Ministry of the
Solicitor General

OCC Inquest - Fleck 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Fleck
Given name(s): Russell
Age: 45

Held at: 97 Thomas St Napanee
From: May 8, 2018
To: May 9, 2018
By: Dr. Gautam Walia
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Russell Fleck
Date and time of death: August 28th 2016 at 5 a.m.
Place of death: Kingston General Hospital, Kingston Ontario
Cause of death: Accident
By what means: Hypoxic ischemic encephalopathy due to cardiac tamponade due to penetrating nail injury of the left chest

(Original signed by: Foreperson)


The verdict was received on the 9 of May, 2018
Coroner's name: Dr. Gautam Walia
(Original signed by coroner)


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


Inquest into the death of:

Russell Fleck


Jury Recommendations

To the Ministry of Labour:

  1. Recommend regulations that require small business construction employers and employees to have standard First-Aid certifications.

To the Ministry of Labour and Infrastructure Health and Safety Association:

  1. To increase public awareness in the construction industry about the risk and rates of serious injuries and fatalities from the use of nail guns including what to do in the event of a nail gun injury.

To the Ministry of Labour:

  1. Recommend regulations that require employers to provide regular training and documentation to employees on the safe use of nail guns, including what to do in the event of a nail gun injury.
  2. Recommend regulations that require small business construction employers to specifically include in their employer safety manuals information on nail gun safety and what to do in the event of a nail gun injury.
  3. Recommend regulations on the use of contact or non-sequential nail guns by construction workers in circumstances similar to the facts of this inquest. Specifically to the use of contact or non-sequential nail guns when performing work over one’s head.
  4. That the Ministry of Labour mandate Occupational Health and Safety training on the use of nail guns for new and existing small construction business owners which includes information on how to access nail gun safety guides and information online
  5. The Ministry of Labour should conduct a public awareness campaign with respect to the dangers of nail guns, with particular focus on the use of different trigger types.