Eleventh Christmas Without You, 2017

So many just don’t comprehend!
Those who do have experienced the same!

When your parents die, you have lost your past.
Memories of your youth are what you hold on to.

When your child passes, you have lost your future.
Memories, yes, but what was yet to come has expired too!

So at present, I merely exist.

Christmas’ are to be better than the first,
Instead each one is followed by the worst!

Four were the members of our family,
Now in solitude we remain at three.

At this time of year, I am so unhappy; that’s my life!
Love you, Terra.
Love you Brandy,
Love you Paulette.


THE HOSPITAL --under jurisdiction of Liberal Minister of Health

THE CHIEF CORONER'S OFFICE--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections and is a member of the CPSO and CMPA!

THE DEATH INVESTIGATIVE OVERSIGHT COUNCIL--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections --has Chief Coroner or Deputy sitting on this council!


THE HEALTH PROFESSIONS APPEAL AND REVIEW BOARD--appointed by Liberal majority government --under jurisdiction of Liberal Minister of Health

THE ONTARIO OMBUDSMAN--appointed by Liberal majority government

THE ONTARIO PATIENT OMBUDSMAN--appointed by Liberal majority government

THE ONTARIO PROVINCIAL POLICE--under jurisdiction of Liberal Minister of Corrections

THE INDEPENDENT POLICE REVIEW DIRECTOR--appointed by Liberal majority government and --under jurisdiction of Liberal Minister of Corrections

THE LIBERAL MINISTER OF HEALTH and is a member of the CPSO and CMPA!






Without a doubt; a Conspiracy exists,
Self-protecting Officials; such hypocrites!

If you were a MPP’s daughter; it would cause a fit,
Because you’re mine; they don’t give a shit!

For years we have yearned for justice,
The lack of moral integrity merely disgusts us!

Government institutions that won’t expose,
The Medical negligence concealed by those!

Medical Immunity granted; regardless of guilt,
Preserving Ontario Health Care’s patchwork quilt!

So many individuals paid through our taxes,
Failing us all; what a bunch of asses:

--with regard to Terra Dawn Kilby Those who should be held accountable by the newly elected Conservative government in 2018

Premier of Ontario --Premier Wynne, Premier McGuinty,

Ontario Minsters of Health --Dr. E. Hoskins, D. Matthews, Rick Bartolucci

Ontario Ministers of Corrections --Yasir Naqvi, Madeleine Meilleur

Ontario Members of Provincial Parliament --majority of them from 2006 to the present

Defeat the above who in are still present in the next election 2018

CPSO -- Angela Bates Manager Committee Support Area Investigations and Resolutions--then Director, Regulatory Affairs at Retirement Homes Regulatory Authority no longer there and presently founded her own company SIGNAL REGULATORY SOLUTIONS angela.bates@signalregulatory.com , Sandra Keough Investigator

HPARB --Chair Janice Vauthier--should be replaced and not be appointed to any Ontario government position, Past Chair Linda Lamoureux---now Executive Chair of Safety, Licensing Appeals and Standard Tribunals of Ontario,--should be replaced and not be appointed to any Ontario government position, Lori Coleman Registrar--should be replaced and not be appointed to any Ontario government position, Anna Dunscombe--should be replaced and not be appointed to any Ontario government position

Third Appeal Chair Tom Kelly, Members Stephen Jovanoviorc and Brenda Petryna--these three should never be allowed to serve on any Ontario appeal/review board

Ontario Ombudsman --Paul Dube Ombudsman--should be replaced and not be appointed to any Ontario government position, A Marin-Ombudsman, Investigator Lorraine Boucher- Investigator--should be replaced and not be appointed to any Ontario government position, Fran Cappe-Investigator,

Humber River Hospital --CEO B. Collins--now CEO of the hospital--should be replaced and not be appointed to any Ontario government position, past CEO Rueben Devlin,

Ontario Chief Coroner’s Office --Dr. D. Huyer,--should be replaced and not be appointed to any Ontario government position Dr. A. McCallum--now head of Onge,--should be replaced and not be appointed to any Ontario government position '

Dr. A. Lauwer--now CEO of Ross Memorial Hospital in Lindsay, Ont--should be replaced and not be appointed to any Ontario government position

