Ministry of the
Solicitor General

OCC Inquest - Janssens Maukonen Swan 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Name(s) of the deceased: Janssens, John; Maukonen, Michael; Swan, William
Held at: 425 Grand Ave West, Chatham, Ontario
From the: 8 April, 2019
To the: 11 April, 2019
By: Dr. Elizabeth Urbantke, Coroner for Ontario
having been duly sworn/affirmed, have inquired into and determined the following:

Surname: Janssens
Given name(s): John
Age: 73
Date and time of death: January 15, 2016 at 2:20 pm
Place of death: Chatham-Kent Health Alliance, Chatham Campus , 80 Grand Ave W, Chatham, ON
Cause of death: Bronchopneumonia due to head injury due to fall from height
By what means: Accident

Surname: Maukonen
Given name(s): Michael
Age: 19
Date and time of death: June 28, 2016 at 7:30 pm
Place of death: Malden Park Continuing Care Centre,  1453 Prince Road, Windsor, ON
Cause of death: Pneumonia due to old traumatic craniocerebral injury due to fall
By what means: Accident

Surname: Swan
Given name(s): William
Age: 56
Date and time of death: May 16, 2017 at 12:42 pm
Place of death: Charlotte Eleanor Englehart Hospital, Bluewater Health, 450 Blanche St., Petrolia, ON
Cause of death: Multiple trauma
By what means: Accident

(original signed by Foreman and Jurors)


This verdict was received on the 11th of April, 2019
Coroner’s Name: Dr. Elizabeth Urbantke
(original signed by coroner)


Inquest into the deaths of:

John Janssens, Michael Maukonen and William Swan


Jury Recommendations

To the Ministry of Labour:

  1. We recommend that investigating inspectors be equipped with appropriate equipment such as telescopic lenses, camera, and/or drones to assist investigations at heights.
  2. We recommend that Ontario Regulation 213/91 Section 26 as it is currently written: 1. Falling more than 3 m (10 feet) be amended to read:  1. Falling more than 2.4 m (8 feet) in order to be consistent with Ontario Regulation 213/91, Section 26.3(1) where guardrails are required at 2.4 metres.
  3. We recommend that the Ministry of Labour ensure that revenue generated from MOL construction related fines be used to promote construction safety awareness within the municipality where they are collected.

To the Infrastructure Health and Safety Association (IHSA):

  1. We recommend that the IHSA create and/or maintain a social media campaign encouraging the use of licensed contractors.
  2. We recommend that an educational brochure be created informing homeowners of their responsibilities and liabilities when hiring a contractor and questions to ask to ensure worker safety. The IHSA is to work with municipalities to distribute the brochure with property tax notices.

To the Ministry of Municipal Affairs and Housing:

  1. We recommend that all new builds incorporate a permanent roof anchor system.

To construction companies:

  1. We recommend that since compliance is a learned behavior,
    1. supervisors/lead hands be required to take the Basics of Supervising course and other work type specific safety courses to help ensure competency,
    2. construction companies be required to provide work type specific safety training annually to employees
    3. construction companies be required to join an organization that has a continuing education component.
  2. We recommend that employers supply CSA approved safety gear or an allowance, complete regular maintenance inspections on such gear and ensure its proper use on work sites.

To the Ministry of Education:

  1. We recommend that workplace safety training should be incorporated into the technical courses curriculum in secondary schools.