Verdict to the Coroner`s Jury

May
Office of the Chief Coroner
Bureau du Coroner
25 Morton Shulman Avenue
25 Avenue Morton Shulman
Toronto ON M3M OB1
Toronto ON M3M 081
en
Chef
25 2016
Ms Aliza
Karoly
Carranza LLP
1280 Finch Avenue West
200
Toronto ON
Dear Ms
M3J 3K6
Karoly
Inquest into the deaths of Holly Harrison Marilee Towle Benjamin Twiddy
Deceased April 29 2012 and Kevin Dunsmuir Jennifer Dunsmuir Robert
Re
Dunsmuir Cameron Dunsmuir Deceased March 29 2013 Our file Q2016 15
Please find enclosed a copy of the verdict of the coroners jury and the coroners verdict
explanation from the inquest into the deaths of Holly Harrison Marilee Towie Benjamin
Twiddy Kevin Dunsmuir Jennifer Dunsmuir Robert Dunsmuir and Cameron Dunsmuir We
are also attaching for your information
a list of the recipients that have been asked to
respond to the recommendations
As you
represented parties with standing the above material is being sent to you for your
information
Sincerely
Dirk
Huyer
MD
Chief Coroner for Ontario
DH pc
End
File
02016 15
For Implementation
Office of the Chief Coroner
25 Morton Shulman Avenue
Toronto ON
M3M OBI
Recommendation
33
Mr Ross Nichols
Fire Marshal of Ontario and Chief of Emergency Management
Office of the Fire Marshal and Emergency Management
Ministry of Community Safety
and Correctional Services
25 Morton Shulman Avenue
Toronto ON M3M OB1
1 to 11 25 27 to 32
Recommendations
Ms Laurie LeBlanc
Deputy Minister
Ministry of Municipal Affairs
College
17th Floor
and Housing
Park
777
Bay
Street
Toronto ON M5G 2E5
Recommendations
6 to 14 27 to 32
George Zegarac
Deputy Minister
Ministry of Education
22nd Floor Mowat Block
900 Bay Street
Mr
Toronto ON M7A 1L2
Recommendations
17 to 19
Mr Matthew Torigian
Deputy Minister Community Safety
Ministry of Community Safety and Correctional
George Drew Building
11th Floor
25
Grosvenor Street
Toronto ON M7A 1Y6
Recommendations
20 to 23
Mr Jean Pierre Blais
Chairman and Chief Executive Officer
CRTC
624 55 St Clair Avenue East
Toronto ON M4T 1M2
Recommendation
26
Services
2
Q2016 15
File
For Implementation
Mr
Stephen Hemen
Fire Chief
President Ontario Association of Fire Chiefs
22 530
Ajax
Westney Road South
ON LIS6W6
Recommendations
15 16 27 to 32
Mr Ron Bain
Executive Director
Ontario Association of Police Chiefs
605 40
College
Street
Toronto ON M5G 2J3
Recommendation
16
Mr Brian J Patterson
President and Chief Executive Officer
Safety League
212 2585 Skymark Avenue
Mississauga ON L4W 4L5
Ontario
Recommendations
24 and 25
INO1JEST
TOUCHING THE DEAlli OF
Frolly Harrison
Man Lee Towle
Benjamin Twiddy
Kevin Dunsmnil Jennifer Dunsnauir Robert Dunsmuir
and Cameron Dunsmuir
JURY VERDICT AND RECOMMENDAel IONS
April 2016
Office of the
Chief Coroner
Verdict of Coroners
Bureau du
Verdict du
coroner an
jury
Jury
du coroner
chef
The Coroners Act
Lal
cur
lep compers
Province of Doted
Province de lOntano
We the undersigned Nous soussIgnes
the
jury serving
the inquest into tie death
on
s
of
de
ol
de
of
do
of
de
of
de
memhres clamant assermentos du fury a
of
Given Names
Surname Nom de famile
renguete
curio daces de
Prenoms
Holly
Harrison
18
aged
Toronto
held at
rage de
Ontario
fence a
29 March
from the
to uie
du
29th April
16
20
cli
By
DayinlEgans
Br ID
coroner for Ontario
coroner
Per
having
been
atone fait
duly
sworn
enquete
affirmed have
pour lOntario
Inquired Into and determined the following
qul suit
dans raffalre at avons conclu ce
Name of Deceased
Horn Mr Mont
Holly Honison
Date and Time of Death
Apra 2914
20L2
Date et heure du daces
0208 firs
Place of Death I Lieu du daces
Alreaicl
Health Centro 1 Hospital Court Oshawa Ontario
Cause of Death
Cause du deces
Smoke InbaLstion
Dy what means Circonstances
du deces
Accident
The verdict was received
on
29th
the
Coroners Name Please print
David
day
Nom du coroner
Month
en
lams moulees
Date
ag
Signed Chentimmidd
Cffioner
We the jury wish to make the following recommendations
Nous membres du jury forrnulons lee
S Queens Printer forOntario
see
page 2
recommanddons suivantes
sok page 2
2014101mprimeurde le Relne pour rOntario
2014
16
Mots
2016 04 29
ems
arksees Signature 1 SIgnerstreell
11136 12014 o61
April
of
low I low
Ce verdict a ate regu Is
Date de la
signature aaeaMmidffi
Verdict of Coroners Jury
Office of the
Chief Coroner
Verdict du
Bureau du
coroner an
jury
The Coroners Act
Lot guiles coroners
1
the fury sewing
on
of
tie
of
de
of
de
of
de
of
de
Given Names
mile
Province de lOntano
cur
Prenoms
Mad Lee
Towle
17
aged
et
coroner
Province of Ontario
the Inquest Into ihe cetrunpj of mantras figment assermentes du jury a tenguete
Norn de
Surname
du
chef
Toronto
held at
rage de
Ontario
tenue
29Ih March
from The
16
20
to the
du
au
By
DalidEV8118
Dr 1 De
Coroner for Ontario
Par
coroner
pouf Ontario
having been duly sworn affirmed have Inquired Into and determined he following
avohs fait enquote dens laffaire at evons condo ce qui suit
Name of Deceased
Nom du defunt
Madlee Towle
Date and lime of Death
Apri129th
Place dl Death
Date et heure du deces
0107 hours
2012
Lieu du deces
917 Dundas Steer West
Cause of Death
Whitby Onto
Cause du daces
Smoke inhalation
By what
means
Circons
ances
du deces
Accident
A
The
The verdict was received
Ce Verdict a ate repo le
on
Coroners Name Please
prinql
29th
Apth
day of
PaY tow
Nom du
coroner
Month
en
let es moulees
Date
We the
nature Signature
jury wish
to make the
du coroner
following recommendations
see
page 2
Nous membres du Jury formulons les recommendations suivantes
alas 2514 05
Signed yyyythurnIdd I
2016 04 29
David11 Evans
CoMfid C
20
0 Oueen0 Prinlerfor Cask 2014
0
coil page 2
Impdmeurdon Berne poUr fOntano
2014
16
Mols
Date de is
signature
eaaalmm 01
Office
or
Verdict of Coroners
the
Chief Coroner
Verdict du
Bureau du
coroner en
jury du
1
undersigned
Nous
coroner
cher
The Comers Act
We the
Jury
01
5WhOS coinnets
Province of Ontario
Province de lOnlano
soussignes
oi 1 cla
of
de
Of
de
of I de
of
the jury
serving on the inquest
Into the death
ot
s
de
membres dOment assarroentes du fury a
Surname Mom de bindle
riven
ices de
Pummel curie
Names 1Pronoms
Bergamin
Twiddy
19
aged
Toronto
held at
rage de
Ontario
tenue A
29 Match
from the
la the
29th Altd
16
20
au
du
By
EA
David Evans
D
