INSTITUTIONAL BETRAYAL==CHIEF CORONER'S OFFICE OF ONTARIO--Drs. Bert Lauwers, Andrew McCallum, Dirk Huyer


INSTITUTIONAL BETRAYAL—all were given the medical facts and expert opinions mentioned previously

A PRIMER ON THE LAW OF DEFAMATION IN ONTARIO


"Defamation is comprised of two subcategories between libel (libel refers to written defamatory statements)and slander(broadcasting of spoken defamatory words)

Proving a Claim in Libel and/or Slander
"the statement must be false!"

Defences to Actions in Libel and Slander 

 
TRUTH--
"The first defence is the defence of truth. The defence can be made that the statement was truthful and therefor there was nothing false about the statement, meaning therefore, that the statement was not defamatory."


FAIR COMMENT--
"The second defence to an allegation of libelous statement is that the statements made were made as a fair comment. The defence of fair comment would be considered by the Court in situations where, by looking at the statement made, the facts and the situation, a conclusion can be made that the statements made were in actuality a fair commentary on the situation at hand and that the comments were fair and were not malicious."


QUALIFIED PRIVILEGE--
"The defence of qualified privilege arises normally in situations where the individual publishing these statements will escape any liability if it can be proven that the public good could be furthered in open debate.  --     especially considering the numerous deaths which occurred after my daughter's death and the one in Dec of 2012.  Who really knows the real total being concealed by all?

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CHIEF CORONER'S OFFICE OF ONTARIO--Drs. Bert Lauwers, Andrew McCallum, Dirk Huyer--appointed by a Liberal majority gov't

CPSO's Decision “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was NEGLECTED by Dr. (Laz) Klein in this case.” The CPSO issued a secret written caution to Dr. Klein and stated that PERHAPS he MIGHT want to CONSIDER administering the mandatory antibiotic prophylaxis in THE FUTURE when converting from minimal evasive to open surgery! 


A very dangerous precedence has been set by the CPSO, HPARB, THE CCO, THE DIOC AND THE ONTARIO OMBUDSMAN by allowing the CPSO and HPARB decision to stand---- they can now use my case to substantiate other citizens’ complaints should any open surgery occur within Ontario without the mandatory antibiotic prophylaxis being administered, as well as  supporting the non-use of any antibiotics being administered to a patient who has undergone open abdominal surgery (all staples removed from the 8 inch incision) and developing an abdominal incision whereby test results indicated the presence of “many gram negative bacilli”.
SHAME

IT APPEARS WHEN YOU SCREW UP, YOU GET PROMOTED TO ANOTHER GOVERNMENT JOB PAID BY ONTARIO TAX PAYERS!

Andrew McCallum, past Chief Coroner of Ontario, presently Head of Ornge

Bert Lauwers, past Deputy Chief Coroner of Death Investigation, presently President and CEO of Ross Memorial Hospital in Lindsay, Ontario.
 
ONTARIO, CA. CITIZENS BEWARE. Should an adverse medical event take place the hospital, surgeon, doctors, Coroners, CPSO, HPARB, DIOC, Ombudsmans Office, the Provincial Health Minister, the Premier and her cabinet etc etc. will lie and/or do nothing. It is a shame that the majority of Ontario citizens are oblivious to this, until it happens then it is too late, as I unfortunately found out. The truth is out there but not in Ontario.

The Chief Coroner's Office should be held to account for its biased, extremely flawed death investigation ignoring the evidence and they should also be asked to support their opinion with documented fact from medical texts etc. They should be asked to redo the death investigation and not have so many omissions, and they should be asked to hold a public inquest! The Minister of Corrections should get more involved and demand an open public inquest. The Minister of Corrections can step in and demand this.

One must ask if Ontario is really being served by those who are supposed to ensure our safety in terms of Health Care?

How on earth could the, HPARB, the Ontario Ombudsman, and the DIOC be completely duped by the faulty death investigation by the Chief Coroner's Office and the decisions from the CPSO?

All above exhibited the following:

Confirmation bias = seeking or interpreting information that (one thinks) will support one's favored hypothesis or diagnosis.

Ego bias = biasing probability estimates in a self-serving way.

Is it possible that in Ontario we don't truly have transparency and accountability? It appears so.
When the CPSO investigates its own members, and when the Chief Coroner of Ontario, (who is a member of the CPSO) will not consider the expert opinions given from qualified surgeons from around the world, the citizens of Ontario are in deep trouble. This has been so for at least two decades. It is understandable the CPSO will put their members first, but this is wrong. It is understandable that the Chief Coroner can't possible go against the College to which he belongs, so his death investigation involving the medical care or lack thereof is completely flawed and bias when it comes to death investigations involving a hospital/surgeons/doctors.

The CCO's one CPSO expert who was unnamed and the CPSO's one Independent Opinion Provider VS All Qualified Surgeons from around the World who do not belong to the CPSO.

2 CPSO member experts vs 100 experts and I lose??

Statistically impossible but not in Ontario!

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 But in this case, besides the Surgeon, Dr. Klein, I believe a suit could be filed against all who supposedly looked into this death--- Humber River Regional Hospital, Chief Coroner’s Office of Ontario, the Death Investigation Oversight Council, the Ontario Ombudsman's Office, the Ministry of Health, the Ministry of Community Safety and Corrections, the Health Professions Appeal and Review Board. A knowledgeable Law Firm would know the exact reasoning for a suit against the above publicly funded institutions But "Breach of Trust" would not in the least bit be difficult to prove.

Message from beyond:
"I want you all to know how much I love you and miss you. But I am content and watching over all of you. Until we meet again, please remember all of the good experiences we shared and the fun times we had together as a family."

CHIEF CORONER'S OFFICE OF ONTARIO--Drs. Bert Lauwers--CEO of Ross Memorial Hospital but now executive vice president of medical and clinical programs at the Scarborough Health Network, Andrew McCallum--head of Ornge, Dirk Huyer

    BREACH OF TRUST BY AN APPOINTED  PUBLIC OFFICIAL????   DAMN RIGHT!

Coroners Act


ONTARIO REGULATION 273/09

INFORMATION SHARING WITH THE COLLEGE OF PHYSICIANS AND SURGEONS OF ONTARIO
Consolidation Period: From July 27, 2009 to the e-Laws currency date.

1.  The Chief Coroner shall notify the Registrar of the College of Physicians and Surgeons of Ontario in writing if,

(d) the Chief Coroner has reasonable grounds to believe that a member of the College of Physicians and Surgeons of Ontario who provides services under section 28 of the Act, other than a coroner or pathologist, has committed an act of professional misconduct, is incompetent or is incapacitated; 
               

THE OFFICE THAT CONDUCTED MY DAUGHTER'S DEATH REFUSES TO ANSWER THE QUESTIONS POSED TO THEM IN A WRITTEN RESPONSE.

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DR. HUYER
Congratulations on this being your very first e-mail sent to me from the many, many e-mails sent to you from me. Your wife and co-workers must be extremely please with your progress and joining the computer age. A bit of a slow learner, though.
It should be noted you will not comment with a detailed written statement with regard to my other requests.
You have cleverly used the meeting which was oral and no records kept for others to review:

TO CONTINUE TO conceal negligence contributing to my daughter’s death to protect the surgeon and themselves.

YOU CONTINUE TO conceal the deaths of other citizens by the same surgeon


YOU WOULD NOT COMMENT on the temporary closure of this hospital department in 2010 due to more deaths. 

YOU FAILED at that meeting to discuss the issues surrounding the past Deputy Chief Coroner and past Chief Coroner as your oral statement:  “They don’t work here anymore.” 

ARE YOU PREPARING for your own departure from this Office to escape accountability and transparency? 

E-MAIL RECEIVED TODAY, FEB 24, 2016 "At the meeting I told you that I would not be responding to future dialogue about the death investigation of your daughter, her medical treatment or the decision not to hold an inquest as our investigation is complete.
You acknowledged my position at the June 26th meeting and in a subsequent e-mail on July 3, 2014."
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IF YOU TRULY BELIEVE WHAT YOU SAID DURING THE MEETING, WHY NOT PUT IT ON PAPER??????

Do I have a written statement from you with regard to what you state above??? No, and not once did you respond to the e-mails your referred to above. Why? --Again, to avoid a paper trail. And does my e-mails to you agree with what was discussed at our meeting? Of course not.

I would like a written response to my other requests.

Could you provide my MPP with written reasons as to why you will not respond in print to me.

DO YOU HAVE THE "BALLS" TO RESPOND AND ADDRESS MY CONCERNS SPECIFICALLY OR CONTINUE TO COMMENT WTHOUT SAYING ANYTHING AS YOU HAVE DONE TO OTHERS YOU HAVE MET WITH ie-- Charlotte in Northern Ontario, Michael west of Hamilton --do you require the names of others?

From: Huyer, Dirk (MCSCS) Dirk.Huyer@ontario.ca> Sent: February 24, 2016 11:21 AM To: Arnold Kilby Cc: Noonan, Julia (MCSCS) Subject: RE: Formal Requests

Dear Mr. Kilby,

I am writing as a reminder of how we concluded the meeting between you, your family members, Ms. Noonan and I on June 26, 2014.
You requested the meeting so that you could present your questions to me and I provided responses based on my review of the information.
At the meeting I told you that I would not be responding to future dialogue about the death investigation of your daughter, her medical treatment or the decision not to hold an inquest as our investigation is complete.
You acknowledged my position at the June 26th meeting and in a subsequent e-mail on July 3, 2014.     
 Respectfully, Dirk     Dirk Huyer, MD Chief Coroner for Ontario 25 Morton Shulman Avenue Toronto, Ontario M3M 0B1 647-329-1814
Give him a call, he won't personally respond. 
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College’s Decision “The routine use of antibiotics prior to bowel surgery is an important aspect of care that was NEGLECTED by Dr. Klein in this case.

The College recommended to the surgeon that perhaps "he might consider the use of antibiotic prophylaxis in the future when converting to open surgery" HE MIGHT CONSIDER???????
The Chief Coroner's Office, the College of Physicians and Surgeons of Ontario, the Health Professions Appeal and Review Board, the Death Investigative Oversight Council, the Liberal government and Liberal Health Ministers and Premier Wynne apparently agree that it is perfectly within the accepted Standard of Care to:'

--have open abdominal surgery without the mandatory antibiotic prophylaxis
--having not had the above, accepted that there was no need for antibiotics when the abdominal incision was oozing purulent liquid and was so infected that all staples were removed
--when test results showed "many gram negative bacilli", still it was quite acceptable to provide no antibiotics

A VERY DANGEROUS PRECEDENCE HAS BEEN SET BY ALL OF THE ABOVE AS
THIS DECISION CAN NOW BE USED TO JUSTIFY SIMILAR COMPLAINTS. EVEN
 THOUGH, IT WAS AN OBVIOUSLY WRONG DECISION.    
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I did get a response from the Ministry saying they don't have the authority and I should contact the Minister of Corrections and the Chief Coroner's Office???

So I sent the same letter to Minister Naqvi. He has never responded to me before so I doubt I will receive anything now.
ATT: Attorney General of Ontario-- Madeleine Meilleur attorneygeneral@ontario.ca mmeilleur.mpp.co@liberal.ola.org
Please send a request to the current Minister of Corrections who supposedly oversees the Chief Coroner's office.

Yasir Naqvi   MCSCS.Feedback@ontario.ca

ynaqvi.mpp@liberal.ola.org;    ynaqvi.mpp.co@liberal.ola.org
I ALSO SENT A REQUEST TO THE OPP FOR AN INVESTIGATION INTO THE CHIEF CORONER'S OFFICE.
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I should note that that a few years ago, I inquired (Deb Matthews) her assistance with regard to the DIOC. I asked a question as to why the DIOC could not look into the medical aspect of my complaint to them against the Chief Coroner and what she could do. She was Minister of Corrections then.

The answer came back from her constituency office with merely the following letters.   "FYO"

After thinking what the three letters meant, I got it. I think you can figure it out. "f--k you over"  Surprisingly, I received a further e-mail from her office asking me to disregard the previous e-mail as it was sent by mistake.
No, someone in her office was actually stating the truth.
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re:  DEATH INVESTIGATION OF TERRA DAWN KILBY--totally inept death investigation whereby their own independent opinion provider investigating Terra's overall care contained numerous omissions that were very relevant to her death.

Please read the inept report submitted by Dr. Lauwer’s independent opinion provider and supported by both Dr. McCallum and Dr. Huyer.
Then look at the omissions from this report.  Keep in mind all three love to quote/comment from this report.

 PLEASE REFER BACK TO THE MEDICAL RECORDS/INFORMATION.

The Chief Coroner evaluates death investigations and forms his responses to citizens' requests using inept expert testimony with numerous omissions of fact.
"WE SPEAK FOR THE DEAD TO PROTECT THE LIVING" 

November 17, 2008
Dr. A.E. Lauwers,CCFP, FCFP
Associate Deputy Chief Coroner
Office of the Chief Coroner 26 Grenville Street Toronto, Ontario M7A 2G9

Dear Dr. Lauwers: RE: Terra Kilby Deceased: July 20,2006
OCCFileNo.: 2006-11425

As you requested, I have reviewed the file on the above person and provide my report. In reaching my opinion, I have reviewed the following materials:
1. The hospital record from Humber River Regional Hospital related to admissions from March 3 to March 4, 2006 and July 11 to July 20, 2006.
2. The Coroner's investigation statement (statement number 2006-054-8).
3. The report of postmortem examination by Dr. Caroline G. Rowlands dated March 22, 2007.
4. A compact disk containing images taken at autopsy and provided to me by Dr. Rowlands. 

In summary, the deceased presented to Humber River Regional Hospital on March 3rd with abdominal pain. She was found to have a large mesenteric cyst. There were no acute issues, and she was therefore discharged for further investigation as an out-patient. She was assessed by Dr. Klein and underwent further investigation. A decision was reached to resect the mesenteric cyst. On July 11th she underwent attempted laparoscopic resection of the cyst, but because of intraoperative concerns the procedure was converted to laparotomy. Removal required right hemicolectomy with resection of the associated mesentery that contained the cyst. On the second postoperative day, the patient did have a low-grade fever but this resolved by the following day. 

However on the fourth postoperative day it was noted that she had a wound infection. The skin was opened and the infection appeared to be confined to the subcutaneous space and not extend below the fascia. She then had some diarrhea and cultures for Clostridium difficile were negative. This seemed to settle and she was discharged home on the ninth postoperative day. Arrangements were made for Home Care visiting nurses to manage the abdominal wound with the intent that it would heal by secondary intention. The records indicate that on the evening of discharge she collapsed at her parent's home and was returned to hospital by ambulance but died in the emergency room despite resuscitation efforts. 

A Coroner's investigation was undertaken and a forensic autopsy carried out. The  pathologist concluded that the patient died from hemorrhagic shock secondary to acute intraperitoneal bleeding. It was noted that on arrival in the emergency room on the evening of death, the patient had a marked coagulopathy. The pathologist concluded that a clear source for the bleeding was not identified and that the underlying coagulopathy could have been a contributing factor. You have requested that I review the quality of care that this patient received and I have done so. In preparing this report, I have given consideration to the concerns that the patient's family expressed specific to the quality of medical care provided.

I believe that the initial assessment and care plan on March 3rd and 4th was entirely appropriate. Dr. Klein subsequently carried out an appropriate investigation and reached a management plan that reflects a good standard of care. The operative procedure was carried out according to the appropriate standard and good decision making is evident. 

The postoperative care was appropriate.  Specifically, treatment of a superficial wound infection is opening of the wound and allowing drainage. Subsequently allowing the wound to heal by secondary intention is the correct management. The use of antibiotics in the absence of systemic sepsis is not necessary, and does not improve the outcome. Unnecessary use of antibiotics does have risks including increasing the probability of development of antibiotic resistant infections including Clostridium difficile. There were no clinical indications for a CT scan or other investigation. It is not unusual for patients to be discharged without having had a solid bowel movement and there certainly are care paths for bowel resection that do not even require passage of flatus. There was no indication of a pre-existing nutritional deficiency, nor was the length of time without oral intake sufficient to lead to major nutritional deficits. Therefore there was no indication for supplements of things like vitamin K and calcium.

Postoperatively, the hemoglobin, white cell count and platelet count remained within expected ranges. Culture from the infected wound grew the expected bowel related organisms. Samples of the loose stool for Clostridium difficile were negative. The last hemoglobin measurement that I can identify was on July 18 \ There was no evidence of any hemorrhagic event subsequently nor change in vital signs that would have merited repeat laboratory investigations. Discharge on July 20, 2006 was therefore clinically appropriate. I concur with the pathologist that the cause of death was hemorrhagic shock. It is my opinion that the coagulopamy was a dilutionalcoagulopathy as a result of the hemorrhage, rather than a cause of the hemorrhage. I believe that the bleeding came from one of the staple lines on the anastomosis. Following removal of the right colon, the bowel was reconstructed using mechanical staplers and a technique known as a functional postoperatively, or be delayed. When it is delayed it is not uncommon for this to happen 6 to 10 days postoperatively. This complication end-to-end anastomosis. This is the predominant technique in use today for joining two ends of bowel together. This was properly done by Dr. Klein. 

One of the risks of any anastomosis is bleeding or leak from the anastomosis. This can occur very early happens in spite of proper surgical technique. Its incidence varies based on numerous factors, but is generally quoted to be in the order of 1 -5% of all bowel resections. I believe that the defect occurred because of ischemic necrosis at the intersecting staple lines created by the functional end to end anastomosis. This led to an open edge of bowel that subsequently bled. This led to hemorrhagic shock, subsequent dilutional coagulopathy and the patient ultimately expired from these events.  I find no area of concern with respect to the standard of care that she received.
If you have any further questions, I would be happy to discuss this at any time UNSIGNED
********
Now check out the responses from the Chief Coroner's Office and notice how they fully agree with the above expert and also what they state about there being "NO OMISSIONS OR COMMISSIONS" In their own words I believe they confirm their own breach of trust.

