Dr. A. McCallum verdict   Accident. Drugs. Methadone.
HATTON, Robert C. June 18-21, 2007 Dr. B. Mainville verdict & recommendations   Homicide. Custody. Ottawa-Carleton Regional Treatment Centre.
HAUGHTON, Dwight July 18-22, 2005 Dr. D. Evans verdict & recommendations   Accident. Custody. Toronto Police.
HAWKE, Leon Wayne May 6-7, 2002 Dr. D. Evans verdict recommendations Natural. Custody. Toronto Jail
HAWKINS, Richard May 3-5, 2005 Dr. D. Schooling verdict recommendations Accident. Construction. Electrocution.
HAWLEY, Michael Richard June 18, 2003 Dr. R. Caskey verdict no recommendations Natural. Custody. Warkworth Penitentiary
HEIKAMP, Jordan Jan. 9-April 11, 2001 Dr. J. Cairns verdict recommendations Homicide. Chronic starvation of infant.
HEFFERN, Gordon Nov. 15-19, 2004 Dr. J. Deacon verdict & recommendations   Accident. Mines.
HEFFERNAN, Ambrose Aug. 19, 2002 Dr. D. Thompson verdict recommendations not avail online Accident.Traffic. Monster Truck.
HENDERSON, John Aug. 8-11, 2005 Dr. D.M. Child verdict & recommendations   Accident. Construction. Drowning.
HENNING, Daniel Dec. 10-12, 2002 Dr. C. Rathwell verdict no recommendations Suicide. Custody. Guelph Treatment Centre
HIPSON, Michael November 13-22,2007. Dr. J. Stanborough verdict & recommendations   Accident. Construction.
HO, Allen May 8-June 1, 2000 Dr. B. McLellan verdict recommendations Accident. Ecstasy.
HO-NGUYEN, Quang Hein Jan. 19-22, 1999 Dr. T. Gillmore verdict recommendations Suicide. Custody. Don Jail.
HODGE, Sydney David June 23-24, 2003 Dr. A. McCallum verdict   Natural. Custody. Burtch Correctional Facility.
HOEY, David John June 7-10, 2004 Dr. J. Ewen verdict no recommendations Accident. Custody.
HOFFMAN, Victor July 18, 2005 Dr. P. Savage verdict no recommendations Natural. Custody. Oakridges Mental Health.
HULKO, William Walter May 1, 2003 Dr. B. Bechard verdict explanation Accident. Custody. Quinte Detention Centre.
HYPOLITE, John Jan. 25, 2006 Dr. R. McIlquham verdict   Natural. Custody.

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J

JACKPINE, Rodney Nov. 1, 2006 Dr. R. McIlquham verdict   Suicide. Custody.
JAITLY, Shalendra June 30, 2004 Dr. J. Edwards verdict   Suicide. Custody.
JANIC, Vladislav July 12-22, 2002 Dr. W. Lucas verdict recommendations Suicide. Police involvement.
JANIK, Marian Oct. 17-19, 2005 Dr. J.Kovaks verdict recommendations Accident. Construction.
JOANISSE, Stephane Oct. 26-27, 2005 Dr. R. Sawkiw verdict recommendations Accident. Mining.
JOBIN, Stephanie Nov. 18-Dec. 17, 2002 Dr. W. Lucas verdict recommendations Undetermined. Use of restraints. Group home.
JOHNSON, Shanay Jami April 1-May 9, 1997 Dr. R. Bennett verdict recommendations Homicide. Child Protection.
JOHNSON, Steven April 17, 2007 Dr. D. Schooling verdict no recommendations Natural. Custody. Maplehurt Correctional Facility.
JOHNSTONE, Emma Jordan April 22-25, 2003 Dr. R. Mann verdict & recommendations   Accident. Drowning. Backyard pool.
JOLIN, Guy Feb. 7-14, 2005 Dr. D. Wolski verdict & recommendations   Accident. Mining.
JONES, Robert Eric Feb. 26, 2003 Dr. R. McIlquham verdict no recommendations Natural. Custody. Kingston Penitentiary.