coroner tor Ontario
coroner
Par
pour lOntario
having been duly swam affirmed have Inquired Into end determined the following
evens fait anquate dens I affairs et evens conclu ce qul mutt
Name of Deceased Nom do defunt
Benjamin Middy
Date and Time of Death
29
April
2012
Date at hours du daces
0131 hrs
UM du daces
Place of Death
Rouge ValleyHospital 580 Harwoodkve Soda Ajax Ontsio
Cause of Death
Cause du Mobs
Sim nice inhalation
By what
means
Clmonstances du deices
Accident
The verdict was received on the
Ce
verdict
a
eta
29th
pay
repute
Coroners Name Please
print
go
day of
Nom du coroner
en
Data
lettres moulies
5
stuicreirsoroner
We the jury wish to make the following recommendations
see
page 2
Nous membres do jury formulons lee recommendations suivantes
0135 to1 4
05
Signed bny moildsa
2016 04 29
DeSK 3vaus
96ioneri SIgnalLre
seOl satsHSTfor 0niada 2014 la
16
Month Mole
ore
imprimeurde
voA page 2
Belie pourMilled
2014
Date de In
signabre
aaas rnm dd
Office of the
Verdict of Coroners
chief coroner
Verdict du jury du
Bureau du
coroner en
coroner
chef
The Coroners 4c
trusty lee coroners
We the
Jury
Province of Ontario
Province de liOntano
undersigned Nous sousslynes
of
de
of
de
of
de
of de
of
the
jury serving on the inquest Into
Surname Nom
Dunsmuir
the death
s
of
Given Names
de terrine
moats curie daces
de
PrOnoms
Kevin
55
aged
A Fags de
Toronto
held at
lame A
291k March
from the
do
membres digment essermentas du jOry a
to the
du
Ontario
29814th
16
20
au
By
Dr
Data El
Di
OaS
Coronerfor Ontario
Per
coroner
pour lOntario
having been duly sworrdeffirmed have Inquired Into and determined the following
avons fait eng irate dens Venire at avons canclu ce qui suit
Name of Deceased
Nom du defunt
KevinDunsronit
Date and Time of Death
March 291h 2013
4
Date et heure du cloche
1230 hours
Lieu du decas
Place of Death
72 HoeAye Sharon Bast accolimburn Ontudo
Cause of Death
Cause du daces
Smoke inhalation
By what means Circonstances
du daces
Accident
The verdict was racelved on the
Ce
verdict
a
eie regu
Coroners Name Please
David H
29th
April
day of
Day Jour
a
print
Nom du coroner
en
lettres moulees
Date
CotaliedskiSignabb Signature
du coroner
following recommendations
see
page 2
Nous membres du jury formulons les recommendations suivantes
013e 2014 116
Signed
2016 04 29
4svans
We the Jury wish to make the
20
a oneens Materiel Debris 2014
0
16
Mols
your page 2
lamilmeur de la Reins pour lOnlado 2014
yyyy fnenkle I Date de la
signature taaweirnm dd
Office of the
Verdict of Coroners
Chief Coroner
Verdict du
Bureau du
coronet en
jury
Jury
du coroner
chef
The Coroners Act
Lot sur les coroners
Province of Ontario
Province de Ontario
WettleIkiSeisignbe gietisIsbutiignee
the
Jury serving
on
the
Inquest into the
death
51
lAge
ni
29th March
By
Dr
be
of
de
of
dc
of
be
Toronto
held at
tenue a
de
from the
du
of
Given Names Prenoms
Jennifer
Surname Worn de tante
a
be
membres anent asserrnentes du fury a Pampas curie daces de
s
Dunsmth
aged
of
laouthe
29
Orttarle
ciAprn
David Evans
DE
16
20
Coroner for Ontario
Par
coroner
pour lOntario
having been duly sworniaffirmed have inquired Into and determined the following
avons
fait anquete dens rattan at
scone
Donal co qui suit
Name of Deceased Worn du delfunt
conifer Dunamnir
Date and Time of Death
March 296 2013
Date et heure du daces
12 30 hours
Lieu du deck
Place of Death
72 Hooiard Ave Sharon
Cause of Death
Ontutio
Tad
Cause du daces
Smoke inhalation
By What
means
arconstances du daces
Accident
The verdict
wee
received
on
the
Coroners Name Please
David
C
EC
29
29th
day
APifi
of
104 Jour
Ca verdict a ota regu le
print
Horn du coroner
en
lathes moulges
Signature I Signature
du coroner
see
page 2
Nous membres du jury formuions les recommendations suivantes
o5
Signed
20104 29
We the Jury wish to make the following recommendations
alas 2r14
Date
iyaris
Itigiee
0 Cluseals Pdolerior Ontario 2014
0
20
16
Stow main
ImprImeurde
vole page 2
is Reins pour rented
2514
yyyy rruntdd
Date de la
signature
aaaa mm
dd
Cello of the
Verdict of Coroners
Jury
Chief Coroner
Verdict du
Burnett du
trininer
jury
du coroner
char
en
4esato
The Coroners An
Province of Ontario
Lorsly les coroners
Province de POnterio
carrmara
We the
undersigned
Nous
soussignes
of
de
or
dc
of de
of
de
or de
be Jury serving
on
the
Inquest Into be death
of membres dement assermentas du jury a
s
Surname Norn de famlle
IGiven
10
Ontario
tenue 6
March
29
the
29
to be
April
16
20
so
By
Dr
David EV
Dr
Coroner for Ontario
coroner pour
Far
having been duly
avons
daces de
Names I Prenams
Toronto
held at
6 rage de
from
du
stir Is
Robert
Dunsmuix
aged
lenquate
sworn
affirmed have
fait Niguel dens laffaire at
Name of Deceased
Inquired into
condi ce
avons
and determined the
qui
lOntario
following
suit r
Nom du daunt
Robert Dunsnautz
Date and Time of Death
March29th
Place of Death
Dale at heure du daces
1 230 hours
2013
Lieu du daces
72 Howard Ave Sharon East
Cause of Death
Crenlimbuy Ontario
Cause du daces
Smoke inhalation
By what
means
Cfroonstances du deces
Accident
The verdict was received
on
2911a
be
they
Ca verdicts ate rept Is
Coroners Name Please
print
Nom du
day
Apth
of
coroner en
lettres moulees
Date
f
Signature
Signed
2016 04 29
David 171 Evans
CotOner
Signal
We the jury wish to make the
t
du
coroner
following recommendations
see
page 2
Nous membres du jury forrnulons les recommandallons suivantes
1
ar
16
MonthIMole
low
1
n
volr page 2
1
nn
I
Nyy mmidd
Date de Is signature aaaalmmidc1
Office of the
Verdict of
CoronersJury
Verdict du
jury
Chief Coroner
Bureau du
serener en
The Coroners Act
Provinces Onlado
Lot sus les coroners
We the
du coroner
chef
Province de Milted
undersigned Nous soussignes
of
de
of f de
of
de
of
de
of de
theto
yea Ong
on
the
inquest Into the death
s
of I membres clamant assaymentes du jury
Cameron
Donenuir
16
aged
a
sur le dazes de
Given Names I Prenoms
Nom de famile
Surname
4 lenquete
Tomato
held at
Page de
Ontario
tenue
March
29
from the
to the
29th Apo
16
zo
au
By
Dr
Et DavidEvans
Coroner for Ontario
coroner emir
Par
lOntario
having been duly swemraffirmed have Inquired Into and determined the following
enguete dans venire at
avons fait
Name of Deceased
evens
conclu ad gel suit
Nom du defiant
