Ministry of the
Solicitor General

OCC Inquest - Izsak Morneau 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Names of the deceased: Surname: Izsak, Brian; Morneau, Robert
Held at: 245 Windsor Ave., Windsor
From: October 7, 2019
To: October 10, 2019
By: Dr. David Eden
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Izsak
Given name(s): Brian
Age: 53
Date and time of death:  July 26, 2016 at 8:16pm
Place of death: Windsor Regional Hospital – Ouellette Campus, 1030 Ouellette Ave., Windsor, Ontario
Cause of death: Multiple trauma, due to fall from a roof through an opening
By what means: Accident

Surname: Morneau
Given name(s): Robert
Age: 44
Date and time of death:  November 3, 2016 at 2:03pm
Place of death: Windsor Regional Hospital – Ouellette Campus, 1030 Ouellette Avenue, Windsor, Ontario
Cause of death: Multiple trauma, due to fall from a roof through a skylight
By what means: Accident

(Original signed by: Foreperson)


The verdict was received on October 10, 2019
Coroner's name: Dr. David Eden
(Original signed by coroner)


Inquest into the deaths of:

Brian Izsak; Robert Morneau


Jury Recommendations

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

To the Ministry of Labour:

  1. To the Chief Prevention Officer – Working at Heights curriculum be revised to include a section on hazards related specifically to skylights.
  2. That Section 26 Item 6 be reworded to say “falling through an opening, including but not limited to skylights.”
  3. Policy implemented that a daily record of site orientation and safety instructions be kept by the Constructor and provided to the building/business owner.  These records should be kept by the building/business owner and made available for future projects.
  4. Add a regulation that if an opening is exposed, a human spotter is required until a secure cover is in place.

To The National Research Council of Canada:

  1. National Building Code be amended to include a requirement that skylights through which persons may fall shall be designed to be capable of withstanding a load of 2.4 kilonewtons per square metre; or be guarded by a standard skylight screen capable of withstanding a load of at least 2.4 kilonewtons per square metre; or be equipped with a fixed skylight railing on all exposed sides to a measurement of 36 to 42 inches high.
  2. National Building Code be amended to state that warning labels be added to skylights by the manufacturer.
  3. National Building Code be amended to require installation of permanent anchor points on any non-residential buildings, higher than 3 metres, for use with personal fall protection systems.

To The Ministry of Municipal Affairs and Housing (MMAH):

  1. Ontario Building Code be amended to include a requirement that skylights through which persons may fall shall be designed to be capable of withstanding a load of 2.4 kilonewtons per square metre; or be guarded by a standard skylight screen capable of withstanding a load of at least 2.4 kilonewtons per square metre; or be equipped with a fixed skylight railing on all exposed sides to a measurement of 36 to 42 inches high.
  2. Ontario Building Code be amended to state that warning labels be added to skylights by the manufacturer.
  3. Ontario Building Code be amended to require installation of permanent anchor points on any non-residential buildings, higher than 3 metres, for use with personal fall protection systems.