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K

K, M. (youth) Feb. 14-21, 2005 Dr. D. Eden verdict & recommendations   Suicide. Custody. Sprucedale Youth Centre.
KANESHAKUMAR, Jeyaraanie. June 7-21, 1999 Dr. D. Eden verdict recomendations Natural. Health Care. Pregnant.
KEATING, Michael E. Sept. 25-27, 2007 Dr. M. Bourne verdict & recommendations   Accident. Construction.
KENNEDY, Todd Aug. 2-4, 2005 Dr. D. Coates verdict & recommendations   Suicide. Custody. Windsor Jail.
KHEDUP, Rinchen Tsering March 26, 2007 Dr. A. Lauwers verdict recommendations Suicide. Custody. Metro West Detention Centre.
KIDNIE, Elizabeth March 4-15, 2002 Dr. W. Lucas verdict recommendations Undetermined. Pedestrian struck by elderly driver.
KNIGHT, Jerry June 3 - 13, 2008. Dr. W. Lucas verdict recommendations Homicide. Excited Delirium. Peel Police.
KOEKMAN, Andrew P. January 7-9, 2008. Dr. R. Mann verdict and recommendations   Suicide. Custody. Walkerton Jail.
KOLISNYK, Michael June 19-22, 2006 Dr. D. Legge verdict & recommendations   Homicide. Custody. Thunder Bay Police.
KUDRATH, Sheik June 4-6, 2001 Dr. J. Edwards verdict recommendations Natural. Custody. Toronto West Detention Centre.
KWIECIEN, Sophia July 15-25, 1996 Dr. M. Milton verdict recommendations Accident. Health Care.

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L

LADOUCEUR, Martine Ann May 31-July 9, 2004 Dr. D. Legge verdict recommendations Suicide. Custody. THunder Bay District Jail.
LAMIRANDE, Rock Oct. 18-20, 2004 Dr. D. Legge verdict recommendations Accident. Mines. Placer Dome.
LAMOND, Chad November 5, 2007. Dr. R. Sawkiw verdict and recommendations   Accident. Mining.
LAMONDAY, Peter May 2-13, 2005 Dr. T. Wilson verdict & recommendations   Accident. Custody. London Police Service.
LATHAM, Brian Oct. 31, 2005 Dr. J. Deacon verdict & recommendations   Natural. Custody. Frontenac Institution.
LAMOUREUX, Andre March 1-2, 2004 Dr. J. Deacon verdict recommendations Accident. Mines. Falconbridge.
LATIMER, Sabrina June 7-15, 2005 Dr. A. McCallum verdict & recommendations   Accident. Railway. Pedestrian.
LAUZON, Albert Oct. 12, 2005 Dr. R. McIlquham verdict no recommendations Natural. Custody. Kingston Penitentiary.
LAUZON, Mattieu September 11-14, 2007 Dr. D. Evans verdict and recommendations   Accident. Custody. Barrie Police Service.
LAURIER, Brian Feb. 14, 2006. Dr. A. McCallum verdict & recommendation   Accident. Custody.
LAVALLEE, Kevin April 28-30, 2003 Dr. D. Eden verdict   Accident. Custody. Windsor Detention Centre
LEE, Wallace Nov. 28 - Dec. 2, 2005 Dr. W. Lucas verdict recommendations Accident. Martial Arts.
LEFLER, Claude Dec. 19, 2005 Dr.J. Deacon verdict & recommendations verdict and recommendations Natural. Custody. Kingston Penitentiary.
LETREN, Lawrence Jan. 14-15, 2004 Dr. J. Swain verdict recommendations Accident. Construction.
LEVASSEUR, ALbert Joseph March 2, 2005 Dr. R. McIlquham verdict no recommendations Natural. Custody. Bath Institution.
LEWIS, Lana Dale April 22, 2002-Jan. 16, 2004 Dr. B. McLellan verdict recommendations Accident. Stroke.
LIEFSO, Kell December 10-11, 2007. Dr. J. Stanborough verdict and recommendations   Suicide. Custody. Owen Sound Jail.
LINKLATER, Maurice Jan. 20-24, 2003 Dr. D. Legge verdict & recommendations   Undetermined. Police Shooting. O.P.P.
LINO, Carlos Feb 15-18, 1999 Dr. F. Demanuele verdict recommendations Accident. Construction.
LOBKO, Igor June 5-7, 2007 Dr. D. Legge verdict & recommendations   Accident. Mining. Kirkland Lake Gold Mine.
LOCEY, Ronald June 23, 2003 Dr. B. Mainville verdict no recommendations Natural. Custody. Millhaven Correctional Institute.