Cameron Dunstan
Date and Time of Death
March 29th 2013
Place of Death
Date at heure du daces
1230 hours
Lieu du daces
72 Howat Ave Sharon East Gwilimbury Ontario
Cause of Death
Cause du
daces
Smoke inhalation
By what
means
Clmonstances du daces
Accident
The verdict was received
Ce Verdict a eta recu le
Coroner
th2lory
29th
pay
Nom du
day of
Ail
WA
lour
coroner en
lathes moulees
Date
20
Ire
du coroner
wish to make the following recommendations see page 2
membres du Jury formttions lea recommandafions lsuivantes voir page 2
16
Mots
Signed
2016 04 29
ens
Obroners Signature
Nous
the
Name Please print
David
We
on
yyry rtsrddd
Date de In
signature fa
ma mm
6d
Office
or
Verdict of Coroners Jury
the
Chief Coroner
Verdict du
Bureau du
coroner en
jury
du coroner
chef
Province of Ontario
Tha Coroners
Lot sij lea coroners
Province de
rontano
Ingtlist kite the deeth of
Enquete cur Is deees de
Hefty Anson Menke Towle Benjamin
TWiddy
Kevin Jennifer Robert and Cameron Duosmnir
JURY RECOMMENDATIONS
RECOMMANDATIONIS DU JURY
o
the Office of the Fire Marshal and Emergency Management
To consult with stakeholders to define the meaning of
public education in section 2 1
a
ofthe Fire
Mtection and Prevention Act hough a Directive
To develop
a
public education program related to publicfire safety in accessory apartments
To educate The public on its responsibilityto maintain and not dismantle
I
vandalize smoke
To work with the luau awe Bureau of Canada and other stakeholders to increase insurance policyrequize menis
br residential smoke alamosisrank e detectors and carbon monoxide detectors and to develop public service
unouncementsto promote
awarenessofthe
importance ofworking smoke alarms detectors and carbon monoxide
letectors
To continue and expand the accessibility of all taming resources to
municipalities byproviding standard
elearning Train the Trainer pacicages local training opportinities and teaching materials to municipalities
o provide for consistent provincewide trainnig and standards
Urriculum
Co the Office of the Fire Marshal and Emergency
5
Management andMunicipalFireDepartments
To muter incorporatinglessons learned from East Gwillimbury and Whitby
amidents into future
he 911 calls
venation and
or
materials with personal intonation and identifiers removed and without using the audio of
college symposia and training materials including butnot limited to suggestions for self
course
such as fire
self poservatiaa
7
Fire Inspectors to notify tenants OfLandlords non compliance via letter
3
Inspectors fire or building
tparation
must have visual proof of compliance
3
Developa provincial red flag system winch would trigger
compliance conviction under the Fire Code
10
e
g
confirming drywall installationfor fire
Verbal emanationbyproperty owneris not sufficient
Canvass neighbourhood
To the Office
ere
inspection of properties with a historyDimon
conummitypostfire to promote awareness offire safety andprevention
ofthe Fire Marshal and Emergency Management and Municipalities
11
To continue and erp d public education onthe fitct that upon discovery of twice or fire every personmust
immediately get out and stay out ofthe building
12
As part ofpublic education
promote
awareness of different types
Included in ibis education conldbe demonstrations and hands
on
and
appropriate use offire erboaguishers
practice
To Municipalities
13
Consult with stakeholders to
14
Work towards
a
expiatethe installation of clearlyvisible house numb end
provincially integrated computer software Fugal
to
agist dispatching of 911 calls
To the Doted Association of Fire Chiefs
Departments to explore re allocating their current resources and or utilizing resources from the
me prevention public education an fire safety inspections in firer municipalities This could
include a Home Visit Public Education program and literature that will provide occupants home fire safety infontiation
mai as the presence ofsmoke detectors CO detectors escape plans vulnerable occupants physics and copritive
disabilities appliance e g dryer safety delivered by fire fighters as provided by the municipality Such programs
may include a home inspection as determined by the municipality
Fire
15
suppression area for
To the Ontario Association of Fire Chiefs and the Ontario Association of Chiefs of Police
To encourage collaboration between fire departments and police services in the area oftraining with a view to
16
ensuring a safe and efficient response to Sanctum tires and the preservation and collection of fire investigaticin related
evidence
To the
Ministry ofEducation
consult withthe Office ofthe Fire Marshal and Emergency Management and develop fire safety glIffiCTIUor
leaving home for the first time and their parents focusing on fire safety and
the preventionskills including safe cooldng smoke alarms the need for ameans of egress and having and practicing
an emergency ea plan in case ofthe
To
17
for high school students and young adults
To make available to the Schoa Boards the OFMElvl bum room videos and No Time To
la
raise
awareness ofhow
fast and deadly the by products of Ere
can be
e
Spare video to
g smoke
Explore opportunities to work with fire prevention and detection officers as part of the mandatory volunteer
Students For example students could work to getter to find ways to promote fire
safety amongsttheir peers e g Cop Lights Ming A video produced by theRCMP to raise awareness ofmoving over
when cruisers lights are on
19
hours cuniculum for high school
To the Ministry of Community
Safety and Correctional Services
To make a Regulation pusuantto clans 73 1 k of the Fire Protection and Prevention Act requiring
mandatory certification and training to recognized industrystandards for all personnel as defined in the Fire Protection
and Prevention Act Whose primary job function is to perform 1 file inspections 2 public education and or 3
communications call taking dispatch
20
21
To work with the Technical Standards and Safety Association TSSA to promote the
installation of Carbon Monoxide detectors through 1IVACtechnicians who install gas
fund appliances
To amend section 9 8 ofthe Fire Code to address interior finishes of themeans of egress in accessory