Letter dated Oct 27, 2008 from Dr A. McCallum

 “As I write this, I am very mindful of the tragedy that you and your family have experienced.  Please be assured that all of our staff, including Dr. Lauwers, will do their utmost to provide helpful information to you.”

 Letter dated November 17, 2008 from Dr A. Lauwers

“You have requested that I review the quality of care that this patient received and I have done so.”
“The operative procedure was carried out according to the appropriate standard of care and good decision making is evident.” (Dr Lauwers repeating from consultant’s report.) No anti-biotic prophylaxis?

“There was no indication of a pre-existing nutritional deficiency, nor was the length of time without oral intake sufficient to lead to major nutritional deficits. Therefore there was no need for supplements of things like Vitamin K and Calcium.” (This was Dr Lauwer’s repeating verbatim from the expert’s report)

“While the patient suffered the most devastating complications of an operation, and specifically one of the common complications of bowel resection, at all times the record would indicate that she received an appropriate standard of care. In spite of the outcome, I find no area of concern with respect to the standard of care she received.”

JUST ONE YEAR LATER, HOW THIS CHANGE FROM THE DR. McCALLUM'S LETTER TO THIS ONE. THIS IS WHAT HAPPENS WHEN YOU ASK QUESTIONS THAT PUT THEM ON THE SPOT AND THEY DON'T WANT TO ANWSER!

The College of Physicians and Surgeons of Ontario's puppet within the Chief Coroner's Office--Dr. Bert Lauwers -- now VP at Ross Memorial Hospital in Lindsey, Ontario

Letter dated November 5, 2009 from Dr. A Lauwers

Nov 5, 2009
Dear Mr. Kilby:

I am writing to acknowledge our telephone conversation of October 30, 2009.
As previously stated by Dr. McCallum in his letter of July 8, 2009, all the information that our office can provide has been conveyed to you in previous correspondence. The investigative mandate of the Office of the Office of the Chief Coroner is concluded.
To that end, our office will not be in a position to return phone messages to you in the future.

Sincerely,
A.E. Lauwers, MD, CCFP, FCFP
Deputy Chief Coroner-Investigations

It should be noted the telephone call referred to became somewhat heated as he refused to answer very pertinent questions posed to him and merely state his expert found nothing to be concerned about. They also would not respond to my e-mails or letters.

Letter dated March 4, 2009 from Dr. A Lauwers  

“The last issue that the coroner must consider when making a determination about whether or not an inquest is necessary, is the likelihood that the jury on an inquest might make useful recommendations directed to the avoidance of death in similar circumstances.”…. How could HRRH have known that Terra would bleed to death hours following discharge from a site along the line of anastomosis?”

 Letter dated March 13, 2009 from Dr A McCallum

 “As you are aware, I have some background knowledge regarding your daughter’s untimely and tragic death because I met with you and your wife after your daughter’s death in my capacity as Regional Supervising Coroner for Eastern Ontario, prior to my appointment as Chief Coroner.”
 “There has been a great deal of scrutiny or your daughter’s case. As part of that scrutiny, an expert review was obtained from an independent surgical consultant. Based on my review of the independent expert, review’s opinion, I conclude that there are no omissions or commissions during your daughter’s treatment that contributed to or caused your daughter’s death.”

 “Given that the care was appropriate, it is clear that recommendations aimed at the prevention of death will not be possible. Thus, there is no realistic potential for the jury to make useful recommendations at an inquest, directed toward the avoidance of death in a similar circumstance.” 

 “Based on the foregoing, I conclude that the mandatory questions can be answered, and have been answered in the attached Coroner's Investigation Statement. Your daughter died due to natural causes as a complication of treatment and the cause of her death was intra-abdominal hemorrhage consequent to dehiscence or disruption of the joining line in her bowel that had been closed with staples.  As the expert reviewer stated, such a disruption can and does happen despite proper surgical technique. Though it is uncommon, it does occur in 1 to 5% of all bowel resections.”

Letter dated April 1, 2009 from Dr A. McCallum

While I realize that you have many remaining questions, I am not in position to respond. You may wish to speak with your daughter’s caregivers regarding these questions.”
“However, I can state that our investigation did not reveal an issue in care that led to your daughter’s tragic death. This was the opinion of our expert independent consultant. Thus, I can add nothing more at this juncture.”

Letter dated June 25, 2009 from Dr A. McCallum

“The expert consultant who reviewed your daughter’s case had no affiliation with the University of Toronto Faculty of Medicine and thus had no conflict of interest. I can assure you that the review was both thorough and independent.

“As I advised in my letter, our investigation revealed no omissions or commissions contributing to your daughter’s death. The Patient Safety Review Committee’s mandate is to look at systems issues contributing to a death. As there are no systems issues contributing to your daughter’s death identified by our investigation, it would not be appropriate to refer her case to that committee.”

LET US LOOK AT THE OMISSIONS AND COMMISSIONS THEY SAY HAD ABSOLUTELY NO CONTRIBUTING FACTOR IN MY DAUGHTER'S DEATH.

 --NO MENTION OF ALL THE STAPLES BEING REMOVED FROM THE ABDOMINAL INCISION AND THAT TEST RESULTS INDICATED THE PRESENCE OF MANY GRAM NEGATIVE BACILLI (SAME CATEGORY AS C DIFFICILE) No mention of the many Gram Negative Bacilli Seen and how it should be treated? Many species of Gram-negative bacteria are: pathogenic, meaning they can cause disease in a host organism. This results in reduction of oxygen transported to the tissues thus explaining the necrosis of the tissue surrounding the re sectioned colon.

--NO MENTION OF MANDATORY ANTIBIOTIC PROPHYLAXIS NOT BEING ADMINISTERED

--NO ANTIBIOTICS GIVEN AT ANY TIME? THIS IS APPROPRIATE?

--NO MENTION OF ABDOMEN GOING FROM FLAT TO ROUNDED TO ENLARGE Abdominal Distension may occasionally result from the accumulation of fluid in the abdomen, which can be a sign of a very serious medical problem. In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid (Ascites is an accumulation of fluid in the abdominal cavity.), or air

--NO MENTION OF LOW HEMACRIT, LOW RED BLOOD CELL COUNT AND LOW HEMACRIT COUNT Decreased hematocrit indicates anemia, such as that caused by iron deficiency or other deficiencies. Further testing may be necessary to determine the exact cause of the anemia. Other conditions that can result in a low hematocrit include vitamin or mineral deficiencies, recent bleeding etc Red Blood Cells, sometimes referred to as erythrocytes, are responsible for delivering oxygen throughout the body. No mention of low hemacrit, red blood cells & hemoglobin indicates anemia (iron deficiency)

--DOES NOT MENTION LOW ABSOLUTE LYMPHOCYTE  (type of white cells to fight infection)?

--NO MENTION OF HIGH PULSE RATE 34/38 readings above 90

--DOES NOT COMMENT ON MANY PMN'S. (polymorphonuclear Neutrophils) –? hall mark of acute inflammatory process. The presence of many PMN’s implies an inflammatory process. PMN’s are the hallmark of acute inflammation PMN’s are rapidly recruited to tissues upon injury or infection

--NO MENTION OF THE SERIOUSNESS OF THE OOZING, INFECTED ABDOMINAL INCISION -- ALL STAPLES WERE REMOVED DUE TO INFECTION Excessive or prolonged serosanguineous drainage could indicate increased inflammation and the possibility of infection, which could in turn lead to wound dehiscence. This is what happened to Terra, her resection broke down.

THERE WERE FAR TOO MANY ISSUES NOT COMMENTED ON, DELIBERATELY, AND THE COO OFFICE FAILED TO FURTHER INVESTIGATE MY CONCERNS SENT TO THEM!
 
Dr. Lauwers, Dr. McCallum and Dr. Huyer refused to fully comment on any of the above and merely state their investigation is closed and completed as mandated.  Bullshit.
Legislation must be enacted in one of the following two ways:
a.     All personnel employed by the Chief Coroner’s Office MUST not have any affiliation whatsoever with the College of Physicians and Surgeons, nor any Ontario Hospital nor any Ontario University Faculty of Medicine. 

b.   Should this fail; Legislation must be passed to employ in the executive positions only those who comply with the above even if it means these people come from outside of Ontario and outside of Canada.

This is to ensure true transparency and accountability through the Office of the Chief Coroner for the present and future citizens of Ontario.
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I don't know if I have the right to request an investigation by the OPP into the 'breach of trust' criminal offence. If I do, they I truly am requesting one.
I think after reading the medical information and the rather inept death investigation, you would agree the COO not only failed my daughter but all citizens of Ontario.
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"We speak for the dead to protect the living'

The Office of the Chief Coroner for Ontario serves the living through high quality death investigations and inquests to ensure that no death will be overlooked, concealed or ignored. The findings are used to generate recommendations to help improve public safety and prevent deaths in similar circumstances.

The College of Physicians and Surgeons of Ontario, and the Chief Coroners Office are guilty of the following:

Confirmation bias = seeking or interpreting information that (one thinks) will support one's favored hypothesis or diagnosis.
Ego bias = biasing probability estimates in a self-serving way.
This Office has decline multiple requests:

A. my request for a public inquest
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Phone:     (613) 659-2906





Dr. Albert Lauwers
Deputy Chief Coroner
Office of the Chief Coroner
26 Grenville Street
Toronto,  ON  M7A 2G9





Dear
Dr. Lauwers:                                                                          
First, thank you very much for meeting with my relatives and me on December 15, 2008.  We found this meeting constructive, chiefly because it clarified for us some important new information regarding the cause of death of my daughter, Terra Dawn Kilby, which we had not fully previously appreciated.  

More particularly, we now understand that you and the Office of the Chief Coroner have concluded that the coagulopathy Terra suffered was, to paraphrase your letter of November 17, 2008, a result of the hemorrhage, rather than a cause of the hemorrhage and that the bleeding came from one of the staple lines on the anastomosis.  Prior to receiving this letter, and your explanation of its meaning on December 15, 2008, we had been operating under the pathologist’s conclusion that the coagulopathy was the cause of the hemorrhage.

The meeting has assisted us in focussing our questions related to Terra’s surgery and post-operative care.  The remainder of this letter contains these questions, together with recommendations which we believe will lessen the likelihood that Terra’s situation would repeat itself in the future.   We have also included our “Overall Aims” at the end of this letter, to provide context.

As to the ultimate outcome of our earlier meeting and this correspondence with you, our considered and respectful view is that the circumstances surrounding my daughter’s death, mere hours after being released from hospital following major surgery, with only a telephone bill and health card in hand, and with no information as to a potential latent, catastrophic complication, merit an in-depth public inquiry. 

Such an inquiry would benefit Ontario patients, their families, hospital administration and staff, and the general public, as it would indicate areas of concern with regard to patient care in Terra’s case, possible errors in her care, and provide recommendations to

Page Two
improve the health care at this particular hospital (Humber River Regional Hospital, a hospital now known to have a disproportionate number of negative patient outcomes), and other hospitals in Ontario.  As well, my hope is that it would put the “onus” on hospital administration and staff to implement the recommendations brought out by a public inquiry.

We would be pleased to continue to work with you to obtain answers to our questions, preferably in the context of the above-requested inquiry.

I.             QUESTIONS
A.            Questions Relating Primarily to the Surgery (and also Post-Operative Care)
  1. Terra was originally scheduled for a less significant surgery but during the operation it was determined that a more significant surgery was required, which surgery was then performed.  Should this more significant surgery have been performed?  Were Dr. Klein and the Humber River Regional Hospital (“HRRH”) equipped to perform this surgery, or should it have been delayed and/or performed by a different surgeon or at a different hospital?
  2. Can it be determined whether the more significant surgery was properly performed?
  3. Given that the more significant surgery was performed, should Terra and her family have been informed of the potential complication (bleeding or leak from the anastomosis, hereinafter referred to as the “Complication”) that apparently arises in 1-5% of all bowel resections?  Should discussions have occurred, post-operation, as to the nature of this risk and how to monitor it or reduce the chance of it occurring, or address it if it occurs?
  4. Were Dr. Klein and/or HRRH aware of: a) the probability of the Complication; b) the catastrophic consequences that can occur when the Complication materializes; c) the fact that when the Complication is delayed, it is not uncommon for it to arise 6-10 days post-operatively?  (We have no specific indication that they were aware of the risks).
  5. Were Dr. Klein and/or HRRH taking steps to monitor for the Complication or to assess whether it might occur or not?
  6. Should Terra have been discharged on July 20, 2008, given that the risk of Complication still existed, and that such risk could be delayed?

Page Three
  1. Terra did not pass a solid stool prior to her discharge from HRRH.  Should Dr. Klein and/or HRRH have delayed discharge from HRRH until such time as Terra passed a solid stool (or several) and the potential impact of passing such stool on the staples could be assessed?  Given the possibility that the Complication can be delayed for many days after surgery, is it possible that passing a solid stool sometimes causes the Complication?  If so, why were Dr. Klein and/or HRRH not keenly attuned to this risk?
  2. Should all patients who undergo a bowel resection remain in hospital for at least 11 (or more days), given the risk of the Complication?
  3. Should Terra’s diet have been enhanced from liquid, to blended, to regular meals in a manner that allowed Dr. Klein and/or HRRH to monitor the impact of this transition on her bowel?
  4. Should any of the post-operative observations, including Terra’s large, distended abdomen and oozing, foul-smelling wound, have led Dr. Klein and/or HRRH to believe that the Complication may be occurring or may be more likely to occur?
  5. Preparing for colon surgery will require a special bowel preparation to make                                                                             sure the colon is thoroughly clean.   Why was this not done?
  6. Should any of the following lab test results and medical information have caused Dr. Klein and/or HRRH to investigate Terra’s situation more closely, or to delay her discharge?
a.  meals -- primarily liquid diet, skipped blended diet to two regular meals;
b.  no solid bowel movement prior to released after digesting two solid meals;
c.  low potassium level below reference range;
d.  low hemacrit level below reference range
;
e.  low red blood cell count below reference range except for last one at lowest of   the range
f.  low hemoglobin count below reference range
;
g. perhaps anaemic, due to d,e and f, above;
h.  low absolute Lymphocyte count well below reference range;
i.  many gram negative bacilli seen;
j.  many PMN's (Polymorphonuclear Neuophils greater than 15/LPF;                  
k. low blood urea count well below reference range;
l.  incision site infection spread three days after being noticed;
m. incisions site still oozing and having a foul odour when released;
n.  abdomen went from flat to rounded and finally to large when released (is this possibly a sign of something wrong internally?).
Page Four
B.            Questions Relating Primarily to Communication (and also to Post-Operative Care)
  1. Should Dr. Klein have met with and consulted with Terra and her family on the day of her discharge to explain her status, any latent risks, and to provide instructions? (He did not).
  2. Should visits by the operating surgeon with patients who have undergone surgery identical to or of the same class as the surgery Terra underwent, be of a certain number or certain duration, given the risk of the Complication? 
  3. Did Dr. Klein’s surgery schedule cause him to have fewer and/or shorter visits with Terra then he should have had?  Should other physicians also have been assigned to monitoring Terra?
  4. Was Dr. Klein adequately assessing the nurses’ observations and the lab test results?
  5. What steps were taken by HRRH, Dr. Klein and/or the nurses to ensure that  her bowel movements (such as they were, while at HRRH) were observed in some manner, prior to being flushed by the cleaning staff? (We are at least aware of one instance where the toilet was flushed before anyone could observe the contents). 
  6. Did Dr. Klein’s post-operative notes provide enough detail for another surgeon/doctor at HRRH to quickly ascertain Terra’s condition, in the event that Dr. Klein was unavailable on a particular day?  (Two doctors have stated that Dr Klein's notes were insufficient and barely acceptable).
  7. Should Terra and her family have been provided, upon her discharge, with a short, written summary of the operation she underwent and the potential complications (including the Complication) containing detail sufficient to ensure that should an emergency arise, other doctors or first responders could attempt to understand what may be occurring?  (The key document Terra left HRRH with was her phone bill.  During our meeting with HRRH staff in May, 2008, Dr. Jack Barkin explained that such information would be in Terra’s medical records.  Terra did not have such medical records following her operation, and they likely would have been useless in an emergency situation, given that the notes have been described as inadequate and given their substantial volume. Lastly, her medical records were withheld for months following her death).
  8. Should Terra have been allowed to travel several hours away from HRRH, given the risk of Complication, and given that if the Complication arose, the individuals attempting to treat
Page Five
her could not possibly be Dr. Klein or anyone at the HRRH?  (The family had been told, upon asking, that Terra could travel home). 

  1. If the Complication had fully materialized while Terra was at HRRH, would HRRH have had the ability to stabilize her, thus avoiding her death?
  2. HRRH was extremely unhelpful and unresponsive following Terra’ death.  A meeting occurred only in May, 2008, nearly two years after her death.  Should HRRH have played a more active role, given that their patient died less than 24 hours after being released?
  3. Why did the pathologist conclude that the coagulopathy was the cause of the hemorrhage, rather than an effect of the hemorrhage?  This has caused us to have a long-standing misconception as to the actual cause of death.  What sort of an error is this? (i.e., is it a clear, bright-line mistake by the pathologist that clearly should not have happened, or is it the result of a complicated assessment about which pathologists can reasonably disagree?)  Did HRRH have any role or contribute to the pathologist’s conclusion?  Has HRRH been informed of the new conclusion?
II.            RECOMMENDATIONS

Recommendations Relating Primarily to the Surgery (and Post-Operative Care)

1.            Ensure that the surgeon/doctor in charge sees the patient on the day of discharge {Dr Klein did not see Terra on July 20/08, the day of her release}

2.            Ensure that a surgeon/doctor provides adequate visitation time and, as part of his/her visit, to record the time entered and time left.  {Dr Klein's visits could be timed in seconds not minutes.}

3.            Ensure that a surgeon is not overly busy doing elective surgeries to enable adequate time to spend with the post-operative patient.  {If one was able to look at Dr Klein's elective surgery schedule during Terra's hospital stay one would find very little time for post-operative care.}

4.            Ensure that it is the hospital's responsibility that a surgeon is not overextending his/her time in elective surgeries to the detriment of the post-operative patients.