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M

MacKINNON, Tyrell June 28, 2006. Dr. B. Bechard verdict   Natural. Custody.
MAGEE, Christopher Oct. 18-29, 2004 Dr. T. Wilson verdict & recommendations   Accident. Custody. St. Thomas Psychiatric Hospital.
MALESKA, Susan Oct. 23-24, 2006 Dr. B. Bechard verdict & recommendation   Accident. Custody.
MANDY, Lorand March 22-29, 1999 Dr. M. Naiberg verdict recommendations Accident. Mental Health.
MANCHESTER, Allen Oct. 30-31, 2006 Dr. S. McRae verdict & recommendations verdict and recommendations Accident. Construction.
MANSHIP, David John Sept. 22-25, 2006 Dr. G. Watt verdict & recommendation   Suicide. Custody.
MANZANO, Hugo March 14-28, 2000 Dr. W. Lucas verdict & recommendations   Accident. Custody. Toronto Police.
MARCHE, Troy March 27-28, 2001 Dr. A. Jones verdict recommendations Accident. Construction.
MARINZEL, John Sept. 22-23, 2003 Dr. D. Giddens verdict recommendations Accident. Construction. Subway.
MARSKELL, John Allen May 2-3, 2007 Dr. A. Lauwers verdict recommendations Natural. Custody. Toronto West Detention Centre.
MARTIN, Alice Aug. 23-Sept 7, 2004 Dr. B. Bechard verdict & recommendations   Natural. Health Care. Ambulance.
MARTIN, Jonas June 19-20, 2006 Dr. D. Schooling verdict & recommendations   Accident. Construction.
MASON, Scott
PRIESTMAN, Christopher		 June 7-11, 2004 Dr. D. Huyer verdict recommendations Accident. Gravel Pit.
MASSA, Jennifer April 26-29, 1999 Dr. A. Jones verdict recommendations Accident. Custody. RCMP.
MASUKA, Henry April 17-May 3, 2001 Dr. W. Lucas verdict recommendations Undetermined. Police Shooting.
MAY, Arlene
ILES, Randy		 Feb. 16-July 2, 1998 Dr. B. Porter MAY verdict
ILES verdict		 recommendations Murder. Suicide. Domestic Violence
McCABE, Mark Dec. 10-14, 2001 Dr. R. Isaac verdict recommendations Accident. Construction.
McCARRELL, Lawrence Feb. 12-13, 2003 Dr. P. Clark verdict & recommendations   Accident. Custody. Warkworth Penitentiary.
McCARTHY, Sarah April 27, 2007 Dr. A. McCallum verdict & recommendations   Accident. Traffic. Alcohol.
McCONNEY, Calvin James Sept. 27, 2004 Dr. B. Bechard verdict no recommendations Natural. Custody. Kingston Penitentiary
McCRACKEN, Derek 24 Nov., 2003 Dr. C. Rathwell verdict, recommendations and Coroner's Explanation   Accident. Custody. Cocaine poisoning.
McDONALD, James June 11-13, 2003 Dr. P. Savage verdict recommendations Accident. Construction.
McDONALD, Sean May 7, 2008. Dr. R. McIlquham verdict   Natural. Custody. Kingston Penitentiary.
McINNES, James Dec. 14, 2005 Dr. R. McIlquham verdict no recommendations Natural. Custody. Kingston Penitentiary.
McINTOSH, Basil March 10-13, 2008 Dr. D. Evans verdict and recommendations   Natural. Custody. Waterloo Regional Police.
McINTYRE, James Sept. 16-Oct. 10, 1996 Dr. T. Gillmore verdict recommendations Homicide. Homeless shelter.
McKNIGHT, Robert Sept. 27, 2005 Dr. A. McCallum verdict no recommendations Natural. Custody. Hamilton Detention Centre.