apartments with only one means of escape and in particular require that suchfinishes have a maximum flame spread
22
ratirig of 150
For example
9132 2 Where a dwelling mit is served by onemeans of escape conforming M Sentence I the Lame
spread rating of interior wall and ceiling finishes adjacentto Stairs within the dwelling unit leading to the means of
a
escape shallnot exceed 150
b
flame
9 8 3 3 3 Where a dwiling wit is served by one means of escape confonningto Sentence I or 2 the
spread rating ofinterior wall and ceilingfinishes adjacentto stairs withinthe dwelling unit leadingto the means
of escape shall not exceed 150
23
Legislationand or code be created pursuant to the ETTA that mandates that a municipalityclearly and
understandably educate the residents ofthe community on the the protection services providedby the municipality
This shall be done on the department municipalweb pages and printedlitemtureproducedby the municipality This
infomaation should indicate whether fire protection is beingprovidedbyfull time the fighters volunteer the fighters or
a combination ofthe two and their respectivehours of operation
To the Ontario
SafetyLeague
To liaise with existing fire safety agencies and councils such as the Office ofthe Fire Marshal and Emergency
24
Managements Public Fire Safety Council to address the issues of fire safety campaimas Drosnam and education
cuniculums Refer to recommendation
To the Ontario
25
11
Safety League and the Office of the Ontario Fire Mamhal and EmergencyManagement
Explorethe idea of using transit
coimftatid ttget out stay
services advernsing
as a
method of raising fire
safidy atmeties
e
g
seconds
out
To the Media
26
Ask the media to assist in raising
awareness
through smoke alarms and the get out stay out
around fue safety inclnding the importance of early detection
message The public needs to be
aware that
the fire
department may
notbe able to effect a rescue and therefore needs to be more vigilant withregardto fire prevention and fire detection
ensure their own
to
safety
To The lvfinistry of Municipal Affairs and Housing the Office ofthe Fire Marshal and Emergency
Management and the
Ontario Association ofFire Chiefs
To consult with stakeholders research and promote the installation of sprinklers as a component ofthe and life
safetY in all newly constructed residential homes with the appropriate amendment under the Ontario Building Code
27
28
To consult with stakeholders to research and promote two tams of egress for accessory
appiopiate amendment under the
29
Consult with the Real Estate Board and other stakeholders to
level of service they provideto
30
Well as
prospective homeowners
e
explore the ability to list locations of the halls and
g location of schools
When a building permit has been grantedfor renovations
a
apartments with the
Ontario Building Code
or retro
fit afire
inspection must be completed
as
building inspection
Regulation be passed pursuant to the Fire Protection and Prevention Act mandating that municipalities provide
on tax assessments indicating the level of the protectionprovidedto individual property owners This
information should indicate whether the protection is being providedby full time the fighters volunteer the fighters or
a combination ofthe two and their respectivehours of operation
31
information
32
Consider
communicating any changes to the fire bode regradi
a dwelling unitsi to
property
owners
through the
property tax assessment font
To The Office of the Chief Coroner
33
The Office of the Chief Coroner shall request that all organizations andinstitutions
recommendations
provide reports updating their responses within a year of receipt
of these reports the Office ofthe Chief Coroner Mall convene press conference
receivingthese
To inform the public ofthe contents
a year from the
date that the
xecipientpraties Copies of the reports shall be forwarded to the jurors who will
recommendations
be invited to attend the preis conference All recommendationsto be reviewedannually for the next two years with
public reports filed providing an update onto stains ofthejurys final recommendations
were sent out to the
authority
alume Coroners ADS FLS O 109D C C 37 as amended Quasfions abootthls cofiedloa should be
Pelson Informationcontained so fills Ion la collaoledunderthe
directed le Via Chief Cotoner 26 Morton ShulmanAvanue Toronto ON M331 oat TEL 410 914 4000 or Toll Re I 877 091 0030
Les renceIgnements personnels contenus dans cella formule sant mousfilts no vertu dole Lai styles coroners Lft O 1000 chap 0 07 1talle que modifies SI von avaides
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1 877 99 1 0950
Verdict
Explanation
Inquest into the Deaths of
Holly HARRISON Marilee TOWIE Benjamin TWIDDY Kevin DUNSMUIR
Jennifer DUNSMUIR Robert DUNSMUIR and Cameron DUNSMUIR
March 29
April
29 2016
Coroners Courts
25 Morton Shulman Avenue Toronto
Opening
comment
explanation is intended to give the reader a brief overview of the
circumstances surrounding the death of Holly Harrison Mari Lee Towie Benjamin
Twiddy Kevin Dunsmuir Jennifer Dunsmuir Robert Dunsmuir and Cameron
Dunsmuir along with some context for the recommendations made by the jury The
This verdict
synopsis of events and
coroners comments
herein
are
based
on
my recollection
as
presiding coroner of the evidence presented and on what I believe to be the jurys
findings of fact from that evidence This explanation has been written to assist in
understanding the intent of the various recommendations so that recipient
organizations agencies and ministries of governmentmight be in a better position
to consider their implementation
Participants
Counsel to the Coroner
Mr Frank Giordano
Crown Counsel
Central East
Region
201 1091 Gorham Street
Newmarket ON L3Y 8X7
Frank Giordanopontario ca
Investigating Officer
Det Cst Avi
Fagu
Toronto Police Service
Coroners
Inquest Unit
25 Morton Shulman Ave
Toronto ON M3M OB1
Avi Fagu
Coroners Constable
Cst
ontario
ca
James A Murphy
Toronto Police Service
Coroners
Inquest Unit
25 Morton Shulman Ave
Toronto ON M3M OB1
Jim A Murphy
ontario
ca
Court
Reporter
Ms Devon Lockett
Reporting and Mediation
King Street West Suite 3600
Network
100
Toronto ON M5X 1E3
416 359 1611