DIOC --Joseph C.M. James (Chair), Emily Musing (Vice-Chair), John Pearson (Vice-Chair), William (Bill) McLean, David Williams, Dorothy Cynthia (Cindy) Prince, Denise St-Jean, Fiona Smaill, Lidia Narozniak, Lori Marshall, Lucille Perreault, William (Bill) J Shearing, Michael Pollanen, Fiona Foster Manager of DIOC

--All should be replaced and not be appointed to any Ontario government position

Ontario Patient Ombudsman --Christine Elliott, Investigator Marie Claire Muamba --authority and mandate should be expanded especially in light of the Ontario Ombudsman, P Dube's inaction

Ontario Provincial Police --Commissioner J.V.N. (Vince) Hawkes,

Inspector Bradley McCallum--should be investigated with regard to inadequate handling of my submission for Breach of Trust complaint vs Chief Coroners past and present and he should be replaced

OIPRD -- Director Gerry McNeilly

Terra Dawn Kilby
"An Angel In Our Lives"
April 22/78 to July 21/06






--Look on right side under "Blog Archive" (oldest to newest)


College of Physicians and Surgeons - Stories of Failure

What is especially interesting in this recent Star (last week Feb/2016)article is the following:

“We are not a public organization. . . Our accountability is to our members,” said the College’s executive director, Dr. Francine Lemire" CPSO


We already know the CPSO is corrupt and HPARB from the article where it stated "it looks like HPARB just threw up their hands and said we give up"



But for the Ombudsman's Office to swallow such garbage leaves the citizens of Ontario with no where to go.


Terra Dawn Kilby --- A Father's Memories
An Angel In Our Lives, Terra Dawn Kilby November 2014

A tribute to the life of my daughter who died due to the negligence of a surgeon at Humber River Regional Hospital, Toronto, Ontario, Canada. Covered up by Humber River Regional Hospital, the CPSO, HPARB, Chief Coroner's Office of Ontario, the DIOC, Ontario's Ombudsman and the entire Provincial Liberal Party!

TERRA DAWN KILBY April 22, 1978 - July 21, 2006. 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.”…




HPARB's Decisions Kilby vs Laz Klein.
First Decision:
Second Decision:

Third Decision:

The Letter I Sent to the Chief Coroner's Office Outlining My Numerous Concerns
Coroner's Comments.doc

Death Investigative Oversight Council's Decision

2 years after my initial request and after both Chief Coroner and Deputy Chief Coroner left the OCC.
DIOC Decision Aug 2013.doc
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 Ms Deb Matthews 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

And the College/HPARB totally ignored Dr. Andrew McCallum's letter to the College when he was Eastern Ontario Coroner. In it he states that infection was a contributing factor in Terra's death.
One must also wonder how on earth the Chief Coroner's death investigation failed to note the lack of antibiotics plus other issues contained within the hospital records and yet I have numerous pieces of correspondence from both Dr. Lauwers and Dr. McCallum stating they saw no issues with respect to the Standard of Care???

THE OMBUDSMAN'S OFFICE has allowed the College and HPARB to establish the above as precedence for future complaints/appeals made to both of them.





Gan Reporter to appeared July 21, 2015
Terra Dawn Kilby
“An Angel In Our Lives”
April 22, 1978 – July 21, 2006

Tears still appear when we think of you.
Visits to your grave site we often do.
Loving memories convey serenity too!

Our precious daughter, Terra Dawn;
It’s been nine years since you’ve been gone.
Within our hearts you still belong!

July Twenty-first is a time of sorrow.
Additional years, I wish we could borrow.
Maybe then, we’d not feel hollow!

Today, messages guided to heaven above.
Channeled to you on the wings of a dove.
Expressing our heartfelt, everlasting love!


Friday, 7 September 2012

No Accountability or Transparency in Ontario--Dr. Bert Lauwers/Dr. Andrew McCallum/Dr. Laz Klein---Part Ten

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


"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."

"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. 


Arnold Kilby (awkilby@hotmail.com)


September-09-12 12:47:00 PM
To: andre marin (amarin@ombudsman.on.ca)

Mr. Marin

Below you will find the so-called expert's report that Dr. Lauwers from the Ontario Chief Coroner's Office used to investigate my daughter's death.  All of decisions from the Chief Coroner's Office were made due to this report.   Then go back and review all of my support material especially the over 100 surgeons from outside Canada and throughout the world???

Would you be satisfied with this report if it was your daughter who died??????