McLAREN, Norman July 19-20, 1999 Dr. J. Taylor verdict   Natural. Custody.
McLEAN, Ellias
McLEAN, Asha Jade
SHAW, Pearl		 Aug. 12-Oct. 4, 2002 Dr. P. Clark verdict   Accident. Smoke inhalation.
McLEAN, Kimberly May 25 - June 14, 2004 Dr. D. WOlksi verdict   Undetermined. Custody.
McNEIL, Edward Dec. 12-20, 2005 Dr. R. Isaac verdict recommendations Accident. Custody. Toronto Police.
McNEIL, Karl Sept. 27, 2006 Dr. B. Mainville verdict & recommendations   Homicide. Custody.
MEERE, Arthur April 27, 2005 Dr. R. Chivers verdict no recommendations Natural. Custody. Hamilton Detention Centre.
MEFFE, David Jan. 19-April 8, 2004 Dr. D. Evans verdict recommendations Suicide. Custody. Toronto Youth Assessment Centre.
MERRITT, Robert April 2-4, 2003 Dr. E. Spencer verdict & recommendations   Accident. Construction.
MICHAUD, Stephane October 11-31, 2007 Dr. B. Bechard verdict and recommendations   Accident. Custody. Ottawa Airport.
MILLER, Garry Jan. 26, 2005 Dr. R. McIlquham verdict no recommendations Natural. Custody. Kingston Penitentiary.
MILLIKEN, Christopher Dec. 17, 2003 Dr. P. Clark verdict no recommendations Natural. Custody. Warkworth Institute.
MISENER, Allan July 21-23, 2003 Dr. R. Chivers verdict & recommendations   Accident. Construction. Electrocution.
MITCHELL, Leonard June 14, 2007 Dr. J. Deacon verdict   Natural. Custody. Bath Institution.
MITCHELL, Megan
AUCLAIR-MITCHELL, Erica		 May 4-20, 2004 Dr. D. Legge MITCHELL verdict
AUCLAIR-MITCHELL verdict		 recommendations Accident. Hypothermia. Canoe.
MITCHELL, Steven April 10-11, 2007 Dr. D. Giddens verdict recommendations Suicide. Custody. Don Jail.
MITTEN, Benjamin Nov. 27-Dec. 4, 2003 Dr. C. Rathwell verdict, recommendations and coroner's explanation   Suicide. Custody. Brantford Jail.
MONAHAN, Larry
WEST, Kenneth		 Jan. 17-19, 2005 Dr. T. Wilson verdict & recommendations   Accident. Construction.
MONARDO, Frank April 19-20, 1999 Dr. J. Giddens verdict recommendations Accident. Construction.
MONTGOMERY, Patrick Allen April 26-27, 2006 Dr. D. Wolski verdict & recommendations   Suicide. Custody.
MOORE, Douglas Donald March 19-25, 2008. Dr. D. Evans verdict and recommendations   Suicide. Custody. Maplehurst Correctional Facility.
MOORE, Wayne Dec. 18-19, 2000 Dr. J. Giddens verdict recommendations Natural. Custody.
MORADIAN, Morteza May 25-26, 1999 Dr. M. Reingold verdict recommendations Accident. Construction.
MORASSUTTI, Sergio Sept. 13-16, 2006 Dr. B. Lauwers verdict   Accident. Construction.
MORENCY, Craig James July 28-29, 2005 Dr.W. Buckton verdict & recommendtions   Accident. Custody. Windsor Police.
MORRISSETTE, Gerard May 3, 2004 Dr. A. McCallum verdict no recommendations Accident. Custody. Kingston Penitentiary.
MOTTON, Jason
RODRIGUES, Paul G.		 Nov. 30, Dec. 16, 1998 Dr. W. Lucas verdict (Motton)
verdict (Rodrigues)		 recommendations Accident. Undetermined. Custody.
MULDER, Dirk R. October 29, 2007. Dr. R. Jhirad verdict no recommendations Natural. Custody. Maplehurst Correctional Facility.