Parties with
Standing
Families of Harrison Towle and
Ms Aliza Karoly
Twiddy
Carranza LLP
1280 Finch Avenue West
Toronto ON
aliza
Durham
Regional
Police
200
M3J 3K6
carranza on ca
Mr Arend J Wakeford
605 Rossland Road East
Whitby
ON L1N 6A3
Arend Wakeford
The
City of Oshawa
Durham
ca
Ms Visha Sukdeo
The
City of Oshawa
Legal
Services
50 Centre Street South
Oshawa ON L1H 3Z7
VSukdeo
The Town of Whitby
oshawa
ca
Ms Nada Nicola Howorth
Learners LLP
130 Adelaide Street West
2400
Toronto ON M5H 3P5
NNicola
The Town of Richmond Hill
Mr
Municipality
Gwillimbury
Hicks
The
lerners
ca
John Saunders
Morley LLP
77 King Street West Box 371
of East
Toronto ON M5K 1K8
j ohn saunders
York Regional Police
Mr
hicksmorley
Jason Fraser
York Regional Police
47 Don
Hillock Drive
Aurora ON li4 Qi0
5609PYRRGA
2
7
com
York
Regional Emergency
Ms Rebecca Bush
Borden Ladner Gervais LLP
Medical Services
Scotia Plaza Tower
40 King Street West
Toronto 01 11v15113Y4
b1g com
RBush
Whirlpool Corporation
Mr
Timothy Buckley
Borden Ladner Gervais LLP
Scotia Plaza Tower
40
King Street West
Toronto ON M5H 3Y4
TBuckley b1g com
Fifthshire Home Ltd
Mr Karim Hirani
Company LLP
Zuber
100 Simcoe Street Suite 303
Toronto ON M5H 3G2
KHirani
Ontario
zubco
com
John Legge
Legge Legge
Safety League
Mr
65 St Clair Avenue East Suite BOO
Toronto ON M4T 2Y8
leggeandlegge com
jlegge
Ontario Branch of the
Mr Sean McManus
International Association of
McManus Hubler LLP
Fire
Fighters
63 Rockcliff
Calgary
Landing NW
AB T3G 5Z5
MCMANUS HUBLER
sean
ca
Ms Claudia Brabazon
Ontario Fire Marshal and the
Ministry of Community Safety
Crown
and Correctional Services
777 Memorial Avenue 3rd Floor
Attorney
Orillia ON L3V 7X3
Claudia Brabazon
ontario
ca
Summary of the Circumstances of the Deaths
The
inquest looked into the
Towie and
circumstances of the deaths of Holly Harrison Mari Lee
Benjamin Twiddy in
2012 and the Kevin Dunsmuir
Dunsmuir
family
who died in
a
a
house fire in
Jennifer
Whitby
Durham
Region
on
April
29
Dunsmuir Robert Dunsmuir and Cameron
house fire in East
March 29 2013
3
Gwillimbury in York Region on
Benjamin Twiddy had been residing in the second floor apartment at 917 Dundas
Holly
night meal After
removing the food from the oven some how a towel caught fire and ended up in the
stairwell of the exit to the apartment The stairwell soon became engulfed in flanies
blocking their only means of egress from the apartment They called 911 at 00 25 43
and requested fire service to respond to the fire indicating it was from a burning
towel There was some initial confusion about the address and eventually Mr
Street West in
Whitby
for about
a
month Mr
Twiddy had
not
to confirm the
Twiddy
cooking for
Harrison and Mari Lee Towie had been
a
address to the fire call taker
recognize the address The callers fell silent about
The fire trucks
this
were
dispatched
as
the computer system did
2 minutes into the 911 call
at 00 28 44 to the nearest address which was in
915 Dundas Street West Soon after the
case
with two friends
late
police
call taker confirmed the
intersection to the fire call taker The Fire trucks arrived
on scene at
00 30 00 and
noticed smoke visible at 00 31 51 In less than 2 minutes into the 911
response from the victims to calls from the call taker Water
at 00 34 59 The 3 victims were found huddled
window
at the west side of the
was
together at 00
call there is
no
applied to the fire
46 56 underneath the
apartment
Rouge Valley Hospital in Ajax and was pronounced dead
Lakeridge Health Oshawa where resuscitation was
Ms Harrison was taken
continued for approximately an hour before she was pronounced dead Ms Towie
was pronounced dead at the scene
Mr
Twiddy was
taken to
to
The Fire Marshals
a
investigation into the circumstances of the fire found there
were
number of violations of the fire code in the structure which did contribute to the
sudden onset of the fire A significant violation was the presence of wood
used in the stairwell and
on
the wall of the apartment There was
under the wood paneling to have fire
separation between the
no
paneling
dry wall used
stairwell and the
ground floor apartment as required in the fire code
The Dunsmuir family Mr Kevin Dunsmuir Ms Jennifer Dunsmuir Mr Robert
Dunsmuir and Mr Cameron Dunsmuir resided in a two storey detached house
Howard Avenue in East
Gwillimbury
have mobility issues following
05 29 51
a
911 call
was
a
in York Region Mrs Dunsmuir
stroke
received from
a
a
few years
resident of the house
fire and the smoke was very thick He could
difficulty breathing as
the master bedroom
police
not see
on
had arrived
was
indicating there
on scene
the
phone
was no
call
just before the Fire Department and encountered
thick black smoke coming from the upstairs window and found in the kitchen
at the back of the house
was a
having
a total of four people in
was
the second floor in the front of the house There
on
known to
On March 29 2013 at
much and he
he suffered from asthma There were
sound of a smoke alarm going off
The
previously
at 72
They breached the front door but found the hall full
area
of thick
black smoke and very hot and were unable to enter
The Volunteer Fire Department in East
by the
fire call
arrived
Gwillimbury
was
dispatched to
the address
dispatcher based in Richmond Hill at 05 30 24 and the first truck
at 05 42 21 Water was applied to the fire at 05 45 00
on scene
4
The call taker had lost verbal contact with the caller
back when the
original
call
was
dropped
soon
after she had called him
and before the Fire
Department arrived
on
scene
The four victims Mr Kevin Dunsmuir Ms
and Mr Cameron Dunsmuir
Jennifer Dunsmum Mr
found by 06
were
Robert Durismuir
39 45 in and around the master
bedroom in the front of the house
The Fire Marshals investigation indicated the fire had started in the drum of the
dryer
electric clothes
functioning
There
at
on
the time of the fire
were two
laundry room The dryer was found to be not
and the dryer was not the cause of the fire
the main floor
smoke alarms identified in the house
one
in the basement and the
other on the ceiling of the second floor just above the stairs The company who had
security system and smoke alarms indicated they put smoke detectors in
