Ministry of the
Solicitor General

OCC Inquest - Chatelain 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Chatelain
Given name(s): Richard
Age: 58

Held at: Napanee
From: Nov. 21, 2018
To: Nov. 21, 2018
By: Dr. Geoffrey Bond 
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Richard Chatelain
Date and time of death: May 14, 2015 at 8:27 a.m.
Place of death: Bath Institution Regional Treatment Centre
Cause of death: Undetermined
By what means: Undetermined​

(Original signed by: Foreperson)


The verdict was received on Nov. 21, 2018
Coroner's name: Dr. Geoffrey Bond
(Original signed by coroner)


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


Inquest into the death of:

Richard Chatelain


Jury Recommendations

  1.  All Regional Treatment Centre personnel interacting with inmates should have training to observe and document indicators of changing mental and physical conditions.
  2. A daily documentation of active medical problems will allow staff to fully assess their management and implications.
  3.  Each Regional Treatment Centre inmate case with a complex medical history should have a review by a multi-disciplinary medical panel on a periodic basis. This will ensure comprehensive and proactive ongoing treatment rather than only a reactive response to specific concerns and complaints.