OCC Inquest - Badakhshan 2016
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given Name(s): Farshad
Held at: Toronto
From: January 27
To: February 2, 2016
By: Dr. Robert Boyko, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: Farshad Badakhshan
Date and time of death: May 22, 2014 at 23:55 hours
Place of death: 111 Disco Rd., Toronto, Ontario (Toronto West Detention Centre)
Cause of death: Hanging
By what means: Suicide
(Original signed by: Foreperson and Jurors)
The verdict was received on the 2nd of February, 2016
Coroner's name: Dr. Robert Boyko
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
To: The Ministry of Community Safety and Correctional Services
- Implement a consistent use of alert codes as appears on the Offender Tracking Information System (OTIS) Unit Notification Cards across other inmate documentation such as, bed-board and log books.
- When an inmate asks to see a physician, details for the reason for the request shall be documented to allow for appropriate triage.
- That all correctional officers, regardless of part-time or full-time status, receive mandatory yearly re-certification/training in the area of suicide prevention.
- Consider implementing an additional staggered schedule for staff members during peak activity periods within the Special Needs Special Handling Unit.
- Consider implementing mandatory psychiatrist clearance before transfer from enhanced suicide watch status.