the basement and first floor as there was a 120v unit already present on the 2nd
installed
a
floor There
were
connected to
it
was a
a
remains of
low
120v unit
voltage
or a
a
supply
The Fire Marshal
low voltage unit The
connected to the low voltage
wall
smoke alarm found in the ceiling
power
original alarm
was
on
was a
supply would not have functioned
the second floor
identify
unable to
On the main floor
adjacent to the hallway from the laundry room to the foyer and stairs
low voltage power supply for
removed
an
alarm but the unit itself
if
120v unit and if
appeared
to have
was
the
been
possibly during some previous renovations
The jury heard evidence from the 31 witnesses called and the 82 exhibits tendered
over
17
sitting days
Verdict of Coroners fury
The
Name of Deceased
Date Time of Death
Whitby
Fire
Holly Harrison
April 29 2012
0208 hrs
Place of Death
Lakeridge Health Centre
1 Hospital Court Oshawa
Cause of Death
Smoke Inhalation
Manner of Death
Accident
Name of Deceased
Marilee Towie
Date and Time of Death
April
Place of Death
917 Dundas St West
Cause of Death
Smoke Inhalation
Manner of Death
Accident
29 2012
ON
01 07 hrs
Whitby
ON
Benjamin Twiddy
April 29 2012
01 31
Rouge Valley Hospital
Name of Deceased
Date and Time of Death
Place of Death
hrs
580 liarwood Ave South
Cause of Death
SMoke Inhalation
Manner of Death
Accident
The East
Ajax
ON
Gwillimbury Fire
Name of Deceased
Kevin Dunsmuir
Date and Time of Death
March29 2013
Place of Death
72 Howard Ave Sharon ON
12 30
Cause of Death
Smoke Inhalation
Manner of Death
Accident
Name of Deceased
Jennifer Dunsmuir
Date and Time of Death
March29 2013
Place of Death
72 Howard Ave Sharon ON
Cause of Death
Smoke Inhalation
Manner of Death
Accident
Name of Deceased
Robert Dunsmuir
Date and Time of Death
March29 2013
Place of Death
72 Howard Ave Sharon ON
Cause of Death
Smoke Inhalation
Manner of Death
Accident
Name of Deceased
Cameron Dunsmuir
Date and Time of Death
March29 2013
Place of Death
72 Howard Ave Sharon
12 30
12 30
12 30
Cause of Death
Smoke Inhalation
Manner of Death
Accident
ON
Recommendations
To the Office of the Fire Marshal and
Emergency Management
public education in
and Prevention Act through a Directive
To consult with stakeholders to define the meaning of
section 2 1
2
To
a
of the Fire Protection
develop a public education program related
apartments
6
to
public
fire
safety in accessory
Coroners Comments
Evidence was heard that there
thousands of accessory
are
in houses in the province and there
3
To educate the
public
on
its
is no
or
educabon aboutfire
responsibility to maintain
bthththit apartments
safety
and not
dismantle vandalize smoke alarms
4
To work with the Insurance Bureau of Canada and other stakeholders to increase
policy requirements for residential smoke alarms smoke detectors and
carbon monoxide detectors and to develop public service announcements to
promote awareness ofthe importance of working smoke alarms detectors and
insurance
carbon monoxide detectors
Coroners Comment
of identifring afire very early
on and that early warning allows the people at risk to get out before the smoke and
the heat overcomes them When smoke alarms are disabled the people lose that
early warning and are more likely to become victims of the fire
Evidence was heard that smoke detectors
are a means
accessibility of all trainingresources to municipalities
by providing standard curriculum e learning Train the Trainer packages local
training opportunities and teaching materials to municipalities to provide for
consistent province wide training and standards
To continue and expand the
Coroners Comment
There is
a
need to standardize the
trainingfor the firefighters in their various roles
municipalities in the province There should be more than one means of
e learning to reduce the cost to municipalities ofsending people to the
College
Fire
for such training
across
learning i e
To the Office ofthe Fire Marshal and Emergency Management and Municipal Fire
Departments
6
To consider
incorporatinglessons learned from East Gwillimbury and Whitby
incidents into future
course
materials with personal information and identifiers
removed and without using the audio of the 911 calls
such
symposia and training materials includingbut not limited
evacuation and
or
self preservation
as
to
fire
college
suggestions for self
Coroners Comment
nurnlier ofderaYs ofprocedure during bothfire 6cill takers fespOnse to
There vvere
the calls received This included the
relaying of incorrect information
corrected in time not to have had any effect on the outcome
ofbenefitfor the education of otherfire call takers to
these fires
Inspectors to notify tenants of Landlords
use
which was
ofthe events It wouldbe
the scenarios from both
compliance via letter
7
Fire
8
Inspectors fire or building must have visual proof of compliance e g confirming
drywall installation for fire separation Verbal confirmation by property owner is
non
not sufficient
9
Develop a provincial red flag system which would trigger a re inspection of
properties with a history of non compliance conviction under the Fire Code
Coroners Comment
The landlord
of the Whitby
apai tiuent had been
charged under afire code violation
and was heavily fined prior to completing the renovations to the house The fire
inspector had taken his word about the drywallfire separation in the stairwell walls
being present under the wood paneling and did not check physically to confirm for
himself
At present
only
the landlord would be
tenants would have no
10
notified of any non code compliance and any
indication ofthe code violation
Canvass neighbourhood
community post fire to promote awareness of fire safety
and prevention
To the Office ofthe Fire Marshal and
11
To continue and
smoke
or
Emergencyimeeini
and Munldpallties
expand public education on the fact that upon discovery of
must immediately get out and stay out of the
fire every person
building
12
As part of public education
promote awareness of different types and
appropriate use of fire extinguishers Included in this education could be
demonstrations and hands
on
practice
8
To
Municipalities
13
Consult with stakeholders to
explore
the installation of clearly visible house
numbers