5.            Ensure that the surgeon/doctor looks at the nurses' medical charts and lab test   results, with a signature, date and time recorded.  This would benefit the patient and improve patient care.
Page Six
6.            Ensure that after a colon resection operation the patient is able to pass a solid stool on at least two or three occasions prior to release.

7.            Ensure that upon a colon resection operation, the patient remains a minimum of 11 days to ensure that the sutured colon is not leaking, as could be the case in 1 to 5%, which usually occurs between 7 to 10 days. (Terra was released on the 9th day without being seen by her doctor).

8.            To progress the diet in an appropriate manner and not release a patient until the patient is on regular meals (when it comes to colon resection) The patient should have had the blended diet before going onto regular meals. (Terra's diet was a clear liquid diet, then supposedly according to the medical charts a full liquid diet---- however, since a member of the family was present for all meals we saw her have the same meal throughout-- jello, tea, broth and juice for all meals except the last two which were regular).

9.            Ensure that a patient's meal has not been removed without the patient's knowledge and not to be done until the patient's nurse can record whether the patient ate some, none or all of his/her meal.  (In Terra's case, her meals were almost taken and would have been if we were not in the room.  The relatives of the patient sharing the room often asked us to watch her food tray when she went for a walk or for testing.  We had to do the same, as there were times when we returned and left the tray unguarded and it was scooped up and gone by the time we got back.  The nurses at times would assume that the patient ate all of the meal).

10.         Ensure that the surgeon/doctor examines and considers the entire lab test results and information contained within the medical records and assesses the patient's condition and nutritional assessment considering this information. 
 
11.         Ensure that a surgeon's/doctor's patient post-operative notes provide enough detail so that another surgeon/doctor could instantly ascertain the condition of the patient should the attending surgeon/doctor not be available on a particular day.  (I had two doctors state that Dr Klein's notes were insufficient and barely acceptable)
.
B.            Recommendations Relating Primarily to Communication (but connected to Post-Operative Care)

      1.     Ensure proper discharge includes a brief transcript of the operation and instructions (or signs to watch for)   (Dr Barkin, at the May 15th/08 meeting, when asked about this, stated it was in the medical records--- this does the patient and family no good and I only found it when I
Page Seven
demanded the entire medical records and charts.  Terra received a telephone bill and her health card.)

    2.       Ensure that the surgeon/doctor is not overly busy, so time is available for communication between the patient's nurses and the patient's doctor.  {Oct 20/08 I finally received some answers to questions submitted to HRRH by Dr Philip Hebert on my behalf -- one answer stated that Dr Klein disagreed with the description of Terra's abdomen going from flat to rounded to large.  One would think that if Dr Klein was indeed looking at the medical records at the time, he would have conversed with the nurses as to why they felt this.)

     3.      Ensure that a member of the family is present when the surgeon/doctor speaks to the patient about the patient's personal care.  (Again, according to the answers from HRRH, (Oct 20/08), Dr Klein stated that he had a meeting with Terra on July 19th to discuss the above.  His notes do not show this.  And Terra did not mention this as we talked to her daily and her sister was with her from morning to night on that day. This did not take place.  He may be referring to Tuesday, July 18th when I demanded to see someone with regard to Terra's care).

      4.     Ensure that a surgeon's/doctor's visit to the patient occurs when the patient is awake so that the patient can communicate to the doctor.  (One visit Terra was asleep, on another visit while my wife was in the room, Dr Klein came in pushed on the bandaged incision and left, on another I saw him as I was sitting in the waiting room as he went by--I counted “10 steamboats” and left to go to my daughter's room.  As I didn't see him I asked the attending nurse if Dr Klein had been by.  She said yes, just a second ago.  I asked to see him but he had left the floor.)

5.    Ensure that the hospital administration, patient representatives are more open, receptive and able to communicate to the patient's family and in particular with family members when a death occurs with regard to their concerns. 

  1. Encourage and recommend that the Canadian Patient Safety Institute document entitled "Disclosure of Adverse Affects" is in use by the hospital.
  2. Recommend Bill 89 be made law to allow an Ontario Ombudsman to step in to assist families of patients who have been unable to have easy, transparent  communication with hospitals and other medical facilities and health care professionals. (based upon the difficulty I have had dealing with HRRH).
  3. Ensure doctors are aware of the fact that it takes 24 hours before a change of diet occurs.           (When I asked Dr Klein when her diet would change (Tuesday, July 18/07), he said "Oh, right now".  The nurse told him it would take 24 hours.  -- in his statement to OCPS he states that
Page Eight
Terra was on regular meals for two days, which is incorrect and of course not substantiated by the records.  In the hospital's response to me Oct20/08 he again stated the same.}

9.            Investigate the effectiveness of the Hospital’s Patient Representative System and to recommend that Patient Safety Representatives be employed, paid by and be responsible to the Ministry of Health and Long Term Care.  Then, they would not be in a conflicting position trying to represent patients or families’ concerns versus their obligations towards & pressure from the hospital.  They should be truly representatives of the patient. (My dealings have left me with no doubt that they were there to mask, misrepresent or delay my attempts for answers).

10.        Encourage and recommend that correspondence from the hospital to patients or to the family of patients who have died be done so in a timely manner and that the hospital take the initiative and not leave it to the grieving family.   (One example, I wrote Ms Collins the COO of HRRH asking for a copy of their internal investigation into my complaints on Oct 22, 2008 and as of this time, early 2009, I have had no response.  Second example, the family doctor starting requesting the medical records for Terra in late Aug of 2007 and did so three times, until I finally had to call.  Within a week, the doctor received them but could not let me see them or give them to me, as there was a note attached that they were to be destroyed or sent back.  So, I called again and was told my doctor had it wrong and that I could have them, but after seeing the note my doctor did not mistake the note).

11.          Ensure steps are made to educate the cleaning staff to which patients' toilets are not to be flushed until the nurse has check the bowel or bladder movement. (In one situation the cleaning staff flushed the toilet before my wife could stop him/her and the nurse recorded it as the mother doing so which was incorrect).

III.           CONCLUSION
In conclusion, I feel that a public inquiry is necessary, partly to explain the cause of Terra's death, but also to protect her rights (even in death) and the rights of others to have the best possible medical treatment and health care, which is what citizens of Ontario should expect from their health care providers.    I respectfully submit that the independent medical consultant may not have presented to you an unbiased report.  I firmly believe that the circumstances leading to her death have not been fully examined.

Respectfully Yours,                                                                         
  Arnold W. Kilby
Overall Aims                                                      Page Nine
A.      To investigate all aspects of Terra Dawn Kilby’s surgery and post-operative care by all who were responsible for her overall well-being during her hospital stay. See Appendices 1a, 2 a, b, c, & d
B.      To establish an inquiry, so that its findings and recommendations would be a precedent for future patient care inquiries/investigations so that Health Care Institutions will learn from it and avoid similar situations.
C.      To bring to a satisfactory conclusion a frustrating, and at times disrespectful, treatment, and a lengthy period of time trying to find answers and thus help the family’s grieving process.
D.      To improve overall transparency within the health care system.  This would in turn  improve Ontario citizens’ confidence and restore their faith, especially in post-operative care.
E.       To remind the professionals engaged in health care of their prime responsibility, which is to their patients. –See Appendices 3 a, b & c
F.       To allow other members of the public to see that their concerns, which may have never been address before, for a variety of reasons, have now been brought forth.
G.      To allow members of the public to be better aware of patient rights and family rights prior to hospitalization and what should be expected from their health care providers during hospitalization.
H.      To improve Humber River Regional Hospital's patient care by having them assess their policies, practices and procedures and improve upon them when it comes to the overall care of patients from the day of admission, throughout their hospitalization to their discharge from hospital.
I.        To discover any other inadequacies, inefficiencies, deficiencies etc., with respect to patient care and improve patient/doctor/hospital/family interactions. See Appendices 2 e  & f
J.        To provide a "Wake-Up" call to HRRH with regard to their overall practices, procedures and treatment of patients and their families. See Appendix 2 f
K.      To encourage the implementation of the Canadian Patient Safety Institute’s  “National Guidelines For The Disclosure of Adverse Events”  See Appendix 4 c
L.         To speak for Terra to protect the living.        See Appendix 1b
B. MPP Runciman's, now Canadian Senator, request to reconsider the public inquest (has since retired)

Ontario
LEGISLATIVE ASSEMBLY
ROBERT W. RUNCIMAN, MPP
CONSTITUENCY OFFICE:
Leeds-Grenville.
Suite 101 Brockville, Ontario K6V 5J9
Tel. (613) 342-9522 Toll Free: 1-800-267-4408 Fax (613) 342-2501
    July 9, 2009
Dr. Andrew McCallum    Chief Coroner of Ontario   26 Grenville Street   Toronto, Ontario M7A 2G9                                                                                                                                       Dear Dr. McCallum:                                                                                                                                                                 I was recently visited by a constituent, Mr. Arnold Kilby, to discuss his concerns surrounding the circumstances of his daughter's death in July of 2006.  I understand that you are personally familiar with Mr. Kilby and his concerns and that your office rejected the need for an inquest into his daughter's death.
Mr. Kilby, understandably, is quite passionate about determining the real cause(s) of his daughter's death and insuring that, if mistakes were made, that they not be repeated and jeopardize other lives.  During his visit, Mr. Kilby laid out a very persuasive case, raising legitimate questions that, apparently, have never been answered. As a layman I can't speak to many of the issues he raised, but two jumped out at me as very legitimate causes for concern in the way his daughter was dealt with.
The first was the decision to operate without purging the colon for fear of infection; and the second was the nursing charts indicating a persistent "foul odour" at his daughter's incision, an odour that was still present upon her release from hospital and should indicate, to the least trained eye, that infection is present.
After reviewing Mr., Kilby's extensive file, I believe his daughter's death merits reconsideration from your office with respect to the death meriting an inquest. There remains far too many unanswered questions surrounding Terra Kilby's untimely passing, questions that only your office can secure answers to.
I urge you to give every possible consideration to calling an inquest into Terra's death.
Kind regards.  Sincerely,

Robert W. Runciman, MPP Leeds Grenville
c. my request for Terra's death to go before the Patient Safety Death Panel
d. my request for an Eastern Ontario Coroner's Review since Terra passed in Kingston
e. my request to initiate the Chief Coroner's Review Process
f. refused the Ombudsman Office request to meet with me and respond to my concerns
g. refused the OPP Detective's request to meet with me and respond to my concerns.
What do all of the above say about transparency and accountability?
WHAT ARE THEY HIDING? 
Note: Dr Huyer did meet but the meeting was useless. He was careful to state that there were many patient care issues, (did not use the words patient safety) and they should be dealt with by the CPSO and Hospital--- this was a cop out and he neglected his duty to all of Ontario. When I bought up the other two names (McCallum and Lauwers) he basically said they no longer work here so no comment.

I BELIEVE PAST CORONER, DR ANDREW MCCALLUM, PAST DEPUTY CHIEF CORONER DR BERT LAUWERS AND THE PRESENT CHIEF CORONER MAY WELL HAVE "BREACH OF TRUST" OF THE CITIZENS OF ONTARIO

122. Every official who, in connection with the duties of his office, commits fraud or a breach of trust is guilty of an indictable offence and liable to imprisonment for a term not exceeding five years, whether or not the fraud or breach of trust would be an offence if it were committed in relation to a private person.

* R.S., c. C-34, s. 111.Breach of Trust By Public Official Accused intended to use his/her public office for purpose other than public good.

Interpretation of the Offence The purpose of this offence is to ensure that the public retains "the confidence of the public in those who exercise state power"
The offence is a codification of the common law offence of "misconduct in office"
Misconduct of officers executing process 128. Every peace officer or coroner who, being entrusted with the execution of a process, wilfully * (a) misconducts himself in the execution of the process, or * (b) makes a false return to the process, is guilty of an indictable offence and liable to imprisonment for a term not exceeding two years.
* R.S., c. C-34, s. 117.
Actus Reus A "breach of trust" can include "any breach of the appropriate standard of responsibility and conduct demanded of the accused by the nature of his office as a senior civil servant of the Crown."
Mens Rea The mens rea requires a prohibited act that is done intentionally or recklessly, with the knowledge or wilfully blind to the facts making up the offence.
There must also be an "subjective foresight of the consequences" (that their actions will result in a benefit).
There is no need for an intent to act dishonestly. The accused need not be aware that he was breaching trust, it only requires that a reasonable person would conclude that there was a breach of trust.
Pleadings Breach of public trust is a straight indictable offence. The defence has an election under s. 536.
The prohibited act must cause a personal benefit to the accused and must be contrary to the duties imposed upon them. The breach does not need to be in respect of trust property. The offence does not capture mere nonfeasance or neglect of duties. There must be a marked departure from the standard expected from the official.
*********************************************************************
I believe this would apply: Regarding breach of trust offences under s. 122, commission of offences was done in connection with duties of accused’s office and accused breached standard of responsibility and condu
ct demanded of his/her by nature of his/her office. His/Her conduct also represents serious and marked departure from standards expected of an individual in his/her position of public trust. Accused also acted with intention to use his/her public office for purpose other than public good. ie--to conceal the truth, to cover up negligence by a fellow member of the CPSO and others within the CCO.

SHOULD THE CHIEF CORONER LIE TO YOU OR AVOID ANSWERING DIRECTLY TO
 QUESTIONS POSED, AND/OR REFUSES TO PROVIDE FACTUAL DOCUMENTED
EVIDENCE TO SUPPORT HIS OPINION THEN HE MAY BE CHARGED WITH THE
FOLLOWING:

Misleading Justice:
Perjury 131. (1) Subject to subsection (3), every one commits perjury who, with intent to mislead, makes before a person who is authorized by law to permit it to be made before him a false statement under oath or solemn affirmation, by affidavit, solemn declaration or deposition or orally, knowing that the statement is false.
Fabricating evidence 137. Everyone who, with intent to mislead, fabricates anything with intent that it shall be used as evidence in a judicial proceeding, existing or proposed, by any means other than perjury or incitement to perjury is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years. * R.S., c. C-34, s. 125.
Obstructing justice 139. (1) Everyone who wilfully attempts in any manner to obstruct, pervert or defeat the course of justice in a judicial proceeding, * (a) by indemnifying or agreeing to indemnify a surety, in any way and either in whole or in part, or * (b) where he is a surety, by accepting or agreeing to accept a fee or any form of indemnity whether in whole or in part from or in respect of a person who is released or is to be released from custody, is guilty of * (c) an indictable offence and is liable to imprisonment for a term not exceeding two years, or * (d) an offence punishable on summary conviction.
139. (2) Everyone who wilfully attempts in any manner other than a manner described in subsection (1) to obstruct, pervert or defeat the course of justice is guilty of an indictable offence and liable to imprisonment for a term not exceeding ten years.
**********************************************************************
Breach --a failure to perform some promised act or obligation --act in disregard of laws and rules

That HPARB, the CHIEF CORONER OF ONTARIO, The DIOC and the ONTARIO OMBUDSMAN would actually fulfil their duties/responsibilities according to the Ontario Health Regulations Act and the Coroner’s Act of Ontario!
Trust
1. firm belief in the reliability, truth, ability, or strength of someone or something.

2. acceptance of the truth of a statement without evidence or investigation.

That HPARB, the CHIEF CORONER OF ONTARIO, the DIOC and the ONTARIO OMBUDSMAN would actually do this, but in reality did the complete opposite!
Instead ALL have done their utmost to conceal the truth, misrepresent the facts, and prevent Ontario citizens from learning the truth and thus has placed Ontario citizens at serious risk to their physical well-being.

3. the state of being responsible for someone or something.

That HPARB, the CHIEF CORONER OF ONTARIO, the DIO and the ONTARIO OMBUDSMAN would actually fulfill their duties/responsibilities according to the Ontario Health Regulations Act and the Coroner’s Act of Ontario!
Instead ALL have appear to do their utmost to conceal the truth, misrepresent the facts, and prevent Ontario citizens from learning the truth and thus has placed Ontario citizens at serious risk to their physical well-being.