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N

NADEAU, Ricky Jun 16, 2003 Dr. J. Ewen verdict recommendations Accident. Custody.Cocaine poisoning. Maplehurst Correctional Facility.
NAIRNE, Lawrence March 27-April 4, 2001 Dr.R. Isaac verdict recommendations> Accident. Custody. Toronto Police.
NAKIC, Tamara April 18-29, 2005 Dr. W. Lucas verdict recommendations Natural. Health care. Diabetes.
NASIM, Kamran June 17-18, 1999 Dr. A. Jones verdict recommendations Suicide. Custody.
NOAH, Harold May 3, 2006 Dr. R. McIlquham verdict   Natural. Custody.
NOVAK, Stephen Nov. 27, 2006 Dr. T. Gillmore verdict   Natural. Custody.
NUGENT, Braeden March 6, 2006 Dr. J. Deacon verdict & recommendation   Accident. Custody. Methadone.
NUGENT, Lee Roy March 21, 2007 Dr. B. Mainville verdict   Natural. Custody. Collins Bay.

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O

O'BRIEN, James Nov. 1, 2004 Dr. G. Watt verdict   Undetermined. Custody.
OKKUATSIAK, Lucas Henry Nov. 19, 2003 Dr. R. Caskey verdict   Suicide. Custody. Warkworth Institution.
OLAWUYI, Babatunde Nov. 13-15, 2001 Dr.J. Edwards verdict   Natural. Custody. Toronto Don Jail.
OLINSKIE, Christopher Feb. 27 - June 20, 2007 Dr. R. McIlquham verdict & recommendations   Accident. Custody. Kingston Penitentiary.
OLIVER, Robert Nov. 23-25, 2005 Dr. J. Ewen verdict & recommendations   Accident. Custody. Stratford Jail.
ORBAN, Steven Jan. 29, 2003 Dr. R. McIlquham verdict   Natural. Custody. Kingston Penitentiary.
ORSER, Mark June 5-7, 2006 Dr. R. Mann verdict & recommendations   Natural. Custody. Owen Sound Police Service.
OUELLET, Nicole
OUELLET, Olive
OUELLET, Bernard
WHITING, Renie 		April 29-May 1, 2003 Dr. D. Legge verdict & recommendations   Accident. Carbon Monoxide Poisoning.

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P

PADDA, Paramjeet Singh Jan. 12-30, 2004 Dr. K. Acheson verdict recommendations Accident. Custody.
PAIANO, Antonio Jan. 27-28, 2005 Dr. K. Smith verdict recommendations Accident. Construction.
PAIEMENT, Jerry Sept. 13, 2005 Dr. A. McCallum verdict no recommendations Natural. Custody. Kingston Penitentiary.
PARENTE, Antonio March 1-4, 1999 Dr.R. Isaac verdict recommendations Accident. Construction.
PAULIN, Rene Leon March 27-28, 2006 Dr. J. Ewen verdict   Custody. Suicide.
PAYETTE, Kevin March 19, 2007 Dr. S. McRae verdict & recommendations   Accident. Mining.
PAYETTE, Pamela Sept. 28-30, 2004 Dr. David Schooling verdict & recommendations   Suicide. Custody. Grand River Prison for Women.
PIPER, David Anthony May 1, 2002 Dr. R. McIlquham verdict   Suicide. Custody. Kingston Penitentiary
PIRREIRA, Samual J. Nov. 20-23, 2000 Dr. M. Reingold verdict recommendations Suicide. Custody.
PLESINSKI, Waldemar June 7-8, 2004 Dr. R. Mann verdict recommendations Accident. Construction.
PRESSACCO, Renzo Feb. 13,2004. Dr. G. Watt verdict & recommendations   Accident. Construction.
PREVOST, Daniel R. Oct. 25-26, 2004 Dr. D. George verdict & recommendations   Natural. Custody. Fenbrook.
PRIBAG, Richard C. Sept. 14, 2000 Dr. T. Gillmore verdict recommendations Suicide. Custody.

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R

RADFORD, Grace Marie Nov. 8-10 2004 Dr. R. Mann verdict & recommendations   Accident. Construction.
RANDHAWA, Paramjit Sept. 14-16, 2005 Dr. D. Schooling verdict recommendations Accident. Construction.
REDSHAW, Philip Sept. 29, 2004 Dr. B. Bechard verdict   Suicide. Custody. Collins Bay Institution.
REID, Percy Feb. 21-23, 2005 Dr. R. Boyko verdict recommendations Accident. Construction.
REID, Ronald Wayne Nov. 17, 2006 Dr. R. McIlquham verdict   Natural. Custody.
REODICA, Jeffrey May 8 - Oct. 13, 2006 Dr. B. Porter verdict recommendations Homicide. Custody. Police.
RICHARDSON, David August 29, 2007. Dr. R. McIlquham verdict no recommendations Natural. Custody. Kingston Penitentiary.
ROCHON, Michel Dec. 19, 2003 Dr. G. Watt verdict   Accident. Construction. Fall.
RODGERS, Gareth March 22-April 8,2004 Dr. W. Lucas verdict recommendations Accident. Parachuting.
ROESLER, David Sept. 22-28, 2005 Dr. G. Watt verdict   Accident. Occupational.
ROLFE, Kevin March 20-21, 2006 Dr. R. Isaac verdict recommendations Natural. Custody. Don Jail.
RYAN, Andrew April 21-22, 2008 Dr. P. Charron verdict and recommendations   Accident. Construction.

