Ministry of the
Solicitor General

OCC Inquest - Simon 2019

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Simon
Given name(s): Jason Renato
Age: 20

Held at: 110 Laurier Ave. W., Ottawa, ON 
From: Jan. 22, 2019
To: Feb. 1, 2019
By: Dr. Bob Reddoch
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: Jason Renato Simon
Date and time of death: Feb. 15, 2016 at 3:17 p.m.
Place of death: 412 Tremblay Rd., Ottawa, ON K1G 0C2
Cause of death:  Hanging
By what means: Suicide

(Original signed by: Foreperson)


The verdict was received on Feb. 1, 2019
Coroner's name: Dr. Bob Reddoch
(Original signed by coroner)


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


Inquest into the death of:

Jason Renato Simon


Jury Recommendations

A. To the governments of Canada and Ontario:

  1. A National and Provincial Mental Health strategy on Suicide should be implemented in an effort to reduce suicides in Canada.
  2. Consideration should be given to reviewing percentage total of health care expenditures dedicated to mental health care taking into account the amount allocated by other G8 countries. An appropriate share of this increase should be allocated to implement the recommendations that follow.

B. To the Ministry of Health and Long-Term Care and the Champlain Local Health Integration Network (LHIN):

  1. Consider funding the Rapid Access Outpatient Mental Health Services Pilot Project for outpatient mental health services in the Champlain LHIN, consistent with the proposal by the Ottawa Hospital to the LHIN in October 2017.
  2. Consider additional funding for existing community based mental health crisis beds that are not affiliated with any hospital.
  3. Consider funding for services under heading D; under heading F paragraphs 23, 24 and 25; and under heading G paragraph 26, in the event that the hospitals referred to below are not able to fund these services within their existing funding.
  4. Consider developing a dedicated web service with both public facing general mental health education resources and capacity for mental health care providers to interact and share experience and best practices on suicide prevention. Consideration should also be given to incorporating the capacity for individuals to use the site to identify local mental health care providers who are accepting patients.
  5. Continue to review the appropriate research on the utility of emergency psychiatric screening tools and whether these tools improve outcomes in suicide prevention.
  6. The Familiar Faces program adopted by the Montfort Hospital and the Ottawa Hospital should be integrated in all hospitals within the Champlain LHIN. The program should be expanded so that any attendance at a schedule 1 or non-schedule 1 hospital within the Champlain LHIN will automatically be counted for the purpose of activating the program. The program should be expanded to permit an emergency health care provider to manually include an attendance at emergency departments outside of the Champlain LHIN upon becoming aware of the same.
  7. The Ministry of Health should consider implementing a system for a more coordinated approach to mental health services in the region, including common standards, oversight, monitoring and better coordination between hospitals and other providers of mental health services in this region. Central coordination should include as a core principle access to mental health services in French. When developing this approach, consideration should be given to: a) whether the internet service set out in these recommendations is the most appropriate and effective approach; b) whether the delivery of Dialectic Behaviour Therapy (DBT) services should continue through the hospitals or through another regional delivery service model; and c) whether the delivery of case management services, care co-ordinators and/or system navigators for all patients accessing health care services for suicidality should continue through the hospitals or through another regional delivery service model. 

C. To the Ministry of Training, Colleges and Universities:

  1. Consider funding for services under heading F paragraph 23, 24 and 25; and under heading H paragraph 27 in the event that the post-secondary institutions referred to below are not able to fund these services within their existing funding.

D. To the Ministry of Health and Long-Term Care and hospitals within the Champlain LHIN that are mandated to provide psychiatric services (a “Schedule 1 hospital”):

  1. Hospitals should be funded to create a short-stay observation unit adjacent to the local emergency departments. Such a unit must provide for careful suicide risk assessments, a safety plan that includes the patient's natural support network as appropriate, and a plan to remove access to means.
  2. Provide access through hospitals and/or community-based services to full DBT for all patients who have been assessed as requiring DBT​ by a psychiatrist. Funding should be sufficient that the wait list to access full DBT does not exceed a period of 90 days.
  3. Provide access through hospitals and/or community-based services to a short term partial DBT​ program similar to that available at the Ottawa Hospital and the Montfort Hospital to provide immediate service to patients who have been assessed as requiring DBT​ by a psychiatrist. Funding should be sufficient that the wait list to access short term partial DBT​ does not exceed a period of 30 days.
  4. Take steps to increase awareness of and training on the principles of DBT​ therapy for mental health care providers.
  5. Implement as soon as possible a protocol for sharing relevant clinical mental health care information, with the consent of the patient, between Universities and hospitals and between hospitals.
  6. Review the use of risk assessment tools, including the InterRAI and the Columbia Suicide Severity Screening Tool, and develop a policy on the consistent use of these tools, including their use to support clinical practice.
  7. Accept interRAI Brief Mental Health Screener reports when available and offered by police officers; these reports should be reviewed and considered to effectively triage individuals and determine the risk of suicide, self-harm or harm to others.
  8. There should be a follow up call with any patient who has presented with suicidal thoughts once discharged from emergency mental health care. This should be documented on the patient’s chart.

