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Jury returns with 9 recommendations following inquest into death of Matthew Mahoney

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A coroner’s inquest into the death of a Windsor man who was shot by police concluded Friday with the jury making several recommendations for police, hospital and government in their verdict.

Matthew Mahoney, 33, was shot and killed by Windsor police following a confrontation downtown on March 21, 2018.

At the time of his death, Mahoney was walking downtown carrying a butcher block of knives. The inquest heard he had stabbed an officer in the hand before a second officer fired the shots.

The jury determined Mahoney died by homicide, but they cannot assign blame or lay guilt on the officers involved.

Throughout the inquest, the jury heard Mahoney struggled with his mental health. After nearly two weeks of evidence, the jury returned with a verdict and nine recommendations.

“We're really impressed. This jury went above and beyond. It's very clear from their recommendations that they very carefully considered the evidence that was presented to them and they very carefully considered the testimony of the experts that presented what happened,” Matthew’s brother, Michael Mahoney, said following the verdict. “They made really thoughtful, very detailed recommendations.”

They recommend police get enhanced training in addressing mental health-related situations and crises, including “awareness education in recognizing and identifying situations where mental illness may play a role.” A review of current police procedures regarding responses to those with mental illness and providing mandatory standardized training bi-annually on de-escalation strategies and empathy for mental-health-related situations is also suggested.

The jury also recommends the Windsor Police Service review resources for the Community Outreach and Support Team (COAST) to ensure increased support for growing community mental health needs and offer 24-hour support.

“A lot of people have been hurt because it's taken too long to have that training updated," Michael said. "I think it's a shame that we send officers into the field with training that we know is incomplete. That's really dangerous for them, not just the community. It’s important that we recognize and try to fix that.” 

Recommendations directed toward Windsor Regional Hospital and the Ministry of Health include improving the standard for how they offer mental health care. This includes reviewing and auditing core services within the hospital each year to ensure standards are met and keeping pace with community demands.

The jury also suggests establishing a mental health advocate role to create a point-person to help patients and families coordinate services such as scheduling follow-up sessions, offering family meetings within 48-72 hours of hospital admission and “provide mental health services 24 hours a day to better assist communities by expanding self-help services to those in need through online, hybrid, or in-person supports.”

“I’d like to see the recommendations implemented,” Michael said. “It would be a real shame if the agencies involved looked at those and decided not to implement any changes. There was a lot to learn from in this case. We will be watching closely to see what happens.”

The Government of Ontario is also recommended to offer and arrange enhanced legal and mental health support for families of those who die in a police encounter.

The inquest heard from both officers involved as well as Mahoney’s brother and mother before the jury reached their verdict.

“I will remember Matthew,” Michael said. “His personality was really larger than life. I'm never going to forget that smile and that sense of humour.”

The jury’s verdict along with a full list of recommendations is available here.

- With files from CTV Windsor's Sijia Liu

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