Ministry of the
Solicitor General

OCC Inquest - Smith 2018

Office of the Chief Coroner

Verdict of Coroner's Jury

Office of the Chief Coroner

The Coroners Act - Province of Ontario


Surname: Smith
Given name(s): John Francis
Age: 37

Held at: Haliburton, Ontario
From: March 21, 2018
To: March 22, 2018
By: Dr. Mary Beth Bourne
having been duly sworn/affirmed, have inquired into and determined the following:

Name of deceased: John Francis Smith
Date and time of death: July 31, 2013 at 13:33 p.m.
Place of death: Haliburton Family Medical Centre at 7217 Gelert Road, Haliburton, Ontario
Cause of death: Accident
By what means: Multiple trauma

(Original signed by: Foreperson)


The verdict was received on the 22 of March, 2018
Coroner's name: Dr. Mary Beth Bourne
(Original signed by coroner)


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


Inquest into the death of:

John Francis Smith


Jury Recommendations

To the Ministry of Labour:

  1. Prioritize initiatives to improve the use and design of fall protection equipment in residential construction and roofing sectors.  Fall protection equipment should assist and not impede construction productivity and should not create other safety concerns such as tripping hazards.
  2. Develop an information resource kit to highlight key construction health and safety issues for small and medium sized employers.
  3. In order to improve awareness and compliance with the use of safety equipment, mandate the use of signage on construction sites which indicates the types of safety equipment (eg: hard hats, fall protection, ear protection, safety boots, etc.) required to work on a site. The signage should also include information on how to contact the Ministry of Labour to report non-compliance.
  4. Explore new methods to monitor compliance with the Occupational Health and Safety Act in the construction industry, such as implementing an auditing program where companies are required to submit health and safety documentation for specific projects.
  5. Increase the inspection of high risk construction activities, such as residential roofing (see Ministry of Labour Construction Health and Safety Action Plan - May 2017, Objective 6, Recommendation 16, "New and Upcoming Work").

To the Ministry of Labour, Ministry of Government and Consumer Services, Ministry of Municipal Affairs and Infrastructure Health and Safety Association:

  1. Establish distribution protocols for the construction health and safety information resource kit to include Ministry of Labour inspectors, Service Ontario locations, and municipal offices.  The contents of the resource kit should be easily accessible through the Ministry of Labour and Infrastructure Health and Safety Association websites.

To the Ministry of Labour and the Ministry of Education:

  1. Work together to create and implement mandatory workplace health and safety curriculum for elementary, high school and post-secondary students.  The curriculum goal should be to develop knowledge and foster positive attitudes from an early age that safety in the workplace is a priority and is everyone's responsibility.

To the Ministry of Labour and the Ministry of Advanced Education and Skills Development:

  1. Prioritize work with the Ontario College of Trades to identify, renew and enhance health and safety content of apprenticeship training standards in order to increase awareness, training and skill level for those preparing to enter the workforce (see Ministry of Labour's Construction Health and Safety Action Plan - May 2017, Goal 1, Recommendation 8).