Ministry of the
Solicitor General

OCC Inquest - Ikeno 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Ikeno
Given name(s): Michael
Age: 28

Held at: London
From: June 10, 2019
To: June 13, 2019
By: Dr. Elizabeth Urbantke
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Michael Ikeno
Date and time of death:  July 7, 2016 at 9:28 a.m.
Place of death: 1819 Park Ave, London, Ontario
Cause of death: Cachexia due to complicated diverticulitis due to opiate and non-steroidal inflammatory medications for treatment of lower extremity fractures due to a fall
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on June 13, 2019
Coroner's name: Dr. Elizabeth Urbantke​
(Original signed by coroner)


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


Inquest into the death of:

Michael Ikeno


Jury Recommendations

To the Ministry of Health

  1. A centralized electronic medical record where physicians and other healthcare service providers no matter their practice type or location can access a patient's medical records including but not limited to clinical notes, prescription medicines and homecare documentation.
  2. A review of the homecare system to ensure a single point of contact for patients and families for ease of access and the development of a single interdisciplinary care team for each patient, capable of providing all nursing, personal support and allied health care to facilitate continuity of care.

To London Health Science Centre

  1. Implementation of a pain treatment program for patients transitioning from hospital to community to ensure proper pain management including both medications and other forms of treatment such as psychological treatment, acupuncture, massage, medication, etc.

To Health Canada

  1. To increase awareness for patients and doctors, include on product monographs/medication information sheets for opioids the increased risk for the development of diverticulitis in those with diverticulosis and constipation.