How would you feel if the Chief Coroner's Office refuses to answer very pertinent questions?????

How would you feel if the Chief Coroner's Office quite possibly abused their position to use the OPP as a scare tactic to silence you?????

May, with due respect, I remind you of your authority to investigate:

Especially when there is no doubt that a failure by the Chief Coroner's Office has deliberately occurred!!!!!   Citizens of Ontario must be ensured that death investigations are thorough and complete even if it may be detrimental to the reputation of a surgeon/doctor.  If the Chief Coroner's Office is in a position of "Conflict of Interest" then who does an Ontario citizen turn to??????  But You.

The Ombudsman is an independent officer of the legislature whose mandate is to ensure “government accountability through effective oversight of the administration of government services. (More information is available at www.ombudsman.on.ca.)

NOTE:  There is no right of appeal for a Chief Coroner's declining of a public inquest by a complainant or declining a request for a death to go before the Patient Safety Death Panel, or denying a request for an Eastern Ontario Review of the death, or the Chief Coroner's denial of putting together a Chief Coroner's review team to investigate a complaint against a coroner.   It is financially impossible for an ordinary citizens to access the courts for a judicial review!!!!   So, the only alternative is for the Ombudsman's Office to take this on; to protect all Ontario Citizens' rights for a unbiased, transparent, accountable, thorough review of a death!!!
DR. Lauwers', Chief Coroners Office, unnamed expert:       

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 (expert needs an upgrade--not according to my experts), 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. (expert needs an upgrade--not according to my experts), 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 (expert needs an upgrade--not according to my experts), 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. (expert needs an upgrade) 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. (expert needs an upgrade) Discharge on July 20,2006 was therefore clinically appropriate. (expert needs an upgrade--not according to my experts),
I concur with the pathologist that the cause of death was hemorrhagic shock. It is my opinion that the coagulopamy 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.
Following removal of the right colon, the bowel was reconstructed using mechanical staplers and a technique known as a functional 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 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.
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.
While the patient suffered the most devastating complication 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 that she received. (expert needs an upgrade--not according to my experts),

If you have any further questions, I would be happy to discuss this at any time

--the "evidence" that is lacking in his report

1.  No mention of low hemacrit, red blood cells & hemoglobin indicates anemia    (iron deficiency) 

2.  No mention of the many Gram Negative Bacilli Seen and how it should be treated and was not treated?

The Chief Coroner’s expert claims:
“There were no clinical indications for a CT scan or other investigation.”

What about the following?
3.  a.        No mention as to the enlarged abdomen?---That is a sign of something wrong.
     b.   No mention of high pulse rate?  34/38 above 90
     c.   Does not comment on many PMN’s (polymorphonuclear Neutrophils) –? hall mark of acute inflammatory process.
     d.  Does not mention low Absolute Lymphocyte (type of white cells to fight infection)?

4.  No mention of the seriousness of the oozing, infected abdominal incision.

5No mention that no antibiotics were given at any time even after the abdominal incision became infected.  Since she never received the antibiotic prophylaxis, how could a surgeon not prescribe antibiotics.

6.  No mention that the mandatory antibiotic prophylaxis was not given for this operation!!!!         HOW COULD AN EXPERT MISS THIS?????  UNLESS ON PURPOSE!!!!

plus all of the vague statements made without substantiated fact to go with them.

Dr.John Hagen, Dr. Klein's partner in MIS surgery operating out of Humber River Regional Hospital, delivered this presentation during May 2010 in Montreal as part of a symposium on diabetes.  It is the surgical aspect of the shut down that is important.

Dr. Klein who was Terra's surgeon, (not performing bariatric surgery) but general surgery is a part of this team of I believe three or four surgeons.
Deficiencies in the program below that affected Terra are definitely numbers Two Three and Four.

First Canadian Summit on\Metabolic Surgery for Type II Diabetes
May 6-7, 2010 – Hôtel Le Centre Sheraton – Montréal, Q

Bariatric surgery could be performed with few complications ... surgeon must be board certified. 7. Bariatric surgery is to ... Society for Metabolic and Bariatric Surgery ...
t2dmcanadasummit.com/ppt/Hagan.ppt · PPT file

With the help of the Coroner's Office, the program was shut down while an external review was done by a well-known expert.  (according to this power point display mention 5 deaths within 30 days of operation of patients)  My sources say it is higher.