14
Work towards
dispatching
a
provincially integrated computer software program to
assist
of 911 calls
Coroners Comment
The call taker witness indicated that the software program that was used to
dentin
of the address given by the caller on a computer map program can on
occasion be unable perform properly It appears the municipalities do not have the
same software to do this The fire department had some dijficuThi identing the
the location
house because it
was
setbackfrom the road some distance and there was no street
lighting and no house number visible
The fire was not visible from the outside
of the
house at the time thefire trucks arrived
To the Ontario Association ofFire Chiefs
15
Fire
Departments to explore
resources
from the
re
allocating their
current resources
and
or
utilizing
suppression area for fire prevention public education and fire
safety inspections in their municipalities
This could include
a
Home Visit Public
provide occupants home fire safety
information such as the presence of smoke detectors CO detectors escape plans
vulnerable occupants physical and cognitive disabilities appliance e g dryer
safety delivered by fire fighters as provided by the municipality Such programs
may include a home inspection as determined by the municipality
Education program and literature that will
Coroners Comment
Thejury heard that with budget restraints the number ofpersonnel who were
allocated to fire inspections public education andfire safety inspections were
restricted It was suggested that the municipalities investigate the use some ofthe
staff that were already employed on fire suppression duties to assist with these
duties
To the Ontario Association of Fire Chiefs and the Ontario Association of Chiefs of
Police
16
To encourage collaboration between fire
departments andpolice servicesin the
ensuring safe and efficient response to structure
fires and the preservation and collection of fire investigation related evidence
area
of training with
a view to
a
9
Coroners Comment
It was realizedthat fall
OffiCers Cannot act ttefir e fighterS
cind Vieeversh
Collaborative trainingfor the police and fire fighters would help each force fully
understand the others processes and procedures
To the Ministry ofEducation
17
To consult with the Office of the Fire Marshal and Emergency Management and
develop fire safety
curriculum for
high school
students and young adults
home for the first time and their parents focusing
on
fire
leaving
safety and fire
prevention skills includingsafe cooking smoke alarms the need for a means of
egress and having and practicing an emergency exit plan in case of fire
18
To make available to the School Boards the OFMEM burn room videos and No
Time To
of fire
19
Spare video to raise
can
be
e
awareness
of how fast and
deadly the by products
g smoke
Explore opportunities to work with fire prevention and detection officers as part
of the mandatory volunteer hours curriculum for high school students For
example students could work together to find ways to promote fire safety
amongst their peers e g Cop Lights Sling A video produced by the RCMP to
raise awareness of moving over when cruisers lights are on
Coroners Comment
Safety League already has developedfire safety in the curriculum for
Grade 5 and 8 school children Concern was raised by a number of witnesses that the
age group of concern was the one who would be leaving home to go to secondaiy
education and living on their own for the first time and that they and their parents
should be targeted for the reinforced education A number ofvideos shown to the
jury indicated the problem of the thick black smoke and the short time you have to
The Ontario
get out of a fire before you can be overcome
To the
Ministry of Community Safety and Correctional Services
20
Regulation pursuant to clause 78 1 k of the Fire Protection and
Prevention Act requiring mandatory certification and training to recognized
industry standards for all personnel as defined in the Fire Protection and
Prevention Act whose primary job function is to perform 1 fire inspections
public education and or 3 communications call taking dispatch
To make
a
10
2
Coroners Comment
Evidence indicated there is
Perldim
no
requirementfor mandatory training required
to
Fire Protection duties Public education or for Call Takers and Dispatch
operatorsfor the fire service There are Indusby standards which with mandatory
training will ensure the same level ofservice in all municipalities
21
To work with the Technical Standards and
SafetyAssociation
the installation of Carbon Monoxide detectors
install gas fired
TSSA to promote
through HVAC technicians who
appliances
Coroners Comment
Evidence was given that the Carbon Monoxide associated with the smoke from
afire
is very often the
cause
of death
in fires not the heat Also it is
when there is incomplete combustion in
easily mixes with the air
publics only defense against the gas
odourless and
22
a
gas
so
fueledfurnace
produced
The gas is
Carbon Monoxide detectors
are
the
To amend section 9 8 of the Fire Code to address interior finishes ofthe means of
egress in accessory apai iments
with only one means of escape and in particular
require that such finishes have a maximum flame spread rating of 150
For
example
a
9832 2
Where
a
dwelling unit is
served by
one means
of escape
conforming to Sentence 1 the flame spread rating of interior wall and ceiling
finishes adjacent to stairs within the dwelling unit leading to the means of
escape shall not exceed 150
b
983 3
3
Where
a
dwelling unit is
served by
one means
of escape
conforming to Sentence 1 or 2 the flame spread rating of interior wall and
ceiling finishes adjacent to stairs within the dwelling unit leading to the means
of escape shall not exceed 150
23
Legislation and or code be created pursuant to the FPPA that mandates that a
municipality clearly and understandably educate the residents of the community
on the fire protection services provided by the municipality This shall be done on
fire department municipal web pages and printed literature produced by the
municipality This information should indicate whether fire protection is being
