Coroner's inquest deems Matthew Mahoney's death a 'homicide'


The jury in a coroner's inquest looking into the police-involved shooting death of Matthew Mahoney has deemed the Windsor man's death was a 'homicide.'

The decision follows 10-days of testimony and submissions looking into the circumstances around the 2018 death of the 33-year-old Mahoney, who had been diagnosed with schizophrenia.

While his death has been deemed a homicide, the term homicide does not equal intent in a coroner's inquest and the inquest does not assign blame. The decision means, without judgment of whether it was right or wrong, that the death occurred at the hands of another individual.

The jury had been asked to consider whether the death was a homicide, suicide or undetermined.

Nine recommendations aimed at preventing another death in similar circumstances have also been put forward, with the jury approving five that were proposed ahead of the deliberations and also making four more of their own.

The first five recommendations are focused on improving communication and awareness around the availability of mental healthcare services in the community, providing enhanced and improved training for Windsor police officers when it comes to mental health-related situations, and a call for a provincial task force to be struck within six months to review funding, accountabilities, and timely access to care for all community-based mental health services.

The recommendations made by the jury includes a review the resources allocated with the Windsor Police COAST program to ensure and offer increased support based on the growing community mental health needs of the region. 

COAST, which stands for Community Outreach and Support Team, pairs a police officer with a social worker. They work to make contact with people, particularly those with mental health issues, to connect them with various services in the community, with the ultimate goal of diverting them from a hospital emergency room or the justice system.

The jury also recommends that Windsor Regional Hospital and the Ontario Ministry of Health assess the feasibility and impact of establishing a Mental Health Advocate role (or enhancing the abilities of Social Workers) to be the point person helping patients and families coordinate mental health services. 

Those advocates could assist with such things as scheduling follow-up sessions after appointments, check-ins, support after medication changes and consistently offer a family meeting within 48-72 hours of hospital admission to help gather collateral information.

Throughout the inquest, the Mahoney family detailed failed efforts to speak with Matthew's healthcare providers to share information about his situation, but that he would not allow his psychiatrist or any other healthcare providers to share information about his care under patient privacy laws.

The 33-year-old Mahoney was shot and killed on March 21, 2018 after a violent confrontation with police in the Dufferin Place alley, behind the McDonalds at Goyeau Street and Wyandotte Street.

Officers had been called for a report of a man carrying a butcher block with knives. Police asked him to stop but he attacked the officers instead.  Police tasered the man, but it didn't stop him and then shots were fired.

One officer was stabbed during the altercation.

Ontario's Special Investigations Unit cleared police of any wrongdoing in the case, concluding the shots fired by the officers, which struck and killed Mahoney, 'were justified'.



Directed Towards the Ontario Ministry of Health

1. For the purpose of assisting clinicians in directing patients to receive timely mental health services and promoting accountability of community mental health services, a direction requiring that all hospital and community-based mental health services that receive funding from the Government of Ontario:
1. collect and publish monthly non-identifying data regarding
a. wait times for treatment (i.e., actual receipt of mental health services by mental health professionals as opposed to waiting times for intake) and patient volumes;
b. days and hours of mental health services provided; and
2. provide the resources to allow hospitals and community-based mental health services to provide this data; and
3. increase mental health awareness and promotion of initiatives within communities to address the lack of familiarity of services and options available for persons and families dealing with mental health situations

2. Within 6 months of the Jury’s verdict, strike a task force to review, report on, and initiate changes to:
1. funding, accountabilities, and timely access to care for all community-based mental health services that receive funding from the Government of Ontario; and
2. available resources and supports for family members and/or caregivers of patients and community services receiving mental health services; and
3. how family members and/or caregivers and community services can provide support and/or information about patients when patient consent is not provided; and
4. address what information can be shared from family members and other stakeholders; and
5. align services and community agencies to better share information about individuals with mental health concerns in the community.
The task force should focus these reviews on the most vulnerable patients, particularly those diagnosed with moderate to severe mental illness, especially schizophrenia and/or schizophrenia related disorders.

3. Establish further study and review of the criteria and training associated with the Mental Health Act and report on recommendations to address:
1. mandatory refresher training for emergency room physicians and psychiatrists in the province of Ontario on when and how to use the Form 1 options associated with mental health; and
2. the assessment of Box A and Box B criteria for psychiatric evaluation and involuntary detention; and
3. to determine how best to ensure collateral information from family members and relevant community services information can be included as part of the process for determining appropriate treatment options.

Directed to the Government of Ontario

4. The Government of Ontario should offer and arrange enhanced legal and mental health support for families of persons who die in a police encounter and ensure that those services are delivered in a timely and trauma-informed manner.

To the Ministry of the Solicitor General and Windsor Police Service

5. Provide enhanced police training in addressing mental health-related situations and crises, including awareness education in recognizing and identifying situations where mental illness may play a role.
1. provide mandatory standardized training bi-annually on de-escalation strategies and empathy for community mental health-related situations.

6. Review current procedures and processes in respect of police response to persons who have a mental illness.

To Windsor Police Service (COAST Program)

7. Review the resources allocated with the COAST program to ensure and offer increased support based on the growing community mental health needs of the Windsor, Ontario region, to offer support 24 hours a day.

Directed Towards Windsor Regional Hospital & Ontario Ministry of Health

8. Continue ongoing quality assessments to drive continuous improvement of standard operating procedures and protocols, documentation, and best practices with mental health services,
1. to review and audit core services within Windsor Regional Hospital annually to ensure compliance to standards are met and keeping pace with community demands proactively.

9. Assess the feasibility and impact of establishing a Mental Health Advocate role (or enhancing the abilities of Social Workers) to be the point person helping patients and families coordinate mental health services:
1. this Advocate assists with scheduling follow-up sessions after appointments; check-ins, and visits; support after medication changes; recommends community services; collecting collateral information from relevant parties; and
2. based on demand and proper funding, this Advocate will be required to manage multiple concurrent cases effectively within a framework of flagging and following up with the highest risk outpatients; and
3. consistently offer a family meeting within 48-72 hours of hospital admission, regardless of the patient’s status in hospital, to collect collateral information; and
4. Documented offer of a meeting with family members or support team occurs prior to discharge from hospital to ensure a patient with mental health issues has support; and
5. 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.