THE PAST AND CURRENT HEALTH MINISTERS AND MINISTERS OF CORRECTION BY REFUSING TO INVESTIGATE HAVE ALSO NOT FULFILLED THE DUTIES/RESPONSIBILITIES OF THEIR POSITIONS AND THUS ARE: “IN BREACH OF TRUST” according to the Criminal Code Of Canada and the Criminal Code of Ontario.
Code of Ethics for Coroners July 2005

 DR LAUWERS , Dr McCallum and Dr.Huyer have all FAILED THE FOLLOWING:

Coroners shall exercise their duties and responsibilities without fear, favour, prejudice, bias or partiality towards any person.
4. Coroners shall proceed in the public interest to carry out diligently, and with all due dispatch, their duties and responsibilities as set out in the Coroners Act 5. Coroners shall have due regard for the fact that they are performing a public duty and that their actions and decisions affect the public interest as well as the interests of private individuals. 8 Coroners shall not, in the discharge of their duties, make decisions beyond the scope of their personal expertise and knowledge but shall seek guidance from the appropriate source or sources. 21. Coroners shall not conduct themselves in a manner which might tend to bring their office into disrepute or affect public confidence in that office.
**************************                                                                                                             
March 4, 2009                                                                                                                                          
Dear Mr. Kilby:
Please let me extend my sincerest regrets over the sudden and tragic passing of your daughter.
I acknowledge your letters dated January 8, January 20, January 29, and February 9, 2009.
This letter will address my request that followed our meeting on the morning of December 15, 2008, in which you detailed your concerns regarding the tragic death of your daughter. Following that review of your concerns, we agreed that you would provide a written submission, to supplement the verbal submissions that you made that day, regarding why you were requesting an inquest, including potential recommendations you might seek were an inquest held.
In your letter of January 8, 2009, you have asked for a public inquiry. You state, "Such an inquiry would benefit Ontario patients, their families, hospital administration and staff, and the general public, as it would indicate areas of concern with regard to patient care in Terra's case, possible errors in her care, and provide recommendations to improve health care at this particular hospital (Humber River Regional Hospital, a hospital known to have a disproportionate number of negative patient outcomes), and other hospitals in Ontario. As well, my hope is that it would put the "onus" on hospital administration and staff to implement the recommendations brought out by the public inquiry".
The Office of the Chief Coroner does not have the ability to listen to, or grant, requests for public inquiries. Public inquiries are governed by the Public Inquiries Act R.S.O. 1990. Any concerns you might have should be appropriately addressed according to the requirements of the legislation governing public inquiries. (ht tp://www. search, e-la ws. gov. on. ca/en/isysquery/aa 19391c-213c-4 7bO-bc89 3dc548889dfO/3/frame/?search=browseStatutes&context)
In your letter directed to the Chief Coroner Dr. McCallum, sent November 25, 2008, you have asked for an inquest examining your daughter's death. In addition, when we met on December 15, you were provided with the opportunity to provide your concerns regarding her death, and the reasons that you feel an inquest should be held. We agreed that you would provide written submissions following our meeting. Your final submission referencing your concerns is dated February 9, 2009.
During my process for the determination of whether an inquest should be conducted as requested, I have reviewed the following documents:
1.              The Coroner's Investigation Statement.
2.      Medical records from Number River Regional Hospital (HRRH), March 3,
2006.
3.       Medical records from Number River Regional Hospital (HRRH), July 11, 2006
4.      Medical records from Kingston General Hospital (KGH), July 20-21, 2006.
5.       The Ambulance Call Report(s) of July 20, 2006.
6.      The Post Mortem Report of Dr. Carolyn Rowlands.
7.       The response of the Chief Forensic Pathologist for a review of Dr. Rowland's
Post Mortem Report.
8.       The expert opinion of the Professor from the Department of Surgery in an
Ontario teaching hospital.
9.       Review of the Minutes of the Meeting with the Kilby Family of Monday
December 15, 2008.
10.   Many letters provided by Mr. Arnold Kilby, including, but not limited to
November 25, 2008, and dated January 8, January 20, January 29, and
February 9, 2009.
11.   The Coroners Act, R.S.O. 1990.
12.  The Quality of Care Information Protection Act, 2004.
13.The Regulated Health Professions Act.
14.The Public Inquires Act, R.S.O. 1990.
Short Summary of the Case
Ms. Kilby aged 27 presented to HRRH on March 3, 2006 with abdominal pain and was ultimately found to have a large mesenteric cyst. She was discharged, and electively admitted for laparoscopic resection of the cyst. During the surgery, which was performed July 11th, the procedure was converted to a laparotomy, and ultimately, she required right hemicolectomy. On the second postoperative day, she had a low grade fever. On the fourth postoperative day, she developed a wound infection, which was confined to the subcutaneous space and did not extend below the fascia. She was passing diarrheal bowel movements, and cultures for C. difficile were negative. She was discharged home where visiting nurses were to manage the superficial abdominal wound, which was to heal by secondary intention.
Of note, on July 13th, two days after her surgery, her haemoglobin was 106, and her WBC was 8.1. Her haemoglobin rose each day thereafter until July 18th, when it was 119. On that day, her WBC was 6.5 and her platelet count was 240.
She was discharged on July 20th, 2006 at approximately 1330 hours. That same day, her vital signs were, pulse 88, temperature 36.3, respirations 20 and blood pressure 116/74. She was discharged home where visiting nurses were to manage the superficial abdominal wound, which was to heal by secondary intention. Her wound infection was cultured and did not yield any organisms.
That evening, following discharge, she collapsed in her parent's home at approximately 2230 hours. An ambulance was dispatched, and when paramedics arrived, Ms. Kilby was described as sitting on the toilet, conscious, lethargic and pale with a respiratory rate of 40. She suffered a respiratory arrest while in the ambulance, and was ultimately provided with advanced life support care. She arrived at Kingston General Hospital at 2342 hours, where she received aggressive resuscitation. Despite this, she was pronounced deceased at 0040 hours on July 21, 2006.
The Post Mortem Examination
This was conducted pursuant to a Coroner's warrant. It must be understood at the outset that the request for a consultation by a pathologist is a request for an opinion. The coroner is not bound to accept the opinion if the facts, as known, clinically do not support the opinion.
The cause of death was given as "Intra-abdominal hemorrhage with coagulopathy". The coagulopathy reference appears to have arisen from blood work obtained in the emergency department of Kingston General Hospital in the peri-mortem period. This revealed an elevated prothrombin time, increased INR>6, decreased platelets and a haemoglobin of 82 g/L. It also reported the presence of intrabdominal hemorrhage, and a transmural colonic defect close to the anastomosis. The pathologist who performed the autopsy was asked to reconsider her position with respect to the "coagulopathy and the source for bleeding not being identified. Following this, the Chief Forensic Pathologist was asked to review the report, and he communicated on July 1, 2008 that, "I have examined the autopsy report and slides. I have nothing to add. I would go ahead with the surgical review based on the available materials".
As a result, a surgical consultant was engaged to review the clinical materials, and also review the autopsy findings to develop an opinion that accurately reflected and considered clinical pathological correlation. The surgical consultant issued the following opinion:
"I concur with the pathologist that the cause of death was hemorrhagic shock. It is my opinion that the coagulopathy was a dilutional coagulopathy as a result of the hemorrhage, rather than a cause of the hemorrhage. I believe that the bleeding came from one of the staple lines on the anastomosis".
The pathologist's conclusion with respect to coagulopathy was in part based on the peri-mortem blood work, which was obtained at KGH, following a period of cardiac arrest. The results must be interpreted with caution as a result.                                                                                                    
Reasons An Inquest Is Being Requested
As I understand your submission of January 8, 2009, an inquest is being requested to:
1.             "...benefit Ontario patients, their families, hospital administration and staff, and
the general public..."
2.      "...it would indicate areas of concern with regard to patient care in Terra's case,
possible errors in her care..."
3.             "...and provide recommendations to improve the health care at this particular
hospital..."
4.       "As well, my hope is that it would put the "onus" on hospital administration and
staff to implement the recommendations brought out by the public
inquiry"[inquest].
5.       "In conclusion, I feel that a public inquiry [inquest] is necessary, partly to explain
the cause of Terra's death, but also to protect her rights (even in death) and the
rights of others to have the best possible medical treatment and health care..."
6.       "I firmly believe that the circumstances leading to her death have not been fully
examined".
Pursuant to your recommendations, you have offered to work with our office to obtain answers to your questions, which include:
1.               12 questions related primarily to surgery.
2.       11 questions related to communication.
This is followed by a list of 22 potential recommendations related to surgery, post­operative care, and communication. Your submission is then concluded with a description of overall aims, with 5 appendices.
The Coroners Act and Inquests
The Coroners Act of Ontario (Hereinafter "the Act"), in my view, is a complete and exhaustive statutory code. This was the premise upon which the Ontario Court of Appeal based its decision in Beckon v. Beckon (Coroner of) (1992), in which the court indicated, at p. 272 "The legal basis of a coroner's inquest is the Coroner's Act and has no other legal basis".
In terms of the Act being a complete and exhaustive code for the governance of inquests, reference may also be made to section 2:
2. (1) In so far as it is within the jurisdiction of the Legislature, the common law as it relates to the functions, powers and duties of coroners within Ontario is repealed. R.S.O. 1990, c. C.37, s. 2 (1).
(2) The powers conferred on a coroner to conduct an inquest shall not be construed as creating a criminal court of record. R.S.O. 1990, c. C.37, s. 2 (2).
In making my decision as to whether a discretionary inquest will be held or not, I referred to Section 20 of the Coroners Act, which states:
When making a determination whether an inquest is necessary or unnecessary, the coroner shall have regard to whether the holding of an inquest would serve the public interest and, without restricting the generality of the foregoing, shall consider,
(a)                whether the matters described in clauses 31(1)(a) to (e) are known;
(b)                the desirability of the public being fully informed of the circumstances of
the death through an inquest; and
(c)                 the likelihood that the jury on an inquest might make useful
recommendations directed to the avoidance of death in similar
circumstances.
The matters referred to in Section 31 of the Act are:

(1)             Who the deceased was;
(2)             How the deceased came to his (her) death;
(3)             When the deceased came to his (her) death;
(4)             Where the deceased came to his (her) death; and
(5)             By what means the deceased came to his (her) death.
Having reviewed the materials available, I have determined that these five questions can be answered. The answers to these questions are as follows:
1.                  Name of decedent:       Ms. Terra Dawn Kilby
2.        Cause of death:                 Intra-abdominal hemorrhage due to complications of
resection for a mesenteric cyst.
3.         Date of death:                  July 21, 2006
4.         Place of death:                  Kingston General Hospital
5.         Manner of death:             Natural
The answers to the five questions are known.
Terra's death was tragic and unforeseen. The Office of the Chief Coroner has not received any other expressions of interest in an inquest examining Terra's death from the public. Our opinion is that factual circumstances surrounding her death are well known.
The last issue that the coroner must consider when making a determination about whether or not an inquest is necessary, is the likelihood that the jury on an inquest might make useful recommendations directed to the avoidance of death in similar circumstances. This question goes to the heart of the matter at hand. How could HRRH have known that Terra would bleed to death hours following discharge from a site along the line of anastomoses? The answer might be the presence of abnormal vital signs, such as an elevated heart rate or low blood pressure, or an abnormally low hemoglobin. These were checked, and found to be acceptable. In the report of the Professor of Surgery, "There was no evidence of any hemorrhagic event subsequently, nor change in vital signs that would have merited repeat vital laboratory investigations. Discharge on July 20, 2006 was therefore clinically appropriate". Further, he goes on to say, "In spite of the outcome, I find no area of concern with respect to the standard of care that she received". A jury therefore, presented with this evidence, would be unlikely to make useful recommendations directed to the avoidance of death in similar circumstances.
AWKilby’s note:  Look at the hospital/patient records!!   Different operations but this surgeon had many more deaths after my daughter’s--- perhaps patient care is relevant--- did these other patient not receive antibiotics???
Discussion
Possible causes of death provided by Mr. Kilbv
In the many submissions provided by the Kilby Family, various opinions based on Mr. Kilby's research were provided. This discussion will neither attempt to address all the concerns raised, nor to systematically refute the many promulgated theories. The facts in the case are well supported by the medical documentation. There are a few issues worthy of mention, however:
1. The Office of the Chief Coroner (OCC) is completely independent of the College of Physicians and Surgeons of Ontario. In correspondence received November 25, 2008, there is an implication that the CPSO would exert influence on the Office of the Chief Coroner, characterized in Mr. Kilby's letter with such statements as, "Fear of receiving a green/white envelope". The OCC functions completely independent of the CPSO who does not attempt to exert any influence or control over the conduct of death investigations.
The CPSO has in no way attempted to influence Terra's death investigation.

AWKilby’s note:  The mere fact that you, Dr. Lauwers are a member of the CPSO and the CMPA and your inept death investigation certainly would lead one to surmise the above.
2.    In correspondence received on January 20th, Mr. Kilby advances the belief that Terra
had an anastomosis breakdown. Certainly the pathology of the autopsy supports that
there was an anastomotic breakdown from where the exsanguinating hemorrhage
arose. However, this occurred at, or immediately prior to the time of her death. It was
not heralded by an intrabdominal infection. There were no loculated collections of pus or
stool found at autopsy, no sign of peritonitis, fever or an elevated white blood cell count,
which might be present if there were anastomotic breakdown happening during her
hospitalization.
3.         In correspondence received on January 29th, Mr. Kilby advances the belief that Terra
had an enterocutaneous fistula, and that nutritional support prevents this complication
from occurring. The autopsy report did not find any evidence of an enterocutaneous
fistula.
4.    In a 31 page submission received February 9, 2009, Mr. Kilby asserts that an
infection killed Terra. On page 5, Mr. Kilby states, "Postoperative infection delays
healing; it destroys body systems or organs; it produces chronic diseases; it kills. AS IN
TERRA'S CASE!" This appears to have been concluded based on the fact that Terra
did have a draining superficial wound infection.
AWKilby’s note:  So, why does no one tell me what cause the tissue to die according to the autopsy—“necrosis of the tissue”
The best evidence in this regard comes for the pathology report, which states, "There was no evidence of peritonitis". In the summary of abnormal findings, no evidence is provided to support any infectious source or etiology. In addition, the Professor of Surgery commented in his report that, "The postoperative care was appropriate. Specifically, treatment of a superficial wound infection is opening of the wound and allowing drainage. Subsequently allowing the wound to heal by secondary intention is the correct management. The use of antibiotics in the absence of systemic sepsis is not necessary, and does not improve the outcome".
AWKilby’s note:   Not providing the patient with any antibiotics during her entire stay in hospital – no antibiotic prophylaxis done, since this was not done it is mandatory when her incision became infected that antibiotics be administered, and why not any to treat the presence of “many gram negative bacilli”?
5.   In his submission of January 13, 2009 Mr. Kilby states, "I respectfully submit that the
independent medical consultant may not have presented to you an unbiased report".
This statement is proffered without any explanation regarding why it is made.
AWKilby’s note:  I gave the Chief Coroner’s Office numerous issues to address. Dr. Lauwers refused to look into my many concerns and the obvious omissions excluded in his expert’s report. Dr. Lauwer’s would not do further investigation.
Potential recommendations provided
Mr. Kilby has provided 11 recommendations with respect to surgery and post-operative
care. Most relate to requirements that a surgeon perform certain tasks, that patients
remain in hospital for a certain length of time, and issues of diets in post-surgical
patients.
The Regulated Health Professions Act, Schedule 2, Section 3, sets out the objects of the College of Physicians and Surgeons of Ontario (CPSO):
Objects of College
3. (1) The College has the following objects (emphasis added):
1.    To regulate the practice of the profession and to govern the members in accordance with the health profession Act, this Code and the Regulated Health Professions Act, 1991 and the regulations and by­laws.
2.                 To develop, establish and maintain standards of qualification for
persons to be issued certificates of registration.
3.        To develop, establish and maintain programs and standards of
practice to assure the quality of the practice of the profession.
4.        To develop, establish and maintain standards of knowledge and skill
and programs to promote continuing competence among the
members.
5.        To develop, establish and maintain standards of professional ethics for
the members.
6.                 To develop, establish and maintain programs to assist individuals to
exercise their rights under this Code and the Regulated Health
Professions Act, 1991.
7.                 To administer the health profession Act, this Code and the Regulated
Health Professions Act, 1991 as it relates to the profession and to
perform the other duties and exercise the other powers that are
imposed or conferred on the College.
The objects of the CPSO include to "establish and maintain programs and standards of practice." The recommendations that have been suggested by Mr. Kilby are questions of medical practice, and in fact, should be subjected to the rigor of evidence-based peer review scrutiny prior to implementation. The Office of the Chief Coroner does not set standards of practice. This issue properly belongs both to the CPSO and the practicing discipline of medicine for development, rather than a coroner's investigation or inquest. It should be pointed out that even if all the recommendations, which are suggested were enacted, Ms. Kilby's outcome may still not have been any different.
AWKilby’s note:  But should a question of patient care arise, the CCO should be notifying the Hospital and the College and not do their best to cover-up medical negligence perhaps contributing to my daughter’s death.
In addition, Mr. Kilby provides 11 recommendations related primarily to communication. These issues are directly related to hospital quality of care. The Quality of Care Information Protection Act, 2004, which sets out in Section 1, the functions of quality reviews (emphasis added):
Definitions
1, In this Act, "quality of care committee" means a body of one or more individuals,
(a)    that is established, appointed or approved,
(i)    by a health facility,
(ii)   by an entity that is prescribed by the regulations and that provides health care, or
(iii)   by an entity that is prescribed by the regulations and that carries on activities for the purpose of improving or maintaining the quality of care provided by a health facility, a health care provider or a class of health facility
or health care provider,
(b)          that meets the prescribed criteria, if any, and
(c)           whose functions are to carry on activities for the purpose of
studying, assessing or evaluating the provision of health care
with a view to improving or maintaining the quality of the health
care or the level of skill, knowledge and competence of the
persons who provide the health care; ("comite de la qualite des
soins).
The concerns raised by these potential recommendations properly belongs to the HRRH and a death review of Ms. Kilby's death, rather that a coroner's investigation or inquest. It should be pointed out that even if all the recommendations which are suggested were enacted, Ms. Kilby's death would not likely have been prevented.
AWKilby’s note:  I thought a death investigation was also to be used to prevent further deaths?
Adverse events among hospital patients in Canada
In Appendix 4a of his January 13th submission, Mr. Kilby has quoted an article attributed to Dr. Philip Hebert. It reportedly states, "The bottom line is that 0.66% of admitted patients—1 in 165—died on account of a preventable adverse event".
The Canadian Adverse Events Study was published in the Canadian Medical Association Journal in May of 2004. It was, and remains the standard study, which gives voice to a very complex and troubling issue. The authors defined an adverse event as "an unintended injury or complication that results in disability at the time of discharge, death or prolonged hospital stay, and that is caused by health care management rather than the patient's underlying disease process". One of the screening criteria utilized by the study was "unexpected death". The overall adverse events rate in Canadian Hospitals was 7.5%. It was judged in retrospect that 37-51% of adverse events are preventable. In other words, 49-63% were judged to be not preventable. The authors further estimated that "death would be associated with an adverse event in 1.6% of patients with similar hospitalizations in Canada"1.
The important differentiating factor is that Ms. Kilby's death was caused by the use of a common surgical instrument, a mechanical stapler. Its use led to an open edge of bowel that subsequently bled because of ischemic necrosis occurring at the intersecting staple lines created by the functional end-to-end anastomosis. According to the expert, "This was properly done by Dr. Klein. One of the risks of any anastomosis is bleeding or leak from the anastomosis. This can occur very early postoperatively, or be delayed. When it is delayed, it is not uncommon for this to happen 6 to 10 days postoperatively. This complication happens in spite of proper surgical technique. Its incidence varies based on numerous factors, but is generally quoted to be in the order of 1-5% of all bowel resections".
Ultimately, the expert concluded that, "While the patient suffered the most devastating complication of an operation, and specifically one of the most common complications of bowel resection, at all times the record would indicate that she received an appropriate standard of care. In spite of the outcome, I find no area of concern with respect to the standard of care that she received".                                                                                                                                                     1 Baker, Norton et al, The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada, CMAJ 2004; 170(11): 1678-86.
In conclusion, the reasons that the Kilby family have requested an inquest as set out above, have been carefully considered and thoughtfully reviewed.
The circumstances and facts related to the death of Terra are well known. In addition, valuable jury recommendations are in my opinion, highly improbable. The sudden, unexpected and unanticipated hemorrhage, which occurred at her parents' home was not foreshadowed by any clinical indicators. The suture edge suddenly released and Ms. Kilby tragically, rapidly exsanguinated. This fact makes it highly unlikely that a jury could ever make recommendations directed to the avoidance of death in similar circumstances in the future.
As such, I am declining the Kilby Family's request for an inquest examining Terra Dawn Kilby's death.
Please be advised that my decision was reached after a thorough review of all of the information provided and warranted. I recognize the very, very difficult and painful loss you have endured. I know that this is not the answer you had hoped for. Again, please accept my sincerest condolences on the loss that you have suffered.