provided by full time fire fighters volunteer fire fighters or a combination of the
two and their respective hours of operation
Coroners Comment
The Fire code at present does not have any restrictions
interior finishes ofwalls There may be drywallfor fire
11
or
requirementsfor the
separation between dwellings
ofwhat people put on top of the drywall is not covered in the
on what level offire
protection services are provided by their municipality the public would be able to be
lietterpreparedfor anyfireevent
but the flammability
Fire Code It was suggested that by educating the public
To the Ontario
24
Safety Leave
To liaise with
existingfire safety agencies and councils such
Fire Marshal and Emergency Managements Public Fire
the issues of fire
safety campaigns
as
Safety
the Office of the
Council to address
programs and education curriculums
Referto
recommendation ail 11
Coroners Comment
League is already involved in educating the public about all
aspects ofsafety in every day living including Fire Safety By including the Office of
The Ontario Safety
the Fire Marshal and Emergency Managements Public Fire Safety Council the
benefit oftheir input will help the Ontario Safety League to further develop
programs they have been involved in
To the Ontario
Safety League and the Office of the Ontario
the
Fire Marshal and
Emergency Management
25
Explore the idea of using transit services advertising as
safety awareness
e
g
a
method of raising fire
seconds count and get out stay out
To the Media
26
to assist in raising awareness around fire safety including the
importance of early detection through smoke alarms and the get out stay out
Ask the media
message
public needs to be aware that the fire department may not be able
to effect a rescue and therefore needs to be more vigilant with regard to fare
prevention and fire detection to ensure their own safety
To The Mini
The
of Muni
al Affairs and Housin
the Office ofthe Fire Marshal and
Emergency Management and the Ontario Association of Fire Chiefs
27
To consult with stakeholders research and promote the installation of sprinklers
as a
component of fire and life safety in all newly constructed residential homes
with the appropriate amendment under the Ontario Building Code
28
To consult with stakeholders to research and promote two forms of egreSs for
accessory apartments with the appropriate amendment under the Ontario
Building Code
12
29
explore the ability to
they provide to prospective
Consult with the Real Estate Board and other stakeholders to
list locations of fire halls and level of service
homeowners
e
gclocation of schools
Coroners Comment
The jury heard evidence that sprinklers do stop firesfrom
spreading
are more
efficient reducing property damage and can assist people to get out of the
building by slowing the spread of thefire They were recommended by a number of
in
Fire Depal tment witnesses There
was
also evidence given that indicated that
accessory apartments in houses only require one
means
allow people to escape the fire In the
only
means
ofegress is required under the building code
means
eg
of egress and no secondary
suitably sized windows to
Whitbyfire the fire was in the stairwell ofthe
of egress and the window size was not adequate
to
allow the victims to
by to escape
30
a building permit has been granted for renovations or retrofit
inspection must be completed as well as a building inspection
When
a
fire
Coroners Comment
The evidence heard indicated
is required
31
after any home
renovations only
a
building inspection
No fire code inspection is required
Regulation be passed pursuant to the Fire Protection and Prevention Act
mandating that municipalities provide information on tax assessments indicating
the level of fire
protection provided to individual property owners This
information should indicate whether fire protection is being provided by full time
fire
fighters volunteer fire fighters
or a
combination of the two and their
respective hours of operation
32
communicating any changes to the fire code regarding dwelling units to
property owners through the propertytax assessment form
Consider
Coroners Comment
It was indicated in the evidence that most members of the public have no idea
of the
level offire protection provided by their municipality including whether the fire
department was a full time fire fighter department or a full time volunteer
department or a composite of both types It was suggested that this information
could be provided to the members of the municipality on their tax assessment along
with any changes to the fire code that would affect homeowners
13
IPAf 1
Uhl
m
I
To The Office of the Chief Coroner
33
The Office of the Chief Coroner shall request that all organizations and institutions
receivingthese recommendations provide reports updating theirresponses
within a year of receipt To inform the public of the contents of these reports the
Office of the Chief Coroner shall
convene a
press conference
that the recommendations were sent out to the
a
year from the date
recipient parties Copies of the
reports shall be forwarded to the jurors who will be invited to attend the press
conference All recommendations to be reviewed
with
public reports filed providing an update
annuallyfor the next two years
on the status
of the jurys final
recommendations
Coroners Comment
Although
advised of the
procedure of the
recommendations the my
Closing
was
Coroners
Office in dealing
with the
given this recommendation in the joint slate
comment
prepared solely for the purpose of
the
verdict and providing some
understanding
jurys
parties
context for its recommendations so that their intent might be better understood
The comments are based on my personal recollection of the evidence and on what I
believe to be the jurys findings of fact Should the reader contest any of my
recollection of the evidence I would defer to the official record maintained by the
In closing I reiterate that this document has been
assisting interested
court
in
reporter
viwip gotN ma
REP10 6
Pgflo
yp2eoriBIN9
111191Zigir
Y 1J 2
April
David H Evans M B
Presiding
BS
29 2016
OFFICE OF THE CHI rill
FRCSC FAGS
Coroner
OFFICE OF THEMAY
03 2016 Ministry
CommunitY Safety
and
Correctional Services
14
of
rIMMTP