Deficiencies in the program:

1.  Poor selection of Patient
2. Medical conditions not optimized prior to surgery
3.  Lack of integration between ansethesia, internal medicine, surgery and bariatric clinic
4. Inadequate post-op monitoring

   Arnold Kilby

  Terra Dawn Kilby
"An Angel In Our Lives"

   April 22/78 to July 21/06

From: awkilby@hotmail.com
To: fcappe@ombudsman.on.ca
CC: steve.clark@pc.ola.org; pauline@steveclarkmpp.com
Subject: RE: Arnold Kilby
Date: Thu, 6 Sep 2012 19:36:59 -0400

Ms Cappe                                          MPP Steve Clark--sorry, I guess this will be my last e-mail
 Ontario Ombudsman's Office

I am busy tomorrow. I am tired of talking and getting no real positive action by anyone. If people just took the time to look at the entire process I have gone through and material I have submitted, it should be evident that an injustice has occured in several instances.
Perhaps it is Dr. Lauwers whom you should be speaking to and asking him some very pertinent questions since he won't respond to me. He won't respond to you, he will state "for privacy reasons". Which is what Dr. McCallum stated in a response letter to MPP now Senator, Robert Runciman a couple of years ago. In this way the truth can be hidden, but not if one looks at what I have previously submitted.

Dig out his expert's report ---- look for the many items it fails to address and yet Dr. Lauwers states he saw nothing wrong with her care???? Look at what I have sent with regard to Terra's hospital records.

With regard to HPARB, what ever the College of Physicians and Surgeons state in their decision will be accepted as truth. Even though it is now on record from their second decision that Dr. Klein neglected to administer the antibiotic prophylaxis and that it was an oversight.
There is no doubt that this surgeon should be found to be negligent and not providng the standards of care.   Ontario citizens will never know because his record will show nothing if one looks Dr. Klein up in their records.---- Clean Slate?????

As far as the DIOC---- who knows --- how can they ignore all the evidence. And how can they overlook the hospital department being shut down by the Coroner's Office (secretly) in 2010 due to more deaths. I made the Chief Coroner's Office fully aware well before. Lives may have been saved.
As far as the Obudsman's Office, I believe that there is no doubt that the two publicly funded institutions mentioned above, in particular, the Chief Coroner's Office, have failed and that the Ombudsman's Office is entitled to investigate. When the DIOC in a previous piece of correspondence states they are nots sure if my complaint falls within their scope, then who else but the Ombudsman's Office should assume the responsibility

   Arnold Kilby

Terra Dawn Kilby
"An Angel In Our Lives"
April 22/78 to July 21/06

Subject: Re: Arnold Kilby
From: fcappe@ombudsman.on.ca
Date: Thu, 6 Sep 2012 18:15:29 -0400
CC: steve.clark@pc.ola.org; pauline@steveclarkmpp.com; amarin@ombudsman.on.ca
To: awkilby@hotmail.com

Hi Mr. Kilby

I have received your email this afternoon and would like to have the opportunity to speak to you about several of your comments. Can you get back to me and tell me what would be a good time for me to call you tomorrow? I am available all day and can phone at any time that is convenient for you.

I look forward to hearing from you as it is a while since we have had the opportunity to talk.

Fran Cappe


Phone: 416-586-3343
FAX: 416-586-3485Office of the Ombudsman of Ontario | Bureau de l’Ombudsman de l’Ontario

On Sep 6, 2012, at 4:49 PM, Arnold Kilby wrote:
Dear Steve,

This will probably be the last e-mail that I will send to you. I am still waiting for the College Of Physicians and Surgeons to render their third decision which I expect to appeal to the Health Professions Appeal and Review Board. I am still waiting to hear from the DIOC as to whether they will look into my complaint against the Chief Coroner's Office. And I just can't believe that the Ombudsman's Office can't see the obvious cover-up being done or to put it mildly, ---- mistakes which have been made by these government funded institutions --- The Chief Coroner's Office, HPARB and themselves!!, including the Ministry of Health and the Ministry of Corrections. I believe I have provided the Ombudsman's Office with enough material to have them institute a full investigation.
I am completely disillusioned with all the Political Parties within Ontario. Unless they have been doing something quietly in the background, which I don't believe they are, the citizens of Ontario, as well as Terra and her family and friends, have been totally ignored and a chance for effective changes has been lost.