Sincerely,   A. E. Lauwers, MD, CCFP, FCFP Deputy Chief Coroner - Investigations
Did Dr. Lauwers and his so-called expert even look at the medical records?   I would question his opinion as not medically sound.
******************************************************************
March 13, 2009
Mr. Arnold Kilby 888 County Rd #2 Lansdowne, ON KOE 1LO
Dear Mr. Kilby
Re: Terra Dawn Kilby
Date of Death: July 21, 2006 Our File No.: 2006-11425
I write in reply to your letter faxed to my office on March 12, 2009 in which you have asked that I review Dr. Lauwers' decision based on your request for a public inquiry into your daughter's death.
You have made a request for a public inquiry, which is not in my power to grant. However, I will consider this as a request that I review Dr. Lauwers' decision not to hold an inquest into the death of your daughter, as stipulated in Section 26 (2) of the Coroners Act.
As you are likely aware, when making a decision regarding whether or not an inquest should be held, the Coroners Act sets out the criteria that a coroner must consider at S. 20:

What coroner shall consider and have regard to


 When making a determination whether an inquest is necessary or unnecessary, the coroner shall have regard to whether the holding of an inquest would serve the public interest and, without restricting the generality of the foregoing, shall consider,
(a)    whether the matters described in clauses 31 (1) (a) to (e) are known;
(b)   the desirability of the public being fully informed of the circumstances of the death through an inquest; and
(c)    the likelihood that the jury on an inquest might make useful recommendations directed to the avoidance of death in similar circumstances. R.S.O. 1990, c. C.37, s. 20.
Using this statutory framework, I have reviewed Dr. Lauwers' decision not to hold an inquest. In making my final decision regarding this matter, I have reviewed the following:
1.            Dr. Lauwers letter of decision to you dated March 4, 2009.
2.      Your letter dated March 12, 2009.
3.      Your letter dated January 8, 2009, which encompasses information provided in a
number of previous letters from you to our office.
4.      The Report of Postmortem Examination.
5.      The Coroner's Investigation Statement.
6.     The report submitted by the independent expert reviewer.
As you are aware, I have some background knowledge regarding your daughter's untimely and tragic death because I met with you and your wife after your daughter's death in my capacity as Regional Supervising Coroner for Eastern Ontario, prior to my appointment as Chief Coroner.
There has been a great deal of scrutiny of your daughter's case. As part of that scrutiny, an expert review was obtained from an independent surgical consultant. Based on my review of the independent expert reviewer's opinion, I conclude that there are no omissions or commissions during your daughter's treatment that contributed to or caused your daughter's death. I can certainly understand that you would question the loss of someone so dear to you, but I can say that our independent and objective review confirms that Terra died of an unusual and unforeseeable complication, namely the disruption of the staple line where her bowel was joined. This led to a sudden and fatal hemorrhage. All of this information is set out very clearly in the expert reviewer's report.
Based on the foregoing, I conclude that the mandatory questions can be answered, and have been answered in the attached Coroner's Investigation Statement. Your daughter died due to natural causes as a complication of treatment and the cause of her death was intra-abdominal hemorrhage consequent to dehiscence or disruption of the joining line in her bowel that had been closed with staples.   As the expert reviewer stated, such a disruption can and does happen despite proper surgical technique. Though it is uncommon, it does occur in 1 to 5% of all bowel resections.
Given that the care was appropriate, it is clear that recommendations aimed at the prevention of death will not be possible. Thus, there is no realistic potential for the jury to make useful recommendations at an inquest, directed toward the avoidance of death in similar circumstances.
The final matter for consideration is whether or not an inquest would serve the public interest. In making a determination regarding this I must consider whether the public at large would be assisted or whether conducting an inquest into your daughter's death would advance public safety. Having carefully considered all of the foregoing, I conclude that there would be no public interest served by holding an inquest into the death of your daughter.
I therefore have determined that an inquest will not be held into your daughter's death. I would like you to know that in making this determination, I am very mindful of the tragic loss that you have suffered. Though I offer you my deepest sympathy, I know that no words of mine can assuage your grief.  However, I do hope that you will find some small comfort in the knowledge that Terra's case has undergone an independent and thorough review.
Yours truly,
Andrew McCallum, M.D., FRCPC Chief Coroner for Ontario 
*******************************
April 1, 2009
Dear Mr. Kilby:
I write in reply to your letters dated March 17 and March 29, 2009. Your first letter arrived while I was away on vacation, which resulted in a brief delay in responding.
At this stage, our investigation is complete. The required questions under section 31 of the Coroners Act have been answered on the balance of probabilities. Though not directly the purpose of the investigation, we have attempted to answer a number of your questions. While I realize that you have many remaining questions, I am not in a position to respond. You may wish to speak with your daughter's caregivers regarding these questions. However, I can state that our investigation did not reveal an issue in care that led to your daughter's tragic death. This was the opinion of our expert independent consultant. Thus, I can add nothing more at this juncture.
If you wish to receive documents or items not covered under the Coroners Act S. 18 (2), you will need to submit a request using the procedures specified in the Freedom of Information and Protection of Privacy Act. The applicable request form can be downloaded at http://www.ipc.on.ca/imacies/Resources/up-form 2e.pdf.
Andrew McCallum, M.D., FRCPC Chief Coroner for Ontario
***********************************                                                                                                  April 5, 2012     Dear Mr. Kilby:
Re:    Name:                     Terra Dawn Kilby    Date of Death: July 21, 2006                       OCCFileNO.: 2006-11425
I am writing in response to your email dated March 29, 2012, in which you requested a Chief Coroner's Review.
Our investigation into your daughter's death is closed. Unless presented with new and compelling information, I will not be reopening the case. If you have not done so already, please direct your complaint to the Death Investigation Oversight Council. Information on how to file a complaint can be found at www.dioc.gov.on.ca.
Yours truly, Andrew McCallum, M.D., FRCPC Chief Coroner for Ontario
****************************************************                                                                          
June 25, 2009                                                                                                                                                             Mr. Arnold Kilby 888 County Rd #2 Lansdowne, ON KOE 1LO
Dear Mr. Kilby    Re: Terra Dawn Kilby   Date of Death: July 21, 2006                                      
 Our File No.: 2006-11425
I write in reply to your letter faxed to my office on June 23, 2009.   The expert consultant who reviewed your daughter's case had no affiliation with the University of Toronto Faculty of Medicine and thus had no conflict of interest. I can assure you that the review was both thorough and independent.
As I advised in my letter, our investigation revealed no omissions or commissions contributing to your daughter's death. The Patient Safety Review Committee's mandate is to look at systems issues contributing to a death. As there were no systems issues contributing to your daughter's death identified by our investigation, it would not be appropriate to refer her case to that committee.
At this juncture, the investigative mandate of the Office of the Chief Coroner is concluded,                                                                                                                                                    Yours truly,   Andrew McCallum, M.D., FRCPC Chief Coroner for Ontario
***************************************
8 July 2009                                                                                                                                                        Mr. Arnold Kilby 888 County Road #2 Lansdowne, ON KOE1LO
Dear Mr. Kilby:
Re:     Name:
Date of Death: OCC File No.:
October 21, 2009



I have been advised that you contacted our Regional Office in Kingston, Ontario today requesting a Regional Coroner's Review be conducted with respect to Terra's death.
Regional Coroner's Reviews are not ensconced in legislation. They are conducted at the discretion of the Deputy Chief Coroners and Regional Supervising Coroners. These are generally conducted when a death investigation reveals the presence of systemic issues that contributed to the death in question, and where it could be anticipated that the review would lead to recommendations which would prevent deaths in similar circumstances in the future. Given the information provided by the expert opinion our office obtained of your daughter's tragic death, a Regional Coroner's Review would not be indicated.
In conclusion, the Office of the Chief Coroner's investigative mandate has been met in Terra's case and there is nothing further that we can offer you. Please accept our deepest condolences for your tragic loss.
Sincerely,
A.  E. Lauwers, MD, CCFP, FCFP Deputy Chief Coroner - Investigations
NOTE:    From my research according to the Coroner’s Act only the Eastern Ontario Coroner has the authority to deny this request, not Dr. Bert Lauwers
**************************************


November 5, 2009
Dear Mr. Kilby:
I am writing to acknowledge our telephone conversation of October 30, 2009.
As previously stated by Dr. McCallum in his letter of July 8, 2009, all the information that .our office can provide has been conveyed to you in previous correspondence. The investigative mandate of the Office of the Office of the Chief Coroner is concluded.
To that end, our office will not be in a position to return phone messages to you in the future.
Sincerely,
A.E. Lauwers, MD, CCFP, FCFP
Deputy Chief Coroner-Investigations
AEL/rc
**************************************
When Chief Coroner’s Office and the DIOC have definitely abused the citizens of Ontario via this particular case; it is incumbent for the Corrections Minister and the Ministry to get involved. They do have the justification and the authority to do so, to ensure these institutions are not doing the same to other citizens who have brought complaints before them.

Recommended Changes to the Chief Coroner’s Office of Ontario
1. The general public is not as educated in medical matters and they put their trust in you. But you count on their ignorance and turn a blind eye away from matters that may become apparent when you conduct your investigation. You owe it to the citizens of Ontario to protect their safety and rights by being forthright with any discoveries you make during the initial investigation into the complainant's complaint.


1. The Chief Coroner's Office of Ontario has never granted a public inquest into a death that may involve a surgeon or the hospital with respect factors relating to a death. You must take the role that you have been given and protect patient safety by conducting more inquests into these types of deaths.

2. Don't waste a grieving family's time by granting a meeting and then refuses to answer any of the medical questions they may have for you at said meeting. They come seeking answers and explanations from you and your refusal to do so puts more misery and grief in their hearts.

3. Related to number two above, why waste the grieving families time suggesting they write a formal request for a public inquest when you know that you will under no circumstance grant them one?

4. Upon your investigation you must report to the College of Physicians and Surgeons and findings that indicated negligence or incompetence on the part of the attending surgeon and/or hospital.

5. Lobby the Provincial Government to increase your investigative powers and duties so that you can indeed protect patient safety.

6. Don't merely assume that the College of Physicians and Surgeons and the Hospital will effectively and transparently investigate a complainant's concerns with regard to the death of a loved one? They often do not, so it is morally up to you to do so. Both Dr. Lauwers and Dr. McCallum are making a tidy sum from the public purse. (over $700,00 for just two individuals)

7. When you provide your reasons for denying an inquest or for a death to be investigated by the Patient Safety Death Committee panel, do so without the many omissions you obviously intended when preparing the report. What are you trying to hide and why are your hiding this?

8. Use the Death Committees more frequently to improve the quality of health care and protect patient safety. Most people don’t even know of these. Is this transparent?

9. Perhaps taking some courses on "Death and the Grieving Family" left behind will enable you to be more in tuned in what they are going through and perhaps persuade you to fulfill your role as coroners more effectively.

10. Never should you refuse to respond to a grieving family's correspondence whether it is by telephone, fax, e-mail or registered letter.

11. Lobby the government to establish a separate union/federation for all coroners and pathologists to be members of so that you are no longer associated with the College of Physicians and Surgeons. You are unable to conduct a thorough un-bias investigation into other surgeons/doctors as long as you belong to this College.

12. Dr. McCallum, you know that the ultimate decision of granting or denying should not be left solely in your hands. This is not an accountable or transparent role. Please ask the Government to amend this change in the Coroner’s Act. Your decisions should always be accessible to a review by an independent body, such as the Death Investigative Oversight Committee.

SO, WHO ASSESSES AND MONITORS THE CHIEF
CORONER--- CERTAINLY NOT THE MINISTER OF
 CORRECTIONS? 

(Whose authority does it falls to?—the DIOC---merely an institution to protect the Chief Coroner) AS THIS MINISTRY REFUSES TO LOOK INTO MY SITUATION!

The local investigating coroner informed me the Chief Coroner’s Office of Ontario had deemed the death unusual and was going to look into the matter further.  I had looked forward to this until they rendered their decision.   The motto for this office is “We Speak For the Dead To Protect The Living”. 

I would discover, after many years, this to be a fallacy.  When it comes to investigating a death associated with medical care or lack thereof, this Office will ignore the evidence even when pointed out to them.

**************************************************************

 This office denied my request for a public inquest, (they have never granted one involving a hospital), denied my request for my daughter’s death to go before the Patient Safety Death Panel, denied my request for an Eastern Ontario Regional Coroner’s Investigation, denied Mr. Robert Runciman my MPP, presently a Canadian Senator, to reconsider the public inquest, denied my request to assemble a Chief Coroner’s panel to look into Deputy Chief’s decisions, denied a request from the Ontario Ombudsman’s Office to meet with me and address my concerns and finally denied an Ontario Provincial Police Detective’s request to meet with me and address my concerns.  No, instead they used their persuasive authority to contact the Toronto Metropolitan Police to investigate my e-mails. 

When the O.P.P. detective came to my home, he stated that the Chief Coroner’s Office had cut and pasted and taken my e-mails out of context.  This was just an attempt to silence me!  Did this stop my e-mailing and faxing?  No!  Behold, twice more I had to meet with this O.P.P. detective at the station for video taped interviews!  Nothing even close to the laying of charges; it was merely a continued attempt to silence me.

