OCC Inquest - Pinkney 2019
Verdict of Coroner's Jury
Office of the Chief Coroner
The Coroners Act - Province of Ontario
Given name(s): David
Held at: Orillia
From: July 22, 2019
To: Aug. 1, 2019
By: Dr. Mara Goldstein
having been duly sworn/affirmed, have inquired into and determined the following:
Name of deceased: David Pinkney
Date and time of death: Mon., February 6, 2017 at 3:52 p.m.
Place of death: Severn Pines Quarry at 2646 Nichols Line, Severn
Cause of death: Extensive blunt force trauma due to crush injury of the head
By what means: Accident
(Original signed by: Foreperson)
The verdict was received on Aug. 1, 2019
Coroner's name: Dr. Mara Goldstein
(Original signed by coroner)
We, the jury, wish to make the following recommendations:
Inquest into the death of:
- To Walker Aggregates: To ensure that David Pinkney, and the circumstances of his death be remembered and serve to improve the Safety Culture at the workplace, rename the Severn Pines Quarry, to the David Pinkney Quarry.
- To Walker Aggregates: To bolster the internal responsibility system at the workplace, ensure that supervisors directly deal with health and safety matters.
- To Walker Aggregates: To bolster the internal responsibility system at the workplace, ensure there are rapid, assured, and significant consequences for all safety infractions.
- To the Ministry of Education: include the "Live Safe Work Smart" training (or any named replacement, as decided by the Ministry of Education) as a mandatory part of the curriculum for all high school students in Ontario, which should be revised as necessary in consultation with the prevention branch of the Ministry of Labour or other appropriate subject matter experts.
- To the Ministry of Education: To prepare children for the "Live Safe Work Smart" training (or any named replacement, as decided by the Ministry of Education), make the connection between childhood and workplace behaviour, and foster good safe decisions, develop ongoing and progressive curriculum to be administered at all levels of elementary school to teach all students about weighing the risks and the consequences of risk taking behaviour.
- To the Prevention Branch of the Ministry of Labour: Consult as needed with the Ministry of Education to assist in the development and revision of the curriculum related to the "Live Safe Work Smart" training (or any named replacement, as decided by the Ministry of Education).
- To the Ministry of Labour: hire sufficient additional personnel to increase the size of the prevention branch to better address the needs of supporting the enforcement branch
- To the Ontario Stone, Sand and Gravel Association: create an annual award for best safety innovation on the part of a company, or division of a company.
- To the Ministry of Training, Colleges and Universities: the common core curriculum (first three modules) is to include an additional refresher course that needs to be completed every three years.
- To the Ministry of Training, Colleges and Universities: review common core module for generic first line supervisor training, to ensure the inclusion of modules on human behaviour, and promotion of health and safety compliance.