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S

SAKAKEESIC, Anthony June 17-19, 2008. Dr. G. Churchill verdict and recommendations   Undetermined. Custody. Central North Correctional Centre.
SANDFORD, James September 4-7, 2007. Dr. J. Stanborough verdict and recommendations   Accident. Construction. Elevator.
SAUNDERS, Edward March 3, 2004 Dr. R. McIlquham verdict & recommendations   Accident. Custody. Frontenac Institution
SEGUIN, Loic Denis Feb. 24,2006 Dr. G. Watt verdict & recommendations   Accident. Construction.
SERENO, Guiseppe May 27, 2002 Dr. B. Bechard verdict   Homicide. Custody. Millhaven Penitentiary
SETH, Larry William Nov. 15, 2005 Dr. P. Savage verdict recommendations Natural. Custody.
SHAND, Patrick Feb. 23-April 23, 2004 Dr. D. Eden verdict recommendations Accident. Restraint asphyxia. Security Guards.
SHARMA, SHASHI Dec. 1, 2004 Dr. R. Caskey verdict no recommendations Natural. Custody.
SHORE, Lisa Nov. 8, 1999 - Feb. 24, 2000 Dr. J. Cairns verdict recommendations Homicide. Hospital. Child.
SKINNER, Ross William July 12-14, 1999 Dr. D. Giddens verdict recommendations Suicide. Custody.
SLANCO, Michael March 5-7, 2007 Dr. D. Sedran verdict recommendations Natural. Custody.Toronto Jail.
SMART, David Jan. 12-27, 2006 Dr. R. Isaac verdict recommendations Accident. Custody.Mimico Correctional Centre.
SMITH, Bryian June 16-20, 2003 Dr. C. Eisener verdict & recommendations   Accident. Mining.
SMITH, Edward March 26, 2003 Dr. R. McIlquham verdict   Natural. Custody. Kingston Penitentiary.
SMYTH, James Edwin Feb. 9-10, 2005 Dr. D. Wolski verdict recommendations Accident. Construction. Electrocution.
SOLIS, Augusto Cesar Mejia September 17- October 2, 2007. Dr. A. Lauwers verdict recommendations Accident. Discretionary. Building Collapse.
SOLOSKY, William Dec. 15, 2003 Dr. B. Mainville verdict   Natural. Custody. Kingston Penitentiary.
SPARKS, Roger Feb. 14, 2005 Dr. G. watt verdict   Natural. Custody.
SPURN, Gary O. May 24 - 26, 2005 Dr. G. Mann verdict & recommendations   Accident. Custody. Police.
ST. CROIX, Richard Jan. 9-10, 2006 Dr. D. Schooling verdict recommendations Accident. Construction.
STEACY, Jason E. January 21-30, 2008 Dr. G. Watt verdict and recommendations   Homicide. Custody. OPP.
SUKHRAM, Rampersaud April 2-4, 2002 Dr. J. Edwards verdict recommendations Natural. Custody. Toronto East Courts.
SUTTON, Andrea (Manley) April 25-28, 2006 Dr. A.E. Lauwers verdict & recommendations   Natural. Custody.
SYLVESTRE, Charles January 23, 2008. Dr. R. McIlquhama verdict no recommendations Natural. Custody. Kingston Penitentiary

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T

TALLON, Daniel April 19-20, 2005 R. McIlquham verdict & recommendations   Suicide. Custody. Federal.
TANNER, Marie Feb. 9-12, 2004 Dr. J. Cairns verdict & recommendations   Accident. Potassium Chloride injection.
TEIGESSER, Joseph Nov. 17, 2003-May 7, 2004 Dr. J. Edwards verdict recommendations / explanation Natural. Tuberculosis.
TEMPLE-MEDHURST, Mitchell Sept. 26- Oct. 6, 2005 Dr. T. Wilson verdict and recommendations   Accident. Drowning. Child.
THAW, Lorne Leslie Feb. 9-11, 2004 Dr. P. Savage verdict   Natural. Custody.
THOMPSON, Christian Oct. 18, 2006