*********************************************************
Chief Coroner Dr. Andrew McCallum  “As I advised in my letter, our investigation revealed no omissions or commissions contributing to your daughter's death. The Patient Safety Review Committee's mandate is to look at systems issues contributing to a death. As there were no systems issues contributing to your daughter's death identified by our investigation, it would not be appropriate to refer her case to that committee.”
I wrote to Chief Coroner Dr. Andrew McCallum and received no response.
With regard to the above:
You state there were no system issues.  I believe there are numerous issues that would qualify it for the Patient Safety Review Committee.
They would be able to determine the role some or all did play in the colon resection breakdown, thus her death.  & There are more.
  1. When the laproscopic surgery was determined not to be done, why was the open abdominal surgery not postponed to another date so as to properly prepare the patient for major abdominal surgery?  After all, this was supposed to be elective day surgery.  
Systems Issue  YES
----------------------------------------------------------------------------------------------------------------
  1. Why was she not given anti-biotic prophylaxis and a bowel cleansing for this major abdominal surgery that involved the colon?  Systems Issue  YES
The need of prophylactic antibiotics is indisputable in colorectal surgery in order to reduce the rate of postoperative infectious complications.   IT WAS NOT DONE
It is a time tested widely accepted fact among surgeons that efficient mechanical bowel clearance prevents anastomotic dehiscence.  IT WAS NOT DONE
-------------------------------------------------------------------------------------------------------                  
  1. Why was she not given any anti-biotics at all?  .   Systems Issue  YES   
NONE WHAT SO EVER, AT ANY POINT
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4.  Why no nutritional supplements as she was on the liquid diet for 24 of 26 meals?  Why no Parental Nutrition?      Why a more substantial Enteral nutrition not started? Why was a nutritionist not called in to assess her nutritional intake?   Systems Issue  YES
Major surgery causes serious stress to the body. The body’s immune system is weakened and gastrointestinal function is changed after major surgery, leaving the body vulnerable to infection and in a state of nutritional insufficiency.
LACKING 65.9 to 68.8 % OF TOTAL DAILY CALORIE INTAKE!     Systems Issue  YES
LACKING  57% OF TOTAL DAILY CALORIE INTAKE BASED ON HER BASAL METABOLIC RATE.
Basal metabolic rate is the minimum calorific requirement needed to sustain life in a resting individual.  Terra should have been receiving 1,649.98  calories but in fact she was only receiving 687 calories on the full liquid diet.      Systems Issue  YES
Since Terra’s hemacrit count, red blood cell count and haemoglobin count were below standard, Nuitrition does play a major role.
Iron is required for the formation of haemoglobin in red blood cells, which transport oxygen around the body.  LACKING 83.2% OF TOTAL DAILY IRON INTAKE!    Systems Issue  YES

Vitamin K is not readily stored within the body, thus the importance of the daily requirement. The overriding effect of nutritional Vitamin K deficiency is to tip the balance in coagulation toward a bleeding tendency.  LACKING 99.6% OF TOTAL DAILY VITAMIN K INTAKE!    Systems Issue  YES

Magnesium is required for normal energy metabolism and electrolyte balance.  LACKING 75% OF TOTAL DAILY MAGNESIUM INTAKE!  
Systems Issue  YES

Vitamin E significantly strengthens the immune system; supplies oxygen to the blood, which is then carried to the heart and other organs. LACKING 99.7% OF TOTAL DAILY VITAMIN E INTAKE!   Systems Issue  YES

Blood coagulation is dependant on calcium.  LACKING 99.27% OF TOTAL DAILY CALCIUM INTAKE!    Systems Issue  YES
Vitamin C (ascorbic acid) assists the body in the production of collagen, a basic component of connective tissues. Collagen is an important structural element in blood vessel walls, gums, and bones, making it particularly important to those recovering from wounds and surgery. IMPORTANT: Inflammation in the tissues causes the breakdown and destruction of collagen fibers. Sutures will pull away from damaged tissues whether the tissues are damaged by disease or medical negligence. Any infected tissue which is separated by surgery will be slow to heal, or may fail to heal.   
LACKING 91% OF TOTAL DAILY VITAMIN C INTAKE!   Systems Issue  YES
Phosphorus protects against infection, and enhances the immune system; LACKING 70.9% OF TOTAL DAILY PHOSPHORUS INTAKE!
Systems Issue  YES

Zinc is another mineral nutrient protects against infection, and enhances the immune system.   LACKING 82.7% OF TOTAL DAILY ZINC INTAKE!  Systems Issue  YES

Copper is needed for the formation of red blood cells.  Copper is a constituent of many enzyme systems and the body needs copper to be able to use iron properly.   LACKING 99.9% OF TOTAL DAILY COPPER INTAKE!   Systems Issue  YES

Thiamin assists in blood formation.   LACKING 84.7% OF TOTAL DAILY THIAMIN INTAKE!   Systems Issue  YES

Riboflavin is necessary for red blood cell formation, anti-body production, cell respiration, and growth.   LACKING 91.8% OF TOTAL DAILY RIBOFLAVIN INTAKE!   Systems Issue  YES

 Vitamin B-6  Pyridoxine is also used in the production of red blood cells.  LACKING 83.6% OF TOTAL DAILY VITAMIN B-6 INTAKE!
            Systems Issue  YES

Vitamin B12 deficiency impairs the body’s ability to make blood, accelerates blood cell destruction.  It helps in the formation of red blood cells.  LACKING 83.6% OF TOTAL DAILY VITAMIN B-12 INTAKE!   Systems Issue  YES

LACKING 99.99% OF TOTAL DAILY VITAMIN A INTAKE!             Systems Issue  YES 
LACKING 93% OF TOTAL DAILY FIBRE INTAKE!    Systems Issue  YES 
LACKING 81.5% OF TOTAL DAILY SELENIUM INTAKE!    Systems Issue  YES 
LACKING 80.9% OF TOTAL DAILY NIACIN INTAKE!   Systems Issue  YES 
LACKING 47.3% OF TOTAL DAILY PROTEIN INTAKE!       Protein depletion can affect the rate and quality of wound healing.  
Systems Issue  YES

5.  Why was something not done when it was discovered she had “many negative gram bacillia present”?   .   Systems Issue  YES
One of the most common results of joint negligence (doctor and hospital) is postoperative infection. It is also one of the deadliest. Gram negative bacteremia is today's hospital scourge.
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  1.  The description of Terra’s abdomen going from “flat” just after the operation for a couple of days to then be described as “rounded” and then “large” for the last two or three days of her hospital stay not have been a concern?”  Why was this ignored by Terra’s surgeon?  Systems Issue  YES
In the peritoneal cavity, distention may reflect acute bleeding, accumulation of ascitic fluid  (Ascites is an accumulation of fluid in the abdominal cavity.), or air from perforation of an abdominal organ. 
----------------------------------------------------------------------------------------------
  1. Why was the Many PMN (Polymorphonuclear Neutophils greater than 15/LPF ignored by the surgeon?   Systems Issue  YES
The presence of many PMN’s implies an inflammatory process.
PMN’s are the hallmark of acute inflammation
            PMN’s are rapidly recruited to tissues upon injury or infection
*******************************************************************************
Why it is Chief Coroner Dr. Huyer is unable to find any medical support material to go along with his opinion while I can find lots to support my concerns?  

THIS IS JUST FOR THE ANTIBIOTIC PROPHYLAXIS ISSUE, AND NO ANTIBIOTICS GIVEN AT ALL FOR ABDOMINAL INFECTION AND PRESENCE OF “MANY GRAM NEGATIVE BACILLI’  

ANSWER---BECAUSE THERE ARE NO MEDICAL JOURNALS, BOOKS, ARTICLES THAT SUPPORT HI

S B.S. AND HE MERELY WANTS TO PROTECT HIS FELLOW COLLEAGUE AND CPSO MEMBER.

It’s a pretty sad day in Ontario when the father of the deceased has to conduct his own death investigation based on the medical evidence and facts contained within the hospital records supported and verified by qualified surgeons located outside of Canada.  Ontario citizens thought our tax dollars paid for this service; we were wrong!   SHAME

Based upon my thorough, factual, unbiased, transparent and honest death investigation my recommendations are as follow:
1.      When open abdominal surgery is performed, the administrating of antibiotic prophylaxis is mandatory. 
2.      Should for some reason Recommendation #1 cannot be done (ie-due to emergency surgery) then antibiotics must be administer during or right after surgery.
3.      If Recommendations 1 and 2 was not done, antibiotics must be administered at the first physical signs of internal and/or external infection. 
4.      If Recommendations 1 through to 3 was not done, antibiotics must be administered should test results indicate an infection. (ie “many gram negative bacilli) 
5.       Should an abdominal laparoscopic operation be started without the anti-biotic prophylaxis being administered, and then converted to open surgery, this surgery will not take place until the antibiotic prophylaxis is given or the surgery is to be postponed.  

 As in this case:
   OPERATIVE PROCEDURE    I-/  Diagnostic laparascopy attempted for mesenteric mass
                                             2-/ Open right hemicolectomy and excision of mesenteric cyst.     
         
6.  Should a patient be on a liquid diet for more than 3 to 4 days, nutritional supplementation must be started?  Especially if nursing records indicated the patient is not tolerating the current diet.  It is totally unacceptable for a patient to be consuming only 683 calories per day on a liquid diet  (in this case for nine days without nutritional supplementation)

1.      After a colon resection, a patient must not be discharged until after he/she has had two bowel movements after being on a regular diet to ensure the colon resection is functioning without a complication.
2.      A patient should not be discharged without being seen that day by the attending physician/surgeon who ordered it.
3.      Should a patient be asleep during a physician/surgeon post-op visit, the patient should be awakened or the physician/surgeon must visit the patient later that same day.  A patient’s condition cannot really be evaluated when asleep.
4.      When multiple test results are not within the acceptable normal range  (especially if all the following applies as was in this case:
-- low hemacrit, red blood cells, and hemoglobin counts,
--elevated temperatures,
--elevated pulse rates,
--low absolute lymphocytes,
--low blood urea scores,
--many PMN’s Polymorphonuclear Neutrophils greater than 15/KPF,
--presence of many gram negative bacilli, 
--abdominal swelling,
--incision oozing foul purulent discharge, 

The patient should not be discharged until the cause of many of those above are thoroughly investigated and remedied.

5.      Should a surgeon be too busy to adequately monitor the post-op patients, either his surgery schedule should be reduced or another physician be assigned to monitor the patient’s post-operative care.

6.      The nutritional aspect of the patient must be looked into seriously to ensure he/she is not lacking the essential daily vitamins and minerals requirements to aid in post-operative healing.

7.  Upon discharge the patient/family must receive a briefly written but succinct description of the operative procedure that took place for emergency situation that may arise ie – ambulance attendants, emergency room doctors etc
Again, why must the family of a deceased loved one have to do their own death investigation????

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Ministry of Community Safety                     Ministers de la Securite communautaire
and Correctional Services                           et des Services correctionnels
Office of the Minister                                 Bureau du ministre
25 Grosvenor Street                                  25, rue Grosvenor                                                                                                            
 Ontario
18th Floor                                                 18eetage
Toronto ON M7A1Y6                                Toronto ON M7A1Y6
Tel: 416-325-0408                                    Tel. :     416-325-0408
Fax: 416-325-6067                                    Telec. : 416-325-6067
CU 10-04316
CU 10-04424
JAN  20 2011                                                                                                                                       CU10-04442
Mr. Arnold Kilby 888 County Road 2 Landsdowne ON
KOE 1LO
Dear Mr. Kilby:
Thank you for your correspondence requesting a meeting to discuss the circumstances surrounding the death of your daughter, Terra, and requesting information about the Death Investigation Oversight Council. I apologize for the delay in responding.
I would like to extend my deepest sympathies to you and your family. Although I appreciate the difficulties you have experienced dealing with your daughter's death, I regret that I am unable to meet with you.
As you may know, on December 16, 2010, the council was established in order to provide greater oversight of Ontario's coroners and forensic pathologists. The council will also assist the Chief Coroner and the Chief Forensic Pathologist in making further improvements to Ontario's death investigation system.
The council is made up of medical and legal professionals, senior health executives, government representatives and members of the public whose collective knowledge and expertise will provide quality oversight to help strengthen the system.
The council's complaints committee is expected to be operational in early spring 2011, and will deal with complaints about the Chief Coroner and the Chief Forensic Pathologist, as well as pathologists and coroners. However, the committee will not review inquest decisions. The determination whether to hold or not hold an inquest is under the authority of a coroner under the Coroners Act, and the Chief Coroner has the authority to make a final determination on such matters. As you know, you may appeal the Chief Coroner's decision regarding an inquest into Terra's death by accessing the justice system and seeking a judicial review.
For more information about the council, you may wish to visit its website at www.dioc.gov.on.ca. Again, please accept my sincerest condolences on your loss. Yours sincerely,
Jim Bradley Minister




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The Empty Space
Tears emerge as I notice the space,
That once was seated a smiling face.
Memories flood back at this time,
Melancholy arises as I pine.

Glancing at the rear view mirror,
Seeing you are no longer there.
Crushing at my broken heart,
Ever since the day you did depart.

For twenty-eight years we would dine,
The four of us—this family of mine.
But now there sits an empty seat,
My spirit absent of a wholesome beat.

 Ten years now my family has been three,
Those who have suffered would agree.
Our present lives will never be free,
There sits the empty space -- without thee.

Tears emerge as I spot the space,
That once contained a beautiful face.
Memories reappear at this time,
Despondency arises as I pine.

LOVE, DAD
Additional Verse:
Those in the know suppressing the fact,
Honesty and integrity they do lack.
Provincial officials with no guts,
Merely shielding each other’s butts:


********                                                                                                                                        
                                  
     LDPS             Gananoque Secondary       York University          State University of New York
 “Continue the fight, Dad, so changes are made to protect others”                                             

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Should you wish to send your MPP your concerns the addresses of all Ontario MPPs as of August 2020 are listed below:


DEEPAK ANAND, MISSISSAUGA--MALTON

deepak.anand@pc.ola.org

Legislative office

Room 263
Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7528

Fax: 416-326-7504

Constituency office

Unit 11
7895 Tranmere Dr.

Mississauga, ON L5S 1V9

Tel.: 905-696-0367

Fax: 9-696-7545

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Constituency office

803 St. Clair Ave. W

Toronto, ON M6C 1B9

Tel.: 416-656-0943

Fax: 416-656-0875

Legislative office

Room 115
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-0071

Fax: 416-325-4728


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Legislative office

Room 159
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-1872

Fax: 416-325-1912

Constituency office

155 Clarke Rd.

London, ON N5W 5C9

Tel.: 519-668-1104

Fax: 519-668-1941


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Constituency office

2nd Floor
181 St. Andrew St. E

Fergus, ON N1M 1P9

Tel.: 519-787-5247

Fax: 519-787-5249

Toll Free: 1-800-265-2366

Legislative office

Room 180
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A2

Tel.: 416-325-3880

Fax: 416-325-6649


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Legislative office

Room 203
North Wing, Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-0168

Fax: 416-325-0088

Constituency office

The LaSalle Mews

Suite 2
303 Bagot St.

Kingston, ON K7K 5W7

Tel.: 613-547-2385

Fax: 613-547-5001


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Legislative office

Room 444
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7114

Fax: 416-326-7113

Constituency office

830 Sheppard Ave. W.

Toronto, ON M3H 2T1

Tel.: 416-630-0080

Fax: 416-630-8828


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Legislative office

Room 265
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7111

Fax: 416-326-7099

Constituency office

Suite 207
4002 Sheppard Ave. E

Scarborough, ON M1S 4R5

Tel.: 416-297-6568

Fax: 416-297-4962


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Ministry office

Ministry of Government and Consumer Services

5th Floor
777 Bay St.

Toronto, ON M7A 2J3

Tel.: 416-212-2665

Constituency office

Suite 102
805 Christina St. N

Point Edward, ON N7V 1X6

Tel.: 519-337-0051

Fax: 519-337-3246


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TOBY BARRETT, HALDIMAND--NORFOLK

Constituency office

39 Norfolk St. N

Simcoe, ON N3Y 3N6

Tel.: 519-428-0446

Fax: 519-428-0835

Ministry office

Ministry of Agriculture, Food and Rural Affairs

11th Floor
77 Grenville St.

Toronto, ON M5S 1B3

Tel.: 416-325-8404


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Constituency office

Unit 5A
3110 Kingston Rd.

Scarborough, ON M1M 1P2

Tel.: 416-261-9525

Fax: 416-261-0381

Legislative office

Room 385
Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-0908

Fax: 416-325-0685


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Constituency office

Unit 103
719 Bloor St. W

Toronto, ON M6G 1L5

Tel.: 416-535-7206

Legislative office

Room 372
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-1620

Fax: 416-325-1424


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Constituency office

1821 Danforth Ave.

Toronto, ON M4C 1J2

Tel.: 416-690-1032

Fax: 416-690-8420

Legislative office

Room 241
North Wing, Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-2881

Fax: 416-325-2780


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PETER BETHLENFALVY, PICKERING--UXBRIDGE

Constituency office

Suite 213
1550 Kingston Rd.

Pickering, ON L1V 1C3

Tel.: 905-509-0336

Fax: 905-509-0334

Toll Free: 1-888-444-1730

Ministry office

Treasury Board Secretariat
Whitney Block
Room 4320
4th Floor
99 Wellesley St. W

Toronto, ON M7A 1W3

Tel.: 416-327-2333


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GILLES BISSON, TIMMINS

Constituency office

Suite 202
60 Wilson Ave.

Timmins, ON P4N 2S7

Tel.: 705-268-6400

Fax: 705-266-9125

Toll Free: 1-800-461-9878

Legislative office

Room 114
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-7122

Fax: 416-325-7181


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STEPHEN BLAIS, ORLEANS

Legislative office

Room 410/411
111 Wellesley St. W.

Toronto, ON M7A 1A4

Constituency office

Unit 204
4473 Innes Rd.

Orleans, ON K4A 1A7

Tel.: 613-834-8679

Fax: 613-834-7647


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Ministry office

Premier's Office
Whitney Block
Room 6522
99 Wellesley St. W

Toronto, ON M7A 1W3

Tel.: 416-326-7092

Constituency office

Suite 101
96 Nelson St.

Brantford, ON N3T 2X1

Tel.: 519-759-0361

Fax: 519-759-6439


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Constituency office

28 Circle St.

Kapuskasing, ON P5N 1T7

Tel.: 705-335-6400

Constituency office

Unit 6
631 Front St.

Hearst, ON P0L 1N0

Tel.: 705-372-6400

Fax: 705-372-6440

Legislative office

Room 116
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-326-7351

Fax: 416-326-6972


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Constituency office

Unit 102
60 King St.

Welland, ON L3B 6A4

Tel.: 905-732-6884

Fax: 905-732-9782

Legislative office

Room 355
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-3990

Fax: 416-325-3415


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Legislative office

Minister Without Portfolio
Room 223
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A2

Tel.: 416-325-7754

Fax: 416-325-7755

Constituency office

Suite 400
37 Sandiford Dr.

Stouffville, ON L4A 3Z2

Tel.: 905-642-2588

Fax: 905-642-1618

Toll Free: 1-866-531-9551


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Ministry office

Ministry of Finance
Frost Building South
7th Floor
7 Queen's Park Cres.

Toronto, ON M7A 1Y7

Tel.: 416-325-0400

Constituency office

111 Sheppard Ave. W

North York, ON M2N 1M7

Tel.: 416-733-7878

Fax: 416-733-7709


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Ministry office

Ministry for Seniors and Accessibility
College Park
5th Floor
777 Bay St.

