Five recommendations proposed at inquest into shooting death of a Windsor man


The jury in the coroner's inquest into the police-involved shooting death of a Windsor man is being asked to consider five recommendations aimed at preventing another death under similar circumstances.

The presiding officer, Dr. Daniel Ambrosini, will deliver his charge to the jury Friday morning following nine days of testimony and submissions looking at the life and death of Matthew Mahoney, who had been diagnosed with schizophrenia.

The recommendations are focused on improving the the sharing of data when it comes to mental healthcare wait times and patient volumes; that a task force be struck to review and report on funding, accountability and timely access to care; improvements in how family members and caregivers can provide support or information about a patient; and improvements when it comes to training and procedures used by police in respect to dealing with people with mental illness.

The jury is also being asked to decide by what means did the person die, in this case, Matthew Mahoney. The jury must consider if his death was a suicide, homicide or undetermined.

Michael Mahoney, Matthew's brother, told the jury the family would not support this as suicide by police.

"Given the evidence, this would not be supported given his notes from attending physicians or doctors who knew him. While Matt would often make threats (of suicide), these would always be rescinded and were, in our opinion, clear indications of a cry for help, attention or reaction."

Michael Mahoney argued that his brother's intentions were not to provoke a violent interaction as he repeatedly tried to avoid the officers that morning and didn't react until a taser was drawn.

"In that moment, Matt may have felt that was his only option," he says. "We recognize Matthew lived a tortured life that most of us will never understand, be witness or party to. While that wasn't Matt's intention that morning, we also recognize that Matthew was finally going to find peace for once and may have even been thankful that his journey was coming to an end."

The lawyer representing the Windsor Police Service and the lawyers representing the officers involved in the incident made arguments that the jury deem Mahoney's death a suicide.

During testimony in the case, two officers involved in the shooting told the inquest that Mahoney said "thank you" moments after he had been shot, with both officers stating they believed it was suicide by police.

The lawyer representing Dr. Aleem Khan argued Mahoney's death was a homicide. Dr. Khan, a psychiatrist at Windsor Regional Hospital who had contact with Mahoney several times in the months leading up to his death, had assessed him as being capable and not a harm to himself or a harm to others.

Mahoney had been brought to the hospital on at least six occasions before his death for an assessment, which included a number of cases where he said he "felt like killing himself," only to tell healthcare providers that he didn't want to kill himself, he just felt like it.

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'.


A total of five joint recommendations have been submitted, by several parties with standing at the inquest, for the jury to consider:

1. That the Ontario Ministry of Health, for the purpose of assisting clinicians and directing patients to receive timely mental health services and promoting accountability of community mental health services, a direction that all hospitals and community-based mental health services that receive funding from the Government of Ontario, collect and publicize non-identifying data regarding wait times for treatment (actual receipt of mental health services by mental health professionals as opposed to waiting times for intake) and patient volumes. Days and hours of mental health services provided. Provide the resources to hospitals and mental health services to provide this data.

2. That the Ontario Ministry of Health, within six months of the jury verdict, strike a task force to review and report on funding, accountability and timely access to care for all community-based mental health services that receive funding from the Government of Ontario, and available resources and supports for family members and/or caregivers of patients receiving mental health services, and how those family members and/or caregivers can provide support and/or information about the patient when patient consent is not provided. The task force review should focus these reviews on the most vulnerable patients, in particular those with moderate or to severe mental illness, especially schizophrenia or schizophrenia related disorders.

3. That the Government of Ontario should enhance supports for families of persons who die in an police encounter and ensure those supports are delivered in a timely and trauma informed manner.

4. That the Ministry of the Solicitor General and the Windsor Police Service explore providing police training and addressing mental health situations and crisis, including providing awareness, education, recognizing and identifying when mental illness may be playing a role.

5. That the Ministry of the Solicitor General and the Windsor Police Service consider reviewing current procedures and processes in respect to police response to persons with a mental illness.