E. To the Ministry of Health and Long-Term Care and hospitals within the Champlain LHIN:

  1. Develop and implement a model for case management, care co-ordinators and/or system navigators for all patients accessing health care services for suicidality. 
  2. Develop, implement and resource support and educational programs for families of patients addressing issues of suicidality in the health care setting, which may include referring family members to existing resources in the community.

F. To hospitals within the Champlain LHIN and post-secondary institutions providing mental health services:

  1. A safety plan that informs the patient about possible coping strategies and provides the resources to use if a crisis develops should be utilized in all health care settings that treat patients with suicidal ideation. The safety plan should be prepared before discharge and should include education about suicide, discussion of warning signs, the need to take medications as prescribed, a plan to remove access to means of suicide and phone numbers for support or crisis phone lines. The safety plan should be accessible to all members of the circle of care and should be accessible electronically and updated as needed. In developing the safety plan, the mental health care provider should explain to the patient the advantages of involving the family or other supports in the safety plan if appropriate.
  2. Develop and implement a plan for informing patients of all appropriate community based mental health services available to the mental health patients upon discharge from hospital or as appropriate when mental health treatment is offered through a post-secondary institution.
  3. Consider partnering with Peer Support Canada or other accredited peer support programs to implement peer support programs for persons receiving mental health care for suicidal ideation in the emergency health care setting.
  4. Consider adopting the full zero suicide model.
  5. Develop and implement a means to assess the increases in demand for suicide prevention services and available resources over last five to 10 years so that funding for suicide prevention services can be made available to meet the demand for these services.

G. To the Ministry of Health and Long-Term Care, the hospitals and post-secondary institutions in Ottawa, and the Canadian Armed Forces:

  1. Consider holding an annual conference to bring together all professionals involved in suicide prevention for education and to foster inter-professional relationships.

H. To post-secondary institutions within the Champlain LHIN:

  1. Health clinics on campus should implement case management for individuals who present with suicidal thoughts or having attempted suicide. If the physician believes that the patient would benefit from a daily or bi-weekly check in, the physician should explore available community resources to fulfill this increased demand for case management.
  2. Health clinics on campus should review the use of risk assessment tools, including the InterRAI, and develop a policy on the consistent use of these tools, including their use to support clinical practice.
  3. All health clinics on campus should better inform students about counselling waitlists, and students on these lists should be prioritized according to need (for example, stepped care or triage models). Where a student is in crisis and in urgent need of mental health services (such as a counsellor or psychiatrist) but an appointment cannot be made for several weeks, alternative, immediate resources in the community should be explored with the student.

I. To the Office of the Chief Coroner:

  1. Consider establishing a committee to review all deaths by suicide. All deaths by suicide shall be reported to the committee so that the committee can determine the best approach to preventing similar deaths.
  2. Where appropriate, ensure that witnesses are informed of the availability of existing mental health services and supports that are available for witnesses testifying at an inquest.

J. To the Ministry of Health and Long-Term Care:

  1. Consider funding for 24/7 psychiatric emergency nurses in hospital emergency departments.
  2. Consider developing programs or seminars for families to help them cope with the mental illness of a family member and to help them to recognize signs of suicide.
  3. Consider raising the age of adolescence from 18 to 25 for the purposes of receiving mental health care treatment.

K. To the Canadian Armed Forces:

  1. When a Class A reservist presents with symptoms or signs of a mental illness issue they should be informed of mental health services within the community.
  2. In deciding whether to place a Class A reservist on unpaid leave, as a result of mental health concerns consideration should be given to the impact that this may have on their condition.
  3. Consider providing training and information to all new Class A reservists in relation to mental health services available through the military at the earliest possible point in their training.