Toronto, ON M5G 2C8

Tel.: 416-314-0797

Constituency office

Unit B
4559 Sheppard Ave. E

Toronto, ON M1S 1V3

Tel.: 416-297-5040

Fax: 416-297-6767


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Ministry office

Ministry of Municipal Affairs and Housing
17th Floor
777 Bay St.

Toronto, ON M5G 2E5

Tel.: 416-585-7000

Fax: 416-585-6470

Constituency office

Suite 101
100 Strowger Blvd.

Brockville, ON K6V 5J9

Tel.: 613-342-9522

Fax: 613-342-2501

Toll Free: 1-800-267-4408


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Legislative office

Government Caucus Office
Room 251
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A4

Tel.: 416-325-1331

Fax: 416-325-1423

Constituency office

Suite 101
114 Dundas St. E

Whitby, ON L1N 2H7

Tel.: 905-430-1141

Fax: 905-430-1840


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Constituency office

237 Montreal Rd.

Vanier, ON K1L 6C7

Tel.: 613-744-4484

Fax: 613-744-0889

Legislative office

Rm. 412/413
111 Wellesley St. W.

Toronto, ON M7A 1A4

Tel.: 416-325-0007

Fax: 416-325-0172


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MICHAEL COTEAU, DON VALLEY EAST

Legislative office

Room 416
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A4

Tel.: 416-325-4544

Fax: 416-325-4525

Constituency office

Suite L02
1200 Lawrence Ave. E

Toronto, ON M3A 1C1

Tel.: 416-494-6856

Fax: 416-494-9937


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Ministry office

Ministry of Infrastructure
4th Floor
777 Bay St.

Toronto, ON M7A 2E1

Tel.: 416-326-7591

Constituency office

Unit 1
74 Rebecca St.

Oakville, ON L6K 1J2

Tel.: 905-827-5141

Fax: 905-827-3786


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Ministry office

Treasury Board Secretariat
Whitney Block
Room 5340
5th Floor
99 Wellesley St. W

Toronto, ON M7A 1W3

Tel.: 416-326-7239

Constituency office

Unit 1 & 2
120 Lakeshore Rd. W

Mississauga, ON L5H 1E8

Tel.: 905-274-8228

Fax: 905-274-8552


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Constituency office

Unit 14
20 Bell Farm Rd.

Barrie, ON L4M 6E4

Tel.: 705-726-5538

Fax: 705-726-2880

Ministry office

Ministry of the Attorney General
11th Floor
720 Bay St.

Toronto, ON M7A 2S9

Tel.: 416-326-2220

Fax: 416-325-1219

Toll Free: 1-800-518-7901


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Ministry office

Ministry of Children, Community and Social Services/Associate Minister Responsible for Women's Issues
7th Floor
438 University Ave.

Toronto, ON M5G 2K8

Tel.: 416-325-5225

Constituency office

14 Coldwater Rd. W

Orillia, ON L3V 3L1

Tel.: 705-326-3246

Fax: 705-326-9579

Toll Free: 1-800-304-7341

Constituency office

TD Canada Trust Bank Plaza
Unit 6
295 King St.

Midland, ON L4R 3M5

Tel.: 705-526-8671

Fax: 705-526-8600


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Ministry office

Ministry of Health
5th Floor
777 Bay St.

Toronto, ON M7A 2J3

Tel.: 416-327-4300

Fax: 416-326-1571

Constituency office

Unit 22
16635 Yonge St.

Newmarket, ON L3X 1V6

Tel.: 905-853-9889

Fax: 905-853-6115

Toll Free: 1-800-211-1881


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VICTOR FEDELI, NIPISSING

Ministry office

Ministry of Economic Development, Job Creation and Trade
18th Floor
777 Bay St.

Toronto, ON M7A 1S5

Tel.: 416-326-8475

Constituency office

219 Main St. E

North Bay, ON P1B 1B2

Tel.: 705-474-8340

Fax: 705-474-9747


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Legislative office

Deputy House Leader
Main Legislative Building
Room 223
111 Wellesley St. W

Toronto, ON M7A 1A8

Tel.: 416-325-7754

Fax: 416-325-7755

Ministry office

Ministry of Children, Community and Social Services (Children and Autism)
7th Floor
438 University Ave.

Toronto, ON M5G 2K8

Tel.: 416-325-5225

Fax: 416-325-5240

Ministry office

Mailing address: Ministry of Children, Community and Social Services
Hepburn Block
6th Floor
80 Grosvenor St.

Toronto, ON M7A 1E9

Constituency office

Unit 4
4281 King St. E

Kitchener, ON N2P 2E9

Tel.: 519-650-9413

Fax: 519-650-7006


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Legislative office

Room 154
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-6913

Fax: 416-325-6942

Constituency office

Suite 220
100 Regina St. S

Waterloo, ON N2J 4P9

Tel.: 519-725-3477

Fax: 519-725-3667


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DOUG FORD, ETOBICOKE NORTH

Constituency office

823 Albion Rd.

Etobicoke, ON M9V 1A3

Tel.: 416-745-2859

Fax: 416-745-4601

Legislative office

Premier's Office
Room 281
Legislative Building, Queen's Park

Toronto, ON M7A 1A1

Tel.: 416-325-1941

Fax: 416-325-3745

Ministry office

Ministry of Intergovernmental Affairs
Queen's Park

Toronto, ON M7A 1A1

Tel.: 416-325-1941


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JOHN FRASER, OTTAWA SOUTH

Legislative office

Room 448
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A4

Tel.: 416-325-4670

Fax: 416-325-4671

Constituency office

1828 Bank St.

Ottawa, ON K1V 7Y6

Tel.: 613-736-9573

Fax: 613-736-7374


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Legislative office

Room 185
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-0117

Fax: 416-325-0084

Constituency office

Unit 2
78 Centre St. N

Oshawa, ON L1G 4B6

Tel.: 905-723-2411

Fax: 905-723-1054


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MERRILEE FULLERTON, KANATA--CARLETON

Ministry office

Ministry of Long-Term Care
6th Floor
400 University Ave.

Toronto, ON M7A 1T7

Constituency office

Suite 100
240 Michael Cowpland Dr.

Kanata, ON K2M 1P6

Tel.: 613-599-3000

Fax: 613-599-8183

Toll Free: 1-800-267-1020


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Legislative office

Room 169
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-212-6102

Fax: 416-212-6106

Constituency office

Unit 1
6746 Morrison St.

Niagara Falls, ON L2E 6Z8

Tel.: 905-357-0681

Fax: 905-357-9456

Constituency office

Douglas Heights Seniors Centre
265 High St.

Fort Erie, ON L2A 3R4

Tel.: 905-871-8868

Fax: 905-871-4717


*************************************


Legislative office

Room 186
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-9203

Fax: 416-325-9185

Constituency office

Hanmer Valley Shopping Plaza
Suite 15
5085 Hwy. 69 N

Hanmer, ON P3P 1P7

Tel.: 705-969-3621

Fax: 705-969-3538


*************************************


Constituency office

Unit 30
6179 Perth St.

Richmond, ON K0A 2Z0

Tel.: 613-838-4425

Fax: 613-838-6045

Legislative office

Room 212
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A4

Tel.: 416-325-4890


*************************************


Ministry office

Ministry of Municipal Affairs and Housing
Suite 2302
23rd Floor
777 Bay St.

Toronto, ON M5G 2E5

Tel.: 416-585-7000

Constituency office

Unit 206
400 Main St. E

Milton, ON L9T 4X5

Tel.: 905-878-1729

Fax: 905-878-5144


*************************************

CHRIS GLOVER, SPADINA--FORT YORK

Toronto, ON M5T 2R9

Tel.: 416-603-9664

Fax: 416-603-1214

Legislative office

Room 343
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7196

Fax: 416-326-7172


*************************************

MICHAEL GRAVELLE, THUNDER BAY--SUPERIOR NORTH

Legislative office

Room 421
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A4

Tel.: 416-325-4757

Fax: 416-325-4752

Constituency office

179 Algoma St. S

Thunder Bay, ON P7B 3C1

Tel.: 807-345-3647

Fax: 807-345-2922


*************************************


Legislative office

Room 172
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-0235

Fax: 416-325-0873

Constituency office

2443 Dougall Ave.

Windsor , ON N8X 1T3

Tel.: 519-977-7191

Fax: 519-977-7029


*************************************


Constituency office

2nd Floor
12 Perry St.

Woodstock, ON N4S 3C2

Tel.: 519-537-5222

Fax: 519-537-3577

Toll Free: 1-800-265-4046

Ministry office

Ministry of Agriculture, Food and Rural Affairs
11th Floor
77 Grenville St.

Toronto, ON M5S 1B3

Tel.: 416-326-3074


*************************************


Legislative office

Room 328
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7648

Fax: 416-326-7639

Constituency office

109 Catherine St.

Ottawa, ON K2P 0P4

Tel.: 613-722-6414

Fax: 613-722-6703


*************************************


Ministry office

Ministry of Natural Resources and Forestry
Whitney Block
Room 6601
6th Floor
99 Wellesley St. W

Toronto, ON M7A 1A1

Constituency office

Unit 3 & 4
63 Arthur St. S

Elmira, ON N3B 2M6

Tel.: 519-669-2090

Fax: 519-669-0476


*************************************


Legislative office

Room 325
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A2

Tel.: 416-326-6961

Fax: 416-326-6957

Constituency office

1965 Weston Rd.

Toronto, ON M9N 1W8

Tel.: 416-243-7984

Fax: 416-243-0327


*************************************


Legislative office

Room 363
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-6773

Fax: 416-325-6795

Constituency office

Unit 1
5452 Tecumseh Rd. E

Windsor, ON N8T 1C7

Tel.: 519-251-5199

Fax: 519-251-5299


*************************************

RANDY HILLIER, LANARK--FRONTENAC--KINGSTON

Legislative office

Whitney Block
Room 1304
99 Wellesley St. W

Toronto, ON M7A 1A2

Tel.: 416-325-2244

Constituency office

Unit 1
105 Dufferin St.

Perth, ON K7H 3A5

Tel.: 613-267-8239

Fax: 613-267-7398


*************************************


Constituency office

Unit 21
195 Norseman St.

Etobicoke, ON M8Z 0E9

Tel.: 416-259-2249

Ministry office

Solicitor General
George Drew Building
18th Floor
25 Grosvenor St.

Toronto, ON M7A 1Y6

Tel.: 437-288-7903


*************************************


Legislative office

Room 381
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-7116

Fax: 416-325-8222

Constituency office

Suite 200
20 Hughson St. S

Hamilton, ON L8N 2A1

Tel.: 905-544-9644

Fax: 905-544-5152


*************************************

MITZIE HUNTER, SCARBOROUGH--GUILDWOOD

Constituency office

Unit B1
3785 Kingston Rd.

Scarborough, ON M1J 3M4

Tel.: 416-281-2787

Fax: 416-281-2360

Legislative office

Room 447
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A4

Tel.: 416-325-4800

Fax: 416-325-4785


*************************************


Ministry office

Solicitor General
George Drew Building
18th Floor
25 Grosvenor St.

Toronto, ON M7A 1Y6

Tel.: 416-325-0408

Fax: 416-326-0498

Constituency office

Suite A
3rd Floor
180 Broadway Ave.

Orangeville, ON L9W 1K3

Tel.: 519-941-7751

Fax: 519-941-3246


*************************************


Legislative office

Room 441
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-4850

Fax: 416-325-4884

Constituency office

Unit 5
450 Alden Rd.

Markham, ON L3R 5H4

Tel.: 905-305-1935

Fax: 905-305-1938


*************************************


Legislative office

Whitney Block

Room 1308B

99 Wellesley St. W

Toronto, ON M7A 1A2

Constituency office

Suite 101

498 Eagle St. N

Cambridge, ON N3H 1C2

Tel.: 519-650-2770

Fax: 519-650-3918


*************************************


Legislative office

Room 204
North Wing, Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-3017

Fax: 416-325-2937

Constituency office

2849 Dundas St. W

Toronto, ON M6P 1Y6

Tel.: 416-763-5630

Fax: 416-763-5640


*************************************

VINCENT KE, DON VALLEY NORTH

Ministry office

Mailing address: Ministry of Heritage, Sport, Tourism and Culture Industries (Culture and Sport)
6th Floor
438 University Ave.

Toronto, ON M5G 2K8

Constituency office

Suite 103
2175 Sheppard Ave. E

North York, ON M2J 1W8

Tel.: 416-494-8778

Fax: 416-494-0110

Ministry office

Ministry of Heritage, Sport, Tourism and Culture Industries (Culture and Sport)
1st Floor
400 University Ave.

Toronto, ON M7A 1T7

Tel.: 416-325-6009


*************************************


Legislative office

Room 362
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7568

Fax: 416-326-7580

Constituency office

Unit 105
400 York St.

London, ON N6B 3N2

Tel.: 519-432-7339

Fax: 519-432-0613


*************************************


Constituency office

Unit 1
237 Mapleview Dr. E

Barrie, ON L4N 0W5

Tel.: 705-722-0575

Fax: 705-722-8835

Ministry office

Ministry of the Environment, Conservation and Parks
5th Floor
777 Bay St.

Toronto, ON M7A 2J3

Tel.: 416-314-6790


*************************************


Legislative office

Room 269
Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7005

Fax: 416-326-6999

Constituency office

8 Dundas St. W

Napanee, ON K7R 1Z4

Tel.: 613-308-9625

Fax: 613-308-9685

Constituency office

26A St. Lawrence St. W
P.O. Box 70

Madoc, ON K0K 2K0

Tel.: 343-600-3310

Fax: 343-600-3329

Toll Free: 855-229-6676


*************************************


Legislative office

Room 429
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7102

Constituency office

Unit 708
10 Kingsbridge Garden Circle

Mississauga, ON L5R 3K7

Tel.: 905-890-1901


*************************************


Ministry office

Ministry of Education
5th Floor
438 University Ave.

Toronto, ON M5G 2K8

Tel.: 416-325-2600

Constituency office

Unit 1
2220 King Rd.

King City, ON L7B 1L3

Tel.: 647-560-9700

Fax: 647-560-9701


*************************************


Constituency office

Suite 212
25 Frederick St.

Kitchener, ON N2H 6M8

Tel.: 519-579-5460

Fax: 519-579-2121

Legislative office

Room 170
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-326-7221

Fax: 416-326-7217


*************************************

LISA MACLEOD, NEPEAN

Ministry office

Ministry of Heritage, Sport, Tourism and Culture Industries
6th Floor
438 University Ave.

Toronto, ON M5G 2K8

Tel.: 416-314-1400

Ministry office

Mailing address: Ministry of Heritage, Sport, Tourism and Culture Industries
Hearst Block
9th Floor

Toronto, ON M7A 2A1

Constituency office

Unit 222/3
250B Greenbank Rd.

Nepean, ON K2H 8X4

Tel.: 613-823-2116

Fax: 613-823-8284


*************************************


Legislative office

Room N201
Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-326-7692

Fax: 416-326-7690

Constituency office

Unit 104
73 King St.
P.O. Box 176

Sioux Lookout, ON P8T 1A1

Tel.: 807-737-2210

Fax: 807-737-1592

Toll Free: 1-888-444-1723


*************************************


Legislative office

Room 160
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-1938

Fax: 416-325-1976

Constituency office

14 George Walk

Elliot Lake, ON P5A 2A4

Tel.: 705-461-9710

Fax: 705-461-9720

Toll Free: 1-800-831-1899


*************************************


Ministry office

Ministry of Health
5th Floor
777 Bay St.

Toronto, ON M7A 2J3

Tel.: 416-327-4300

Constituency office

2882 Dufferin St.

Toronto, ON M6B 3S6

Tel.: 416-781-2395

Fax: 416-781-4116


*************************************


Ministry office

Ministry of Francophone Affairs
15th Floor
56 Wellesley St. W

Toronto, ON M5S 3L6

Tel.: 416-325-4947

Constituency office

Centre Street Square
Unit 4
1136 Centre St.

Thornhill, ON L4J 3M8

Tel.: 905-731-8462

Fax: 905-731-2984


*************************************


Constituency office

Time Square
120 Second St. W

Cornwall, ON K6J 1G5

Tel.: 613-933-6513

Fax: 613-933-6449

Ministry office

Ministry of Municipal Affairs and Housing
Suite 2302
23rd Floor
777 Bay St.

Toronto, ON M5G 2E5

Tel.: 416-585-7000


*************************************

Ministry office

Ministry of Labour, Training and Skills Development
14th Floor
400 University Ave.

Toronto, ON M7A 1T7

Tel.: 416-325-4910

Constituency office

Unit 104
472 Brock Ave.

Burlington, ON L7S 1N1

Tel.: 905-639-7924

Fax: 905-639-3284


************************************

MONTE MCNAUGHTON, LAMBTON--KENT--MIDDLESEX

360 James St.

Wallaceburg, ON N8A 2N5

Tel.: 519-627-1015

Fax: 519-627-7174

Ministry office

Ministry of Labour, Training and Skills Development
14th Floor
400 University Ave.

Toronto, ON M7A 1T7

Tel.: 416-326-7600

Constituency office

81 Front St. W

Strathroy, ON N7G 1X6

Tel.: 519-245-8696

Fax: 519-245-8697


*************************************


Constituency office

289 Queenston Rd.

Hamilton, ON L8K 1H2

Tel.: 905-545-0114

Fax: 905-545-9024

Legislative office

Room 357
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-0707

Fax: 416-325-0853


*************************************


Ministry office

Ministry of Intergovernmental Affairs
Frost Building South
6th Floor
7 Queen's Park Cres.

Toronto, ON M7A 1Y7

Tel.: 416-325-1012

Constituency office

Unit 1
165 Manitoba St.

