"All of the 57 recommendations made by coroner's jury are aimed at Ontario government. The top five recommendations include:
1. Develop a public position statement within 60 days recognizing that jails are not the appropriate environment for those with significant mental health issues.
2. Take immediate steps to make sure anyone suffering an acute mental health crisis in custody is admitted to hospital for assessment and, where appropriate, treatment.
3. Adopt a principle of equivalence so that those in custody receive equal quality health care as they would outside.
4. Develop a committee to ensure the inquest's recommendations are properly considered and any responses fully reported on.
5. Establish an independent provincial corrections inspectorate."