I'm am sure that your children have all been prescribed antibiotics to fight an infection. Yet, Terra went through major abdominal surgery and post operative care with an incision infection and many gram negative bacillis present on a test, and she received no antibiotics at all!!!! But the COLLEGE, The CHIEF CORONER'S OFFICE, HPARB AND THE HOSPITAL DON'T SEEM TO FIND THIS UNUSUAL. HPARB place absolutely no interest in the over 100 named surgeons I provided to them and relied on the six unnamed surgeons provided to the HPARB panel. ??????????????

Don't take this as an alarm button with regard to my state of mind, but I am tired of living. As are my wife and Terra's sister. I have been on antidepressants for over six years now and my doctor has now prescribe a different one as I believe my body just became use to the original one.

I find it very disappointing that not once have I heard from the Conservative leader!! But I have from some of your fellow Conservative MPP's and from the NDP. Nothing from the Liberals.

If the Conservative MPP dealing with Ontario's Health Issues truly read what I have provided, it would be very clear that a major injustice has occurred and by not acting on it, Patient Safety and Acountability within Ontario will continue to suffer.

I sincerely, hope that you or your fellow MPP's don't have to have a tragic death occur within your families for the politicians to finally act.

Respectfully yours
Arnold Kilby

Terra Dawn Kilby
"An Angel In Our Lives"

April 22/78 to July 21/06

From: Arnold Kilby [mailto:awkilby@hotmail.com]
Sent: April 27, 2012 8:38 PM
To: andre marin; fran cappe
Cc: dioc@ontario.ca; Clark, Steve; Pauline SteveClarkBrockville Office
Importance: High

Mr Marin

I know that my daughter did not have the appropriate standard of care given to her and that there indeed was pre and post operative neglect. This is a fact! --supported by Terra's hospital records and the many surgeons I have contacted outside of Canada.

Reread all that I have sent, in particular my second complaint I filed with HPARB and my complaint sent to the DIOC.
I just can't believe that there is nothing your Office can do??
The problem is with the close connection between the College of Physicians and Surgeons and the Chief Coroner's Office of Ontario.

I won my first appeal with HPARB a couple of years ago and will win the second appeal by HPARB which is apparently being written right now.

The College is protecting the Chief Coroner's Office----- Should they finally admit that the standards of care were not met and that there was pre and post operative neglect this would conflict with the Chief Coroner's statements. I have a complaint with the DIOC which has been stalled. And all along, the Chief Coroner's Office was protecting the surgeon and then themselves. 99.9% of people would merely accept whatever the Chief Coroner's Office states. I am the .1% that didn't and this is why this OFFICE has been so uncooperative, and non transparent.

Ministers, Ms Matthews and Ms Meilleur ignore my pleas, yet it is within their authority to look into the above situation.

There is nothing to stop this from happening again.
The Ombudsman is an independent officer of the legislature whose mandate is to ensure “government accountability through effective oversight of the administration of government services. (More information is available at www.ombudsman.on.ca.) The Ombudsman has the power to review and investigate any decision, recommendation, act or omission of a government body that affects a person in his or her personal capacity for which there is no right of appeal or objection to any court or tribunal, or for which all rights of appeal or objection have either been exercised or have expired.

Keep in mind that HPARB had no real authority and the College can play the game over and over more as many years that it takes until I die. And the DIOC, by stating that they can't proceed with my complaint against the Chief Coroner's Office while I have a complaint being dealt with by HPARB/College is merely another attempt to stall.

Following an investigation, the Ombudsman has the power to report government decisions, recommendations, acts or omissions that are, in his or her opinion, contrary to law, unreasonable, unjust, oppressive, improperly discriminatory, based on a mistake of law or wrong, to the governmental authority in question as well as the relevant minister. A recommendation for steps to be taken (such as further consideration, rectification, cancellation or variance) or reasons provided are to accompany the report. If action is not taken within a reasonable time frame, the Ombudsman may make a report to the Premier and the Assembly.

The Ombudsman also has the power to refer matters to appropriate authorities in the event that he or she is of the opinion that there is evidence of a breach of duty or of misconduct by an officer or employee of a governmental organization. The decisions of the Ombudsman may not be challenged, reviewed, quashed or called into question in any court.

Arnold W. Kilby

"Terra Dawn Kilby, An Angel In Our Lives"
April 22, 1978--July 21, 2006