Bracebridge, ON P1L 1S3

Tel.: 705-645-8538

Fax: 705-645-8148

Toll Free: 1-888-267-4826

Constituency office

26 James St.

Parry Sound, ON P2A 1T5

Tel.: 705-746-4266

Fax: 705-746-1578

Toll Free: 1-888-701-1176


*************************************


Constituency office

2063 Lawrence Ave. E

Scarborough, ON M1R 2Z4

Tel.: 416-615-2183

Fax: 416-615-2011

Legislative office

Room 427
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7374

Fax: 416-326-7377


*************************************


Legislative office

Room 207
North Wing, Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-9820

Fax: 416-325-9800

Constituency office

Suite 105
105 Main St. E
P.O. Box 1886

Atikokan, ON P0T 1C0

Tel.: 807-597-2629

Fax: 807-597-2402

Constituency office

409 George St.

Thunder Bay, ON P7E 5Y9

Tel.: 807-622-1920

Fax: 807-622-3263

Toll Free: 1-833-673-4129


*************************************


Legislative office

Room 344
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-326-7171

Constituency office

329 Parliament St.

Toronto, ON M5A 2Z3

Tel.: 416-972-7683

Fax: 416-972-7686


*************************************


Ministry office

Ministry of Francophone Affairs
25th Floor
700 Bay St

Toronto, ON M7A 0A2

Ministry office

Ministry of Transportation
5th Floor
777 Bay St.

Toronto, ON M7A 1Z8

Tel.: 416-327-9200

Constituency office

Unit 8
45 Grist Mill Rd.

Holland Landing, ON L9N 1M7

Tel.: 905-895-1555

Fax: 905-895-0337


*************************************


Legislative office

Room 369
Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-0714

Fax: 416-325-0980

Constituency office

316 Talbot St. N

Essex, ON N8M 2E1

Tel.: 519-776-6420

Fax: 519-776-6980

Toll Free: 1-800-265-3909


*************************************


Constituency office

Unit B
115 Erie St. N

Tel.: 519-326-3367

Fax: 519-326-0404

Constituency office

Suite 100
111 Heritage Rd.

Chatham, ON N7M 5W7

Tel.: 519-351-0510

Fax: 519-351-7714

Toll Free: 1-800-265-3992

Legislative office

Room 440
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-9099

Fax: 416-325-9000


*************************************


Ministry office

Ministry of Education
5th Floor
438 University Ave.

Toronto, ON M5G 2K8

Tel.: 416-326-1697

Constituency office

Unit M1
4961 King St. E

Beamsville, ON L0R 1B0

Tel.: 905-563-1755

Fax: 905-563-1317


*************************************


Constituency office

Unit 602
3601 Hwy. 7 E

Markham, ON L3R 0M3

Tel.: 905-474-3288

Fax: 905-474-2878

Ministry office

Mailing address: Ministry of Heritage, Sport, Tourism and Culture Industries (Tourism)
6th Floor
438 University Ave.

Toronto, ON M5G 2K8

Ministry office

Ministry of Heritage, Sport, Tourism and Culture Industries (Tourism)
1st Floor
400 University Ave.

Toronto, ON M7A 1T7

Tel.: 416-325-6009


*************************************


Ministry office

Ministry of the Attorney General
11th Floor
720 Bay St.

Toronto, ON M7A 2S9

Tel.: 416 326-2220

Constituency office

23 King St. W

Bowmanville, ON L1C 1R2

Tel.: 905-697-1501

Fax: 905-697-1506


*************************************

MICHAEL PARSA, AURORA--OAK RIDGES--RICHMOND HILL

Ministry office

Treasury Board Secretariat
Whitney Block
Room 5340
5th Floor
99 Wellesley St. W

Toronto, ON M7A 1W3

Constituency office

Suite 201
13085 Yonge St.

Richmond Hill, ON L4E 3S8

Tel.: 905-773-6250

Fax: 905-773-8158

Toll Free: 888-486-5352


*************************************


Ministry office

Ministry of Agriculture, Food and Rural Affairs
11th Floor
77 Grenville St.

Toronto, ON M5S 1B3

Tel.: 416-326-3073

Constituency office

Unit 2
55 Lorne Ave. E

Stratford, ON N5A 6S4

Tel.: 519-272-0660

Fax: 519-272-1064


*************************************


Ministry office

Ministry of Finance
Frost Building South
7th Floor
7 Queen's Park Cres.

Toronto, ON M7A 1Y7

Constituency office

Suite 209
1 Rossland Rd. W

Ajax, ON L1Z 1Z2

Tel.: 905-427-2060

Fax: 905-427-6976


*************************************


Ministry office

Ministry of Colleges and Universities
5th Floor
438 University Ave.

Toronto, ON M7A 2A5

Tel.: 416-326-1600

Ministry office

Mailing Address: Ministry of Colleges and Universities
14th Floor
315 Front St. W

Toronto, ON M7A 0B8

Constituency office

117 Peter St.

Port Hope, ON L1A 1C5

Tel.: 905-372-4000

Fax: 905-885-0050


*************************************


Constituency office

Unit 38
2300 Finch Ave. W

North York, ON M9M 2Y3

Tel.: 416-743-7272

Fax: 416-743-3292

Legislative office

Room 330
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7585

Fax: 416-326-7634


*************************************


Legislative office

Room 271
Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7028

Fax: 416-326-7085

Constituency office

Unit 315
1420 Burnhamthorpe Rd. E

Mississauga, ON L4X 2Z9

Tel.: 905-238-1751

Fax: 905-238-4918


*************************************


Ministry office

Ministry of Energy, Northern Development and Mines
Whitney Block
Room 5630
5th Floor
99 Wellesley St. W

Toronto, ON M7A 1W1

Tel.: 416-327-0633

Fax: 416-327-0665

Constituency office

300 McClellan Ave. East Room

Kenora, ON P9N 1A8

Tel.: 807-467-2415

Fax: 807-467-2641

Toll Free: 1-800-465-8501

Constituency office

Unit 1
279 Scott St.

Fort Frances, ON P9A 1G8

Tel.: 807-274-7619

Fax: 807-274-3721

Constituency office

Unit 2
439 Government St.

Dryden, ON P8N 2P4

Tel.: 807-223-6456

Fax: 807-223-6593

Toll Free: 1-800-465-8501

Ministry office

Ministry of Indigenous Affairs
Suite 400
160 Bloor St. E

Toronto, ON M7A 2E6

Tel.: 416-327-4464


*************************************


Ministry office

Ministry of Children, Community and Social Services
7th Floor
438 University Ave.

Toronto, ON M5G 2K8

Tel.: 647-309-4348

Constituency office

Unit 500
1580 Merivale Rd.

Nepean, ON K2G 4B5

Tel.: 613-721-8075

Fax: 613-721-5756


*************************************


Ministry office

Ministry of Colleges and Universities
5th Floor
438 University Ave.

Toronto, ON M7A 2A5

Tel.: 416 326-1600

Constituency office

Suite 102
390 Bay St.

Sault Ste Marie, ON P6A 1X2

Tel.: 705-949-6959

Fax: 705-946-6269


*************************************


Constituency office

Unit 40
4181 Sladeview Cres

Mississauga, ON L5L 5R2

Tel.: 905-820-8851

Fax: 905-820-4307

Ministry office

Ministry of Heritage, Sport, Tourism and Culture Industries
1st Floor
400 University Ave.

Toronto, ON M7A 1T7

Tel.: 416-326-7253

Fax: 416-326-7244


*************************************


Legislative office

Room 261
Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-6903

Fax: 416-326-6899

Constituency office

Unit 309
10 Gillingham Dr.

Brampton, ON L6X 0G6

Tel.: 905-595-1532

Fax: 905-457-8496


*************************************


Ministry office

Ministry of Economic Development, Job Creation and Trade
7th Floor
56 Wellesley St. W

Toronto, ON M7A 2E7

Constituency office

Unit 412A
7700 Hurontario St.

Brampton, ON L6Y 4M3

Tel.: 905-796-8669

Fax: 905-796-8069


*************************************


Constituency office

Unit 106
240 Commissioners Rd. W

London, ON N6J 1Y1

Tel.: 519-657-3120

Fax: 519-657-0368

Legislative office

Room 359
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-6908

Fax: 416-325-7030


*************************************


Legislative office

Room 451
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A2

Tel.: 416-325-4664

Fax: 416-325-4666

Constituency office

173 Woolwich St.

Guelph, ON N1H 3V4

Tel.: 519-836-4190

Fax: 519-836-4191


*************************************


Ministry office

Ministry of Infrastructure
5th Floor
777 Bay St.

Toronto, ON M7A 2J3

Tel.: 416-327-4412

Constituency office

14 Lindsay St. N

Lindsay, ON K9V 1T4

Toll Free: 1-800-424-2490


*************************************


Legislative office

Room 202
North Wing, Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-6890

Fax: 416-326-6885

Constituency office

177 King St. W

Dundas, ON L9H 1V3

Tel.: 905-628-2755

Fax: 905-628-1280


*************************************

AMANDA SIMARD, GLENGARRY--PRESCOTT--RUSSELL

Room 425
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-6206

Fax: 416-325-6182

Constituency office

290A McGill St.

Hawkesbury, ON K6A 1P8

Tel.: 613-632-2706

Fax: 613-632-1554

Toll Free: 1-800-294-8250


*************************************


Constituency office

Unit 307
1 Gateway Blvd.

Brampton, ON L6T 0G3

Tel.: 905-799-3939

Fax: 905-799-9505

Legislative office

Room 156
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-326-7178

Fax: 416-326-7166


*************************************


Legislative office

Room 331
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7610

Fax: 416-326-7615

Constituency office

Lakeridge Plaza
Unit 12
456 Vodden St. E

Brampton, ON L6S 5Y7

Tel.: 905-454-1233

Fax: 905-454-8292


*************************************


Ministry office

Ministry of Economic Development, Job Creation and Trade
17th Floor
777 Bay St.

Toronto, ON M7A 2E7

Constituency office

Suite 104
2000 Garth St.

Hamilton, ON L9B 0C1

Tel.: 905-679-3770

Fax: 905-679-0288


*************************************


Constituency office

Unit 4
1123 Water St.

Peterborough, ON K9H 3P7

Tel.: 705-742-3777

Fax: 705-742-1822

Ministry office

Ministry of Energy, Northern Development and Mines (Northern Development and Mines)
Whitney Block
Room 5501
5th Floor
99 Wellesley St. W

Toronto, ON M7A 1W3

Tel.: 416-326-7406

Ministry office

Ministry of Indigenous Affairs

Tel.: 416-326-7406


*************************************

TODD SMITH, BAY OF QUINTE

Constituency office

Unit D
5503 Hwy. 62 S
P.O. Box 6-2

Belleville, ON K8N 0L5

Tel.: 613-962-1144

Fax: 613-969-6381

Ministry office

Ministry of Children, Community and Social Services
7th Floor
438 University Ave.

Toronto, ON M5G 2K8

Tel.: 416-212-7432

Fax: 416-212-7431

Ministry office

Mailing address: Ministry of Children, Community and Social Services
Hepburn Block
6th Floor
80 Grosvenor St.

Toronto, ON M7A 1E9

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JENNIFER STEVENS, ST. CATHARINES

Constituency office

Unit B
209 Carlton St.

St. Catharines, ON L2R 1S1

Tel.: 905-935-0018

Fax: 905-935-0191

Legislative office

Room 387
Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-326-7127

Fax: 416-326-7126


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Legislative office

Room 157
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-326-7202

Fax: 416-326-7200

Constituency office

1199 Bloor St. W

Toronto, ON M6H 1N4

Tel.: 416-535-3158

Fax: 416-535-6587


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Ministry office

Ministry of Transportation
5th Floor
777 Bay St.

Toronto, ON M7A 1Z8

Tel.: 416-327-9200

Fax: 416-327-9188

Constituency office

Lloydmanor Shopping Centre
Unit 102
201 Lloyd Manor Rd.

Etobicoke, ON M9B 6H6

Tel.: 416-234-2800

Fax: 416-234-2276


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Legislative office

Room 165
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A5

Tel.: 416-325-3250

Fax: 416-325-3252

Constituency office

923 Danforth Ave.

Toronto, ON M4J 1L8

Tel.: 416-461-0223

Fax: 416-461-9542


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Constituency office

Unit 110
154 Queen St. S

Mississauga, ON L5M 2P4

Tel.: 905-569-1643

Fax: 905-569-6416

Ministry office

Ministry of Economic Development, Job Creation and Trade
7th Floor
56 Wellesley St. W

Toronto, ON M7A 2E7

Tel.: 416-326-8475


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Legislative office

Room 371
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A4

Tel.: 416-325-1796

Fax: 416-325-1863

Constituency office

Unit 202
555 Concession St.

Hamilton, ON L8V 1A8

Tel.: 905-388-9734

Fax: 905-388-7862


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Constituency office

Unit 105
8130 Sheppard Ave. E

Toronto, ON M1B 3W3

Tel.: 416-283-8448

Fax: 416-283-1597

Ministry office

Ministry of Transportation
5th Floor
777 Bay St.

Toronto, ON M7A 1Z8

Tel.: 416-327-9200


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Constituency office

408 Queen St.
P.O. Box 426

Blyth, ON N0M 1H0

Tel.: 519-523-4251

Fax: 226-523-9296

Ministry office

Ministry of Government and Consumer Services
5th Floor
777 Bay St.

Toronto, ON M7A 2J3

Tel.: 416-212-2665

Constituency office

Unit 2
807 Queen St.

Kincardine, ON N2Z 2Y2

Tel.: 519-396-3007

Fax: 519-396-3011

Toll Free: 1-866-396-3007


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MICHAEL TIBOLLO, VAUGHN--WOODBRIDGE

Constituency office

Unit 3
5100 Rutherford Rd.

Woodbridge, ON L4H 2J2

Tel.: 905-893-4428

Fax: 905-893-4537

Ministry office

Ministry of Health
Whitney Block
Room 1618
99 Wellesley St. W

Toronto, ON M7A 1A2

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Ministry office

Ministry of Long-Term Care
6th Floor
400 University Ave.

Toronto, ON M7A 1T7

Tel.: 416-325-6200

Constituency office

Unit 570
2525 Old Bronte Rd.

Oakville, ON L6M 4J2

Tel.: 905-825-2455

Fax: 905-825-0663


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Legislative office

Room 348
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-325-2000

Fax: 416-325-1999

Constituency office

2nd Floor
193 King St.

Sturgeon Falls, ON P2B 1R8

Tel.: 705-753-0200

Fax: 705-753-0800

Constituency office

Pinewoods Centre
Unit 5
247 Whitewood Ave.
P.O. Box 398

New Liskeard, ON P0J 1P0

Tel.: 705-647-5995

Fax: 705-647-1976

Constituency office

63B Government Rd. W

Kirkland Lake, ON P2N 2E6

Tel.: 705-567-4650

Fax: 705-567-4208


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Ministry office

Ministry for Seniors and Accessibility
College Park
5th Floor
777 Bay St.

Toronto, ON M5G 2C8

Tel.: 416-314-0797

Constituency office

Suite 409
9555 Yonge St.

Richmond Hill, ON L4C 9M5

Tel.: 905-884-8080

Fax: 905-884-1040


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Ministry office

10th Floor

77 Grenville St.

Toronto, ON M7A 2C1

Tel.: 416-325-6242

Constituency office

Suite 100
920 1st Ave. W

Owen Sound, ON N4K 4K5

Tel.: 519-371-2421

Fax: 519-371-0953

Toll Free: 1-800-461-2664


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Legislative office

Room 347
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-7144

Fax: 416-326-7280

Constituency office

Unit 4B
555 Barrydowne Rd.

Sudbury, ON P3A 3T4

Tel.: 705-675-1914

Fax: 705-675-1456


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JIM WILSON, SIMCOE--GREY

Constituency office

50 Hume St.

Collingwood, ON L9Y 1V2

Tel.: 705-446-1090

Fax: 705-446-3397

Constituency office

Suite 28
180 Parsons Rd.

Alliston, ON L9R 1E8

Tel.: 705-435-4087

Fax: 705-435-1051

Legislative office

Whitney Block
Room 1306
99 Wellesley St. W

Toronto, ON M7A 1A8

Tel.: 416-325-2069

Fax: 416-325-2079


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KATHLEEN WYNNE, DON VALLEY WEST

Legislative office

Room 420
Main Legislative Building, Queen's Park

Toronto, ON M7A 1A4

Tel.: 416-325-4705

Fax: 416-325-4726

Constituency office

Suite 101
795 Eglinton Ave. E

Toronto, ON M4G 4E4

Tel.: 416-425-6777

Fax: 416-425-0350


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Ministry office

Ministry of Natural Resources and Forestry
Whitney Block
Suite 6630
6th Floor
99 Wellesley St. W

Toronto, ON M7A 1W3

Tel.: 416-314-2301

Constituency office

The Victoria Center
Unit 6
84 Isabella St.

Pembroke, ON K8A 5S5

Tel.: 613-735-6627

Fax: 613-735-6692


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Legislative office

Room 206
North Wing, Main Legislative Building, Queen's Park

Toronto, ON M7A 1A8

Tel.: 416-326-6727

Fax: 416-326-6726

Constituency office

Unit 7
10215 Kennedy Rd. N

Brampton, ON L6Z 0C5

Tel.: 905-495-8030

Fax: 905-495-1041


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Constituency office

Suite 201
750 Talbot St.

St. Thomas, ON N5P 1E2

Tel.: 519-631-0666

Fax: 519-631-9478

Toll Free: 1-800-265-7638

Ministry office

Ministry of the Environment, Conservation and Parks
5th Floor
777 Bay St.

Toronto, ON M7A 2J3

Tel.: 416-314-6790


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