Ministry of the
Solicitor General

OCC Inquest - Adam 2019

Office of the Chief CoronerVerdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Adam
Given name(s): Zoltan Jr.
Age: 19

Held at: Brampton, Ontario
From: Sept. 9, 2019
To: Sept. 10, 2019
By: Dr. Bob Reddoch
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Zoltan Adam Jr.
Date and time of death: May 10, 2016, 3:41 p.m.
Place of death: LOT M73, Brampton, Ontario (nearest intersection: Goreway Drive & Burlwood Road)
Cause of death: Acute aspiration of gastric contents. Other significant conditions contributing to the death but not causally related to the immediate cause: compressive head and abdominal trauma.
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on September 10, 2019
Coroner's name: Dr. Bob Reddoch
(Original signed by coroner)


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


Inquest into the death of:

Zoltan Adam Jr.


Jury Recommendations

To the Ministry of Labour (MOL)

  1. All construction workers should be mandated to take online education through the Ministry of Labour website instructing them on employee’s responsibilities related to ingestion of alcohol, prescription drugs and legal recreational drugs. This would include rules for ingestion within X number of hours before working (example: 12 hours), based on scientific expert opinion, where impairment could result in jeopardizing the safety of the workplace. This should be an annual expectation of all construction and tradespersons. A copy of completed education should be provided to those hiring employees or contracted workers prior to engaging in any paid work.
  2. MOL alerts should be distributed to all active job sites.
  3. Training program guidelines should be established for all heavy equipment types and be standardized by the MOL.

To general constructors

  1. Employers (site supervisor) should control issue of keys to machines or equipment. Only trained certified persons should be given keys to machine or equipment. Keys should also be returned back to the employer (site supervisor) so they do not sit in the machine or equipment and be misused.
  2. There should be controlled access to the job site with signing in and signing out of all personnel. Only pre-approved workers would be given access to the job site. Copies of certificates for each worker should be maintained at the job site office.
  3. Alcohol and drug training certificates should be provided to gain access to site and to be maintained on file.
  4. All MOL alerts should be distributed to workers that are certified for their job site.
  5. All employers should establish rules clearly prohibiting the consumption of any substance including alcohol, prescription drugs and legal recreational drugs by any employees. Employers should ensure that any employees found to have contravened any such rule and consumed any substances before or during work not be at the workplace.
  6. Further to recommendation #3, above, employers should establish that employees who are using heavy equipment machinery such as elevated work platforms have received standardized training and keep a